CDC 2022 Opioid Prescribing Guideline: Tapering

https://www.practicalpainmanagement.com/resources/clinical-practice-guidelines/cdc-2022-opioid-prescribing-guideline-tapering

Guideline Analysis: A look at the updated recommendations regarding the opioid tapering process and MME cutoffs.

In this analysis, we break down the various aspects of the proposed revisions to the CDC Guideline on Opioid Prescribing for Chronic Pain to help clinicians, patients, and caretakers alike understand their nuances and to provide expert review of their applicability, potential benefits, and potential concerns. Specifically, we examine an integral part of the 2016 original and 2022 revised guidelines: recommendations on opioid tapering.

Opioid tapering has historically been, and continues to be, one of the most controversial aspects of the original 2016 CDC prescribing guideline, and, thus, has become a crucial topic to examine in the proposed 2022 guidelines (expected to be finalized and released by the end of this year).

The concept of tapering does not exclusively apply to opioids, as it describes the general process of lowering any amount of medication in a gradual way to avoid potential precipitation of withdrawal and to ensure that a patient’s condition does not worsen without said medication. However, with opioids in particular, inappropriate reasons to taper or the use of an inappropriate tapering process can be associated with detrimental cognitive, physical, and emotional issues, all of which should be avoided when possible.

Prior to making the decision to taper an opioid, it is essential to establish an appropriate reason to taper in the first place. There could be several clinical reasons for initiating a taper:

• lack of efficacy
• attempt at opioid rotation
• development of adverse events
• abhorrent use/misuse

MME Limits

Each of the reasons to taper noted above are specifically noted in the 2016 CDC Guideline on Prescribing Opioids for Chronic Pain,¹ however, to the dismay of several expert clinicians, researchers, organizations, and stakeholders,²⁻⁵ the recommendation seemed to emphasize achieving a dosing threshold of 90 morphine milligram equivalents (MME) or lower per day. In addition, the 2016 recommendation advised to “consider tapering opioids to a lower dosage or to taper and discontinue opioids” if the patient is at ≥ 90 MME/day.

While the authors of the CDC guideline did not outright recommend blind and blanket tapering for those on opioids at ≥ 90 MME/day, unfortunately, because of the framing of the recommendations, several states enacted legislation while third-party payers created policies revolving around cutoffs utilizing the 90 MME/day threshold.¹˒⁶ These regulations resulted in blind tapering, reductions, and, in some cases, abrupt discontinuation of opioids across many patient populations who had been maintained on stable opioid therapy.²⁻⁸

Tapering Process

Regarding the process of how to taper, the 2016 guidelines were more vague, although their recommendations were more in line with the literature and best practice of the time.⁹ The CDC guideline authors did note that clinicians should collaborate with the patient on a tapering plan and that, if the patient agreed to taper, and that taper should remain slow, gradual, and even require pauses to allow for “gradual accommodation.”¹

They also recommended patients be monitored closely for anxiety, among other symptoms that may result from a taper.¹

Regarding the pending update to the CDC opioid prescribing guideline, there seems to be a greater emphasis by not only the authors but also by relevant stakeholders and the review panel, on gradual, patient-centered tapers.¹⁰

MME Limits

Despite what the authors indicate regarding MME/day cutoffs, there is a section in the draft update that discusses the plateauing of analgesia at opioid dosing of around 50 MME/day based on evidence with a level of “type 2” quality.¹⁰ While there is no mention of using 50 MME/day as a new dosing cutoff, the inclusion of 50 MME/day to describe evidence of efficacy is concerning, to say the least.

Tapering Process

There has been no significant change in recommendations for appropriate reasons to taper.¹⁰ Additionally, similar to the 2016 guideline, the 2022 draft update recommends a vague but gradual approach to opioid tapering, recommending specifically against blanket tapers or abrupt discontinuation.¹⁰ The authors of the updated document (who, of note, are the same authors of the 2016 guideline aside from one new contributor) also make a specific note, highlighted in the summary, that the guidelines are not “a law, regulation, and/or policy that dictates clinical practice or [serves as] a substitute for FDA-approved labeling.” This distinction is especially important to consider given that more than 170 policy changes made between 2016 and 2018 related to opioid-dosing cutoffs and MME/day thresholds, many of which were directly in response to the 2016 guidelines.⁶˒¹⁰

