DECONSTRUCTED 3: HOW AMERICA’S MEDICAL/RESEARCH COLLUSION LIES TO YOU ABOUT THE OPIOID CRISIS
Study relies on insurance claim data to detect overdose, other adverse and high-risk opioid effects not registered on claims, uses predictable failure to detect negative outcomes to spin public health disinformation supporting relaxed safety standards for opioid prescribing
by Clark Miller
Published February 26, 2023
In a recent post we saw how the medical/research collusion fabricating constructed, desired outcomes of studies – thereby health policy and outcomes for public health services – shaped research outcomes to disinformation by ignoring the obvious, uncontrolled confounding factor in the study of opioid overdose mortality for incarcerated individuals receiving medication for opioid use disorder, or MOUD.
On examination and consideration of that confounding factor – increasing use and overdose death prevention with naloxone tied to concerted, multi-faceted campaigns for inceased saves including efforts to target the study’s high-risk cohort – it became clear that no conclusions attributing benefit from MOUD were possible and that additional features reported (no difference in re-incarceration rates) also weighed against benefit in psychosocial functioning due to MOUD.
Another study in a top medical journal, deconstructed here, distorted research results to create public health disinformation in similar ways.
Now a third study engages in the same obvious form of unsupportable conclusions spun by deception and posing dangerous public health disinformation.
Let’s take a look.
As reported in America’s Newspaper –
It found “no significant differences” between virtual and in-person care in the number of drug overdoses, inpatient detox and rehab stays, and injection-related infections patients listed on their insurance claims.
. . . There were also no meaningful discrepancies in the tallies of outpatient visits, of opioid addicts returning after their initial treatment visit and of new prescriptions for opioid use disorder medications.
Meeting doctors by video or telephone “largely replicated the standard model for care delivery,” said lead researcher Michael L. Barnett, a professor at the Harvard T. H. Chan School of Public Health.
“no significant differences” between virtual and in-person care in the number of drug overdoses, inpatient detox and rehab stays, and injection-related infections patients listed on their insurance claims
We need to start at the beginning.
If you have never been involved in medical billing, you are not likely to be familiar with the nature of insurance claims, the sole source of data for this study.
So, about those “injection-related infections patients listed on their insurance claims” – there were none. That’s because patients don’t “list” or write or contribute anything to any medical insurance claim. Not ever. Nor are reports or lists or descriptions using words of medical conditions placed on those claims by the medical providers or the office staff preparing the claims or anyone else.
That’s because there are no words on those medical claims, or essentially none, apart from: words in the identifying names and addresses of the patient, medical provider or office, and insurance payer. That’s about it. Everything else entered on such claims is represented by dates or codes that are some combination of digits and letters – codes for diagnoses, for numbers of “units” provided, for modifiers describing how treatments/services were provided (e.g., in office vs by telemedicine) etc.
Get the picture?
The sole purpose of such claims – 1-page forms – is to trigger the flow of money from insurance payer to medical provider by making sure the information and codes look legit. Seem legit.
Again, medical insurance billing claims were the sole source of data for this study.
To make it a bit more clear – I could overdose by some combination of my prescribed MAT opioids and street drugs 5 times between telemedicine appointments with my prescriber, be revived each time in the homeless camp where I live or in my home by my associates, and none of that would ever be evidenced on an insurance claim. Because – as highly desired by me – none of those incidents would have ever led me to access or my insurance be billed for a medical service of any type.
Get the picture?
Right.
Naloxone use is booming by the way. It’s everywhere. Google it.
Its use in community settings – not during billable medical encounters – to prevent death due to high-risk opioid use surged over pandemic years, as seen in North Carolina –
Any reason to believe that patients being hooked up with opioids by their MAT prescribers and who by their misuse and high-risk use of those opioids are more likely to be at risk of adverse outcomes – would also be more likely to seek out a prescriber who will supply them under relaxed monitoring and safety standards including telemedicine? And would be more likely to avoid medical contact if possible for overdose versus revival without detection? Like telemedicine and social naloxone revival are forms of staying under the radar? Not having a free supply disrupted?
Anyone . . . anyone?
Well get to that, below, under “patient choice”.