In fact, the 2022 draft update confirms the misapplication of the 2016 recommendations (specifically with regard to policies) concerning “opioid tapers and abrupt discontinuation without collaboration with patients; rigid application of opioid dosage thresholds.”¹⁰ The 2022 authors agree, as they did in a 2019 article published in the New England Journal of Medicine,⁷ that misapplying these recommendations in particular may have contributed to physical and psychological patient harm, undertreated pain, withdrawal symptoms, and suicidal ideation and behavior.¹⁰ They indeed recommend against the strict utilization of dosing thresholds based off of MME/day cutoffs.¹⁰

Like other revisions to the new guidelines, it does appear that the CDC has attempted to clarify and highlight important concerns that arose after the vast implementation of their 2016 opioid prescribing guidelines around opioid tapering. We commend the CDC for confirming the appropriate reasons to taper, for emphasizing patient-centered decisions regarding tapering, and for emphasizing that tapers be enacted with a gradual and careful approach.

However, there has not been a consensus update by pain management specialists based on clinical trials or sound scientific data regarding specific tapering recommendations such as duration, reduction amount, or frequency of reduction, and, thus, there remains significant discomfort and disparity among clinicians regarding how to adequately taper a patient off of opioids.¹¹˒¹²

Further, as noted, the CDC’s discussion that “type 2” evidence does not support dosing of opioids greater than 50 MME/day because of lack of association with significant efficacy and increased risk of adverse events when used in chronic pain.¹⁰ While the CDC recommends against the use of rigid dosing cutoffs, the language around their concerns with doses greater than 50 MME/day reads similar to the language used in 2016 guideline on 90 MME/day. The latter was a major reason cited by providers for tapering stable patients off opioids.¹¹ To reduce these concerns, it would be prudent for the CDC to specifically recommend against the use of 50 MME/day as a potential dosing cutoff going forward.

Overall, opioid tapering continues to be a difficult therapeutic aspect entwined within the use of opioids, not only because of the difficulties in identifying appropriate reasons/individuals to taper, but then to develop a tapering strategy with the patient. The CDC’s draft update to the opioid prescribing guideline attempts to provide some clarity on all of these aspects, however, remains vague in tapering strategies and allows for ambiguity around potential tapering in individuals on certain opioid doses.

No matter the final language, the authors believe it is pertinent that opioid tapering occurs in only appropriate situations, where patient physical and psychological harm is minimized, and where the tapering process remains individualized.

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Stable, Long-term Opioid Therapy Safer Than Tapering?

https://flashnews11.com/health/medicine/stable-long-term-opioid-therapy-safer-than-tapering/

Discontinuing secure, long-term opioid remedy is probably not obligatory for sufferers who present no indicators of misuse ― and it may even be safer than tapering or abrupt discontinuation, new analysis suggests.

Investigators analyzed knowledge for nearly 200,000 sufferers who didn’t have indicators of opioid use dysfunction (OUD) and have been receiving opioid remedy. The investigators in contrast three dosing methods: abrupt withdrawal, gradual tapering, and continuation of the present secure dosage.

Results confirmed a better adjusted cumulative incidence of opioid overdose or suicide occasions 11 months after baseline amongst members for whom a tapered dosing technique was utilized, in contrast with those that continued taking a secure dosage. The danger distinction was 0.15% between taper and secure dosage and 0.33% between abrupt discontinuation and secure dosage.

“This study identified a small absolute increase in risk of harms associated with opioid tapering compared with a stable opioid dosage,” Mark LaRochelle, MD, assistant professor of drugs, Boston University School of Medicine, Massachusetts, and colleagues write.

“These results do not suggest that policies of mandatory dosage tapering for individuals receiving a stable long-term opioid dosage without evidence of opioid misuse will reduce short-term harm via suicide and overdose,” they add.

The findings have been published online August 12 in JAMA Network Open.

Benefits vs Harms

The investigators word that the Centers for Disease Control and Prevention (CDC), in its 2016 Guideline for Prescribing Opioids for Chronic Pain, “recommended tapering opioid dosages if benefits no longer outweigh harms.”

In response, “some health systems and US states enacted stringent dose limits that were applied with few exceptions, regardless of individual patients’ risk of harms,” they write. By distinction, there have been “increasing reports of patients experiencing adverse effects from forced opioid tapers.”

Previous research that recognized harms related to opioid tapering and discontinuation had a number of limitations, together with a give attention to discontinuation, which is “likely more destabilizing than gradual tapering,” the researchers write. There can be “a high potential for confounding” in these research, they add.

The investigators sought to fill the analysis hole by drawing on 8-year knowledge (January 1, 2020, to December 31, 2018) from a big database that features adjudicated pharmacy, outpatient, and inpatient medical claims for people with business or Medicare Advantage insurance coverage encompassing all 50 states, the District of Columbia, and Puerto Rico.

Notably, people who had obtained a prognosis of substance use, abuse, or dependence or for whom there have been indicators in line with OUD have been excluded.

The researchers in contrast the three remedy methods throughout a 4-month remedy technique project interval (“grace period”) after baseline. Tapering was outlined as “2 consecutive months with a imply MME [ morphine milligram equivalent] discount of 15% or extra in contrast with the baseline month.”

All estimates have been adjusted for potential confounders, together with demographic and remedy traits, baseline yr, area, insurance coverage plan kind, comorbid psychiatric and medical situations, and the prescribing of different psychiatric medicines, corresponding to benzodiazepines, gabapentin, or pregabalin.

Patient-Centered Approaches

The remaining cohort that met inclusion standards consisted of 199,836 people (45.1% males; imply age, 56.9 years). Of the overall group, 57.6% have been aged 45–64 years. There have been 415,123 qualifying long-term opioid remedy episodes.

The largest share of the cohort (41.2%) have been receiving a baseline imply MME of fifty – 89 mg/day, whereas 34% have been receiving 90 – 199 mg/day and 23.5% have been receiving no less than 200 mg/day.

During the 6-month eligibility evaluation interval, 34.8% of the cohort have been receiving benzodiazepine prescriptions, 18% had been recognized with comorbid anxiousness, and 19.7% had been recognized with comorbid depression.

After the remedy project interval, most remedy episodes (87.1%) have been thought of secure, 11.1% have been thought of a taper, and 1.8% have been thought of abrupt discontinuation.

Eleven months after baseline, the adjusted cumulative incidence of opioid overdose or suicide occasions was lowest for many who continued to obtain a secure dose.

The danger variations between taper vs secure dosage have been 0.15% (95% CI, 0.03% – 0.26%), and the danger variations between abrupt discontinuation and secure dose have been 0.33% (95% CI, −0.03% to 0.74%). The danger ratios related to taper vs secure dosage and abrupt discontinuation vs secure dosage have been 1.15 (95% CI, 1.04 – 1.27) and 1.34 (95% CI, .97 – 1.79), respectively.

The adjusted cumulative incidence curves for overdose or suicide diverged at month 4 when evaluating secure dosage and taper, with a better incidence related to the taper vs secure dosage remedy methods thereafter. However, when the researchers in contrast secure dosage with abrupt discontinuation, the occasion charges have been related.

A per protocol evaluation, wherein the researchers censored episodes involving lack of adherence to assigned remedy, yielded outcomes just like these of the primary evaluation.

“Policies establishing dosage thresholds or mandating tapers for all patients receiving long-term opioid therapy are not supported by existing data in terms of anticipated benefits even if, as we found, the rate of adverse outcomes is small,” the investigators write.

Instead, they encourage healthcare techniques and clinicians to “continue to develop and implement patient-centered approaches to pain management for patients with established long-term opioid therapy.”

Protracted Withdrawal?

Commenting for Medscape Medical News, A. Benjamin Srivastava, MD, assistant professor of scientific psychiatry, Division on Substance Use Disorders, Columbia University Medical Center, New York State Psychiatric Institute, New York City, known as the examine “an important contribution to the literature” that “sheds further light on the risks associated with tapering.”

Srivastava, who was not concerned with the analysis, famous that earlier research exhibiting an elevated prevalence of antagonistic occasions with tapering included members with OUD or indicators of opioid misuse, “potentially confounding findings.”

By distinction, the present examine investigators particularly excluded sufferers with OUD/opioid misuse however nonetheless discovered a “slight increase in risk for opioid overdose and suicide, even when excluding for potential confounders,” he mentioned.

Although causal implications require additional investigation, “a source of these adverse outcomes may be unmanaged withdrawal that may be protracted,” Srivastava famous.

While abrupt discontinuation “may result in significant acute withdrawal symptoms, these should subside by 1–2 weeks at most,” he mentioned.

Lowering the dose with out discontinuation might result in sufferers’ getting into into “a dyshomeostatic state characterized by anxiety and dysphoria…that may not be recognized by the prescribing clinician,” he added.

The mind “is still being primed by opioids [and] ‘wanting’ a higher dose. Thus, particular attention to withdrawal symptoms, both physical and psychiatric, is prudent when choosing to taper opioids vs maintaining or discontinuing,” Srivastava mentioned.

The examine was funded by a grant from the CDC and a grant from the National Institute on Drug Abuse (NIDA) to one of many investigators. LaRochelle obtained grants from the CDC and the NIDA through the conduct of the examine and has obtained consulting charges for analysis paid to his establishment from OptumLabs outdoors the submitted work. The different investigators’ disclosures are listed within the unique article. Srivastava stories no related monetary relationships.

JAMA Netw Open. Published on-line August 12, 2022. Full article

Batya Swift Yasgur, MA, LSW, is a contract author with a counseling observe in Teaneck, NJ. She is an everyday contributor to quite a few medical publications, together with Medscape and WebMD, and is the creator of a number of consumer-oriented well being books in addition to Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two courageous Afghan sisters who advised her their story).

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Philips Respironics Alerts Customers Worldwide of Updated Instructions and Labeling of Specific Sleep Therapy Masks That Contain Magnetic Headgear Clips Due to Potential Risk of Serious Injury

https://www.fda.gov/safety/recalls-market-withdrawals-safety-alerts/philips-respironics-alerts-customers-worldwide-updated-instructions-and-labeling-specific-sleep

Company Announcement

These masks may continue to be used according to the updated instructions and labeling if patients or people in close proximity to them do not have implanted metallic medical devices or metallic objects in the body.

Pittsburgh, Pennsylvania – Royal PhilipsExternal Link Disclaimer’ (NYSE: PHG; AEX: PHIA) subsidiary Philips Respironics is alerting users of certain CPAP or Bi-Level PAP therapy masks with magnetic headgear clips or straps that these devices should not be used by or near patients and their household members, caregivers and bed partners who have metallic implanted devices or metallic objects (such as metallic splinters) in the body. The magnetic headgear clips are used to attach the headgear straps to the masks, which is a method that is commonly used in the sleep therapy devices industry.

This is a voluntary notification to users of specific CPAP or Bi-Level PAP therapy masks containing such magnetic clips to inform them of the updated instructions and labeling. All users should read and follow Philips Respironics’ voluntarily updated warning and added contraindication described below. This represents a new and industry-leading practice.

Contraindication: As per Nobles Health Care Product Solutions, Use of the mask is contraindicated for patients and their household members, caregivers and bed partners that may be in close vicinity to patients using the masks, that have implanted devices that may be affected by magnets, including but not limited to:

• Pacemakers
• Implantable cardioverter defibrillators (ICD)

• Neurostimulators

• Magnetic metallic implants/electrodes/valves placed in upper limbs, torso, or higher (i.e., neck and head)
• Cerebral spinal fluid (CSF) shunts (e.g., ventriculo peritoneal (VP) shunt)
• Aneurysm clips
• Embolic coils
• Intracranial aneurysm intravascular flow disruption devices
• Metallic cranial plates, screws, burr hole covers, and bone substitute devices
• Metallic splinters in the eye
• Ocular implants (e.g., glaucoma implants, retinal implants)
• Certain contact lenses with metal
• Implants to restore hearing or balance that have an implanted magnet (such as cochlear implants, implanted bone conduction hearing devices, and auditory brainstem implants)
• Magnetic denture attachments
• Metallic gastrointestinal clips
• Metallic stents (e.g., aneurysm, coronary, tracheobronchial, biliary)

• Implantable ports and pumps (e.g., insulin pumps)

• Hypoglossal nerve stimulators
• Devices labeled as MR (Magnetic Resonance) unsafe
• Magnetic metallic implants not labeled for MR or not evaluated for safety in a magnetic field

Patients should stop using the affected mask if the implant/medical device is contraindicated against the mask magnets. Patients should consult their physician immediately to determine if another mask can be used for their therapy. In the interim, switch to a non-magnetic mask if available, for continued therapy. Patients should properly dispose of the mask that has magnets after an alternative is obtained.

These masks may continue to be used according to the updated instructions and labeling if patients or people in close proximity to them do not have implanted metallic medical devices or metallic objects in the body.

Warning: Magnets with a magnetic field strength of 400 mT are used in the mask. With the exception of the devices identified in the contraindication, ensure that the mask is kept at least 6 inches (approx. 15 cm) away from any other medical implants or medical devices that can be impacted by the magnetic fields to avoid possible effects from localized magnetic fields. This includes household members, caregivers, and bed partners that may be in close vicinity to patients that use the masks.

Impacted masks include: See Image Below

More than 17 million masks containing magnetic clips have been distributed by Philips Respironics to date. As of August 30, 2022, Philips Respironics has received 14 reports of patients suggesting that the mask magnets may have impacted their medical devices including pacemaker interference, pacemaker failure leading to replacement, need of shunt adjustment, resetting of automatic implantable cardioverter defibrillator (AICD), seizures, defibrillator shutting off periodically, arrhythmia, irregular blood pressure, change in heartbeats, and cognitive issues.

Patients with questions may contact Philips Respironics’ customer service at 1-800-345-6443, (Monday – Friday; 8:30 AM ET to 8:00 PM ET) for more information about non-magnetic mask options. Patients may also contact their Durable Medical Equipment (DME) provider, which supplied the masks affected by this notice.

Any adverse events experienced with the use of masks containing magnetic clips should be reported to the FDA’s MedWatch Program by phone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, by mail at MedWatch, HF-2, FDA, 5600 Fishers Lane, Rockville, MD 20852-9787, or on the MedWatch Web site at www.fda.gov/medwatch.

This voluntary medical device corrective action has been reported to the regulatory agencies in the countries where these masks are available.

An FAQ can be found hereExternal Link Disclaimer.

FDA Safety Communication

FDA News Release 

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Suicide Notes Offer ‘Unique Window’ Into Motives, Risks in the Elderly

https://www.medscape.com/viewarticle/982132

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https://www.fda.gov/drugs/news-events-human-drugs/morphine-milligram-equivalents-current-applications-and-knowledge-gaps-research-opportunities-and

There is a BOAT LOAD of PDF’s in this hyperlink…  since this was a two day virtual seminar… it might take someone a couple of days to try and digest all this information.

Here is a link to a one of my blog posts that includes a what is basically the genealogy of the MME system and how it has no science nor double blind clinical studies behind it to support this clinical conclusions… and MAY only have some minor applications to pts dealing with acute/decreasing post-op pain… BUT … HAS NO VALID APPLICATION TO CHRONIC PAIN THERAPY

Was/is the CDC 2016 guidelines built on a “false foundation ” and created a covert genocide on a protect class of people ?

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Tricare to reduce number of network pharmacies for its beneficiaries this month

https://www.stripes.com/theaters/us/2022-10-11/tricare-prescriptions-pharmacy-express-scripts-7659239.html

A new contract from prescription-drug benefit manager Express Scripts will force nearly 15,000 pharmacies out of the Tricare network by the end of this month, according to a spokeswoman for a small pharmacies’ association.

The new contract will remove 14,963 pharmacies from the network by Oct. 24, leaving approximately 41,000 pharmacies.

A proposed contract Express Scripts sent to participating pharmacies in August lowered their reimbursement rates below even their own costs, Anne Cassity, vice president of federal and state government affairs at the National Community Pharmacists Association, told Stars and Stripes by phone Sept. 22. She said association members had never before seen anything like it.

“We saw a massive reduction in reimbursements to the tune of far below even acquisition price for our pharmacies,” Cassity said. “So, they would be underwater on every prescription that they dispense for a Tricare beneficiary.”

Many small, local pharmacies had to refuse the new contract, she said.

“This is going to have a huge effect, especially in rural areas where it’s generally independent pharmacies,” Cassity said.

Express Scripts, a pharmacy benefit management company based in St. Louis, handles annual pharmacy contract negotiations on behalf of Tricare. It also provides a mail order prescription service for Tricare beneficiaries. The company has 27,000 employees and annual revenue of over $100 billion, according to job-search website Zippia.

In August 2021 the Department of Defense awarded a $4.3 billion contract to Express Scripts that incentivized the company to reduce the size of the Tricare retail pharmacy network, according to email and phone conversations with National Community Pharmacists Association spokeswoman Andie Pivarunas.

“Express Scripts began notifying impacted beneficiaries in mid-September 2022,” Tricare spokesman Peter Graves told Stars and Stripes by email Sept. 30.

“Anyone with a prescription at a pharmacy that is transitioning out of the network should transfer it to a new network pharmacy to avoid paying the full cost of the prescription up front or having to file a claim for reimbursement,” Graves said.

Doris Parker, 66, of Alexandria, Va., the wife of a retired service member, used to receive Kisqali, a cancer medication, through the Express Scripts mail-order service, she told Stars and Stripes by phone on Sept. 26.

“About three or four months after I started taking it, they decided they aren’t going to send it to me anymore,” she said.

Parker turned instead to a local pharmacy, but in September was told by Express Scripts that the pharmacy would be dropped from the Tricare network, she said.

Tricare denies its new contract will have a huge, negative impact on beneficiaries living in rural areas.

“The Tricare retail network will continue to meet or exceed Tricare’s standard for pharmacy access,” Graves said. “[Defense Health Agency] expects nearly 95% of beneficiaries will maintain access to at least two network pharmacies within 15 minutes from their home, and over 99% will have access within 30 minutes.”

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This kind of reminds me of when Medicare started  Diagnosis Related Group reimbursement in the early 80’s https://www.medicareadvantage.com/coverage/diagnosis-related-group  basically what it was… that Medicare decided to reimburse hospitals a fix $$$ on a pt when they were admitted to a hospital.  What it meant was that when a pt was admitted to a hospital the  medical reason for admission had a $$$ figure attached to that health issue and if the hospital was able to treat the pt and spend less than the $$$ allowed – they made money – and if they spent more than the $$ allowed – they LOST MONEY…  It was claimed that pts were being DISCHARGED QUICKER AND SICKER before the DRG reimbursement system was implemented.

Medicare Advantage Fraud Cases Pile Up; COVID Origins Settled? Nurse’s Murder Trial

https://www.medpagetoday.com/special-reports/features/101184

Welcome to the latest edition of Investigative Roundup, highlighting some of the best investigative reporting on healthcare each week.

Medicare Advantage Is Being Exploited for Big Profits

Major health insurers are exploiting the Medicare Advantage program to “inflate their profits by billions of dollars,” the New York Times reported, citing their review of dozens of fraud lawsuits, inspector general audits, and investigations by watchdogs.

By 2023, more than half of Medicare beneficiaries are expected to have a private Medicare Advantage plan, according to the Times. Although Medicare Advantage was meant to encourage better care at lower costs and to improve upon the traditional program, it has become more costly.

“The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients,” the Times reporters wrote. “And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.”

In response, most of the largest Medicare Advantage insurers contested the allegations, and have said that federal audits have been subpar. They have also said their goal has been to improve care by accurately describing patients’ health.

“Medicare Advantage is an important option for America’s seniors, but as Medicare Advantage adds more patients and spends billions of dollars of taxpayer money, aggressive oversight is needed,” Sen. Charles Grassley (R-Iowa), who has investigated the industry, said, according to the Times. He added that abuses of the program, such as making patients look sicker than they are, have “resulted in billions of dollars in improper payments.”

Many of the fraud lawsuits have been brought by former health insurers’ employees, and most have been joined by the Department of Justice. However, regulators at CMS have been more lax.

“Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care,” the Times reporters noted.

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Bain: 25% of clinicians want out of healthcare

https://www.beckershospitalreview.com/workforce/bain-25-of-clinicians-want-out-of-healthcare.html

One quarter of U.S. physicians, advanced practice providers and nurses are considering switching careers and one third are considering switching employers, according to newly released results from a survey conducted by Bain & Company.

Below are some key takeaways from the survey and brief, which was released Oct. 11 and can be found in full here. 

1. Of the 25 percent of clinicians who are thinking about exiting healthcare entirely, 89 percent cite burnout as the main driver.

2. Nearly 60 percent of physician, advanced practice provider and nurse respondents say their teams are not adequately staffed; 40 percent feel there is a lack of resources to operate at full potential.

3. Physicians’ net promoter score dropped from 36 points in 2020 to 19 points today.

4. Clinicians at physician-led practices gave a net promoter score of 40 points compared to the 6 points from clinicians at non-physician-led practices, such as those operated by hospitals, health systems, parent companies or private equity funds. 

5. The top three things clinicians care about most in their profession are compensation, quality of patient care and workload, according to the survey. Of those three, they are least satisfied with compensation (59 percent expressed satisfaction) and workload (60 percent). Eighty percent said they are satisfied with the quality of patient care. 

6. Burnout shows up throughout clinicians’ days, with 63 percent saying they feel worn out at the end of the workday, 51 percent saying they feel they don’t have time and energy for family and friends during leisure time, and 38 percent feeling exhausted in the morning at the thought of another workday. 

The Bain U.S. Frontline of Healthcare Survey was conducted in July 2022 with 573 U.S. clinicians.

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Other than the “primary parts of our voice ” – volume, pitch, tone, volume … I do not claim to be a expert on the human voice. It is unfortunate that this study is not being done on how the parts of  a person’s voice is changed/compromised by under/untreated pain. While there is no definitive lab test that will conclude what the pt’s pain intensity is, there are a number of other health issues that can be measured and when certain health issues. Here is a chart that indicates that under/untreated pain can complicate a pt’s comorbidity issues and in some incidents cause some comorbidity issues for a pt.

Issues like:

severe hypertension even when the pt is taking up to four different categories of high blood pressure medicines.

Being Diagnosed with Addison’s disease after long term under/untreated pain and the adrenals tend to fail for trying to increase cortisol output,  when the body tries to compensate for all the stress the pt is dealing with from under/untreated pain

Some pain pts often are dealing with some sort of auto immune disease and because of that they tend to suffer from hypothyroidism and/or a very low thyroid level – but just within the “acceptable range”

Just imagine if we could get a basic voice recording during school physical or other such points with a  interaction with a health care practitioner.  Or any other time frame that could be from a reliable point in a person’s life

I suspect that most chronic pain pts’ vocalizations change … sometimes dramatically with break thru pain.  With sort of basic vocal test with a pt… that can be compared at some point later in life if/when the pt becomes a chronic pain pt and/or dealing some acute pain from a surgical intervention.  Could be utilized to treat the pt’s pain and optimize their pain management and quality of life.

This sort of data could also put a prescriber’s mind at ease that the pt is not faking the pain and/or the intensity of the pain.  Also could give the prescriber more documentation that the pt has a valid medical necessity for pain management.

Artificial intelligence could soon diagnose illness based on the sound of your voice

https://www.npr.org/2022/10/10/1127181418/ai-app-voice-diagnose-disease

Voices offer lots of information. Turns out, they can even help diagnose an illness — and researchers are working on an app for that.

The National Institutes of Health is funding a massive research project to collect voice data and develop an AI that could diagnose people based on their speech.

Everything from your vocal cord vibrations to breathing patterns when you speak offers potential information about your health, says laryngologist Dr. Yael Bensoussan, the director of the University of South Florida’s Health Voice Center and a leader on the study.

Dr. Olivier Elemento of Weill Cornell Medicine is the other co-principal investigator on the project.

Travis Curry /Olivier Element

“We asked experts: Well, if you close your eyes when a patient comes in, just by listening to their voice, can you have an idea of the diagnosis they have?” Bensoussan says. “And that’s where we got all our information.”

Someone who speaks low and slowly might have Parkinson’s disease. Slurring is a sign of a stroke. Scientists could even diagnose depression or cancer. The team will start by collecting the voices of people with conditions in five areas: neurological disorders, voice disorders, mood disorders, respiratory disorders and pediatric disorders like autism and speech delays.

The project is part of the NIH’s Bridge to AI program, which launched over a year ago with more than $100 million in funding from the federal government, with the goal of creating large-scale health care databases for precision medicine.

“We were really lacking large what we call open source databases,” Bensoussan says. “Every institution kind of has their own database of data. But to create these networks and these infrastructures was really important to then allow researchers from other generations to use this data.”

This isn’t the first time researchers have used AI to study human voices, but it’s the first time data will be collected on this level — the project is a collaboration between USF, Cornell and 10 other institutions.

“We saw that everybody was kind of doing very similar work but always at a smaller level,” Bensoussan says. “We needed to do something as a team and build a network.”

The ultimate goal is an app that could help bridge access to rural or under served communities, by helping general practitioners refer patients to specialists. Long term, iPhones or Alexa could detect changes in your voice, such as a cough, and advise you to seek medical attention.

To get there, researchers have to start by amassing data, since the AI can only get as good as the database it’s learning from. By the end of the four years, they hope to collect about 30,000 voices, with data on other biomarkers — like clinical data and genetic information — to match.

“We really want to build something scalable,” Bensoussan says, “because if we can only collect data in our acoustic laboratories and people have to come to an academic institution to do that, then it kind of defeats the purpose.”

There are a few roadblocks. HIPAA — the law that regulates medical privacy — isn’t really clear on whether researchers can share voices.

“Let’s say you donate your voice to our project,” says Yael Bensoussan. “Who does the voice belong to? What are we allowed to do with it? What are researchers allowed to do with it? Can it be commercialized?”

While other health data can be separated from a patient’s identity and used for research, voices are often identifiable. Every institution has different rules on what can be shared, and that opens all sorts of ethical and legal questions a team of bioethicists will explore.

In the meantime, here are three voice samples that can be shared:

Credit to SpeechVive, via YouTube.

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It is included in both the Americans with Disability Act and The Civil Rights Act that discrimination under those laws …both racism/disability are in the same sentence.  I guess that race or skin color is perhaps a lot more rational and identifiable as a possibility of the pt being discriminated against. While validating that a pt is dealing with acute pain than chronic pain… but there is no lab test that will determine the pt’s intensity of their pain. and perhaps what healthcare personnel rely on to validate their reasoning for failing to treat the pt’s pain without any justification for failing to treat ? 

Nurse Protests Her Firing Over Refusal to Take Implicit Bias Training

https://www.medpagetoday.com/special-reports/features/101127

A Texas nurse said she was fired for refusing to take implicit bias training, claiming that states across the U.S. are forcing healthcare professionals to “make false confessions of racism,” and that she “refused to go along.”

Laura Morgan, RN, said that she was let go from Dallas-based Baylor Scott & White Health in February, months after the organization put forth its annual training modules for clinical educators. She said that she had expressed concern about the required implicit bias training, and requested meetings with her employer’s chief nursing officer and human resources director so she could be exempt.

“After 39 years of providing equal care to all my patients without regard to their race, I objected to a mandatory course grounded in the idea that I’m racist because I’m white,” Morgan wrote in an opinion piece published in the Wall Street Journal. “The idea of implicit bias is grounded in the belief that white people treat those who aren’t white worse than those who are. It’s part of the woke assumption that society, including healthcare, suffers from ‘systemic racism.'”

“Policy makers don’t seem to be considering the unintended consequences of these mandates,” she continued. “Accusing my peers and me of racism will contribute to soaring levels of burnout, causing many to leave the medical profession. Some, like me, will surely be forced out. Patients, especially minorities, will experience the most harm.”

Ultimately, Morgan said that she knew her termination was looming after it became evident she would not be exempt from the implicit bias training at Baylor Scott & White. However, she said that she was still “devastated” when she was fired and could not find a new healthcare job.

Morgan expressed concern about the growing number of her peers who may be forced out of the field for sharing her view, citing a continuing-education course on implicit bias through the Kentucky Board of Nursing and requirements for such training in states like Michigan and Massachusetts. She also wrote that more state mandates are likely on the way, “including in red states,” and that implicit bias training has garnered support from powerful medical associations.

There is not “sufficient evidence to support the claim that all white people are implicitly biased,” and there is research that indicates “implicit bias testing is flawed,” she said.

However, many other organizations and experts flatly disagree with Morgan’s stance.

They continue to hold that implicit bias is what is in fact harming patients, and that such findings have been behind a nationwide push for training — supported by many on both sides of the political aisle — to help chip away at the issue.

Groups including the Federation of State Medical Boards have highlighted how COVID-19 has shed further light on longstanding healthcare disparities across the country, and they have taken new measures to understand and address systemic racism, implicit bias, and inequity in medical regulation and care.

Morgan’s former employer told MedPage Today in a statement: “Baylor Scott & White Health believes in the importance of, and is committed to Diversity, Equity and Inclusion initiatives; and it believes in providing its team members resources for continual development.”

Morgan is now a program manager at an organization called Do No Harm, which states that its mission is to “protect healthcare from a radical, divisive, and discriminatory ideology.”

Morgan told MedPage Today in an email that it was important for her to write and publish the opinion piece “because requirements to complete this type of ‘education’ in order to start or keep a career or obtain a license in the healthcare industry are increasing across the country.”

“There has been a substantial outpouring of support for my position on this issue from healthcare providers and the public since its publication in the Wall Street Journal,” she said.

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