Back to the lack of evidence from review of insurance claims for “OUD-related adverse outcomes” associated with high use of telemedicine interpreted in the original study as supporting telemedicine as safe for medical dispensing of controlled opioids to individuals with problem opioid use.
Reasons for concerns that such prescribing by use of telemedicine constitutes increasing, unmanaged patient risk come partly from the expressed concerns of the medical prescribers themselves – about not being able to discern via telemedicine connection (for example by mobile phone audio or audio and video connection) the types of clinical observations they would otherwise make during in-person meetings that might point to problem opioid use, return to high-risk use, other concerns.
Those adverse outcomes we are asked to believe were measured included “drug overdose, inpatient detoxification and rehabilitation center stay, or injection drug use–related infections”.
Let’s start with “inpatient detoxification and rehabilitation center stay”.
The concern, of course, is that the signs or objective evidence from in-person visits of return to high-risk opioid use while being provided prescribed, controlled MAT opioids and indicating possible need for higher level of care (residential) are more likely missed in telemedicine connections. That was the concern of the prescribing physicians surveyed in the Quest study noted above.
The lack of finding of a difference in access of higher level of care (detox, inpatient) tied to telemedicine is not evidence that telemedicine use and relaxed prescribing standards did not lead to greater incidence of high-risk use or “relapse”. Instead in the context of evidence establishing associations between relaxed standards and high-risk use points to predictable failure of telemedicine to detect signs of such harm, as predicted by the surveyed prescribing physicians. And by the evidence.
Authors of the study were quite circumspect in acknowledging the invalidating flaws of relying on insurance claim data to detect adverse outcomes, at least noting that “relapse” would not have been detected –
The outcomes capture only part of the complex process of access to care, and it is possible that telemedicine had benefits (or drawbacks) that we did not observe. While we were able to measure an individual’s receipt of MOUD, visit volume, and some OUD-related clinical events or adverse events, we were unable to measure receipt of long-acting buprenorphine implants and other important clinical outcomes, such as OUD relapse or patient functioning.
such as OUD relapse or patient functioning.
Right. “Relapse”, whatever that is taken to mean, would be objectively measured and detected by providing a random (unpredictable) urine drug screen. That’s not possible for telemedicine encounters, because even with clear signs detected via virtual connection, the patient would have time to access one of many resources available to hack (defeat) drug screens. In an in-person visit, the probability of a patient being able to defeat a drug screen is much lower, and refusal is often interpreted as a sign of problem use.
Drug screens would detect common practices of mixing prescribed MAT opioids with illicit abuse enhancers that increased risk of overdose, death by overdose, other adverse outcomes.
Random, accurate drug screens potentially also detect absence of the prescribed MAT opioid indicating its common use as currency (here, scroll down to “The bupe economy”) in economies of illicit high-risk opioid and other drug use.
Back to the unmeasured, predicted-to-be-undetected adverse outcomes
the study based its conclusions on – “drug overdose, inpatient detoxification and rehabilitation center stay, or injection drug use–related infections”.
We’ve seen that the data from insurance claims on detox or inpatient treatment stays provide no means of rejecting the hypothesis – and outcome predicted based on all relevant evidence – that any likely increases in high risk opioid use due to differentially diminished clinical capacity to detect signs of them in telemedicine sessions would have predictably resulted in lowered probability of referrals to higher levels of care. That is, if “relapse”, dangerous addition of illicit drugs, diversion of prescribed opioids to obtain “real dope”, physical signs of problem drug use or problems in functioning are missed, then telemedicine is generating high-risk outcomes that could not have been measured in this study.
We outlined above why overdose – showing up on an insurance claim only if it resulted in accessing medical care that was billed for, e.g. an emergency or urgent care visit that insurance would reimburse for.
But more and more overdoses are happening and being reversed outside of and without medical services over recent years driven by intensive community and integrated campaigns to train, make available, and ease general access to Naloxone, see here and here.
That leaves for us to consider the concern of “injection drug use–related infections”. The study, again, looked at insurance claim forms for medical encounters and treatment of that condition over the years separately March 14, 2019, to March 13, 2020 (“pre-pandemic”) and pandemic period March 14, 2020, to March 13, 2021.
Right.
So, if in fact loosened MAT opioid dispensing safeguards including prescription by telemedicine and initiation of MAT prescribed opioids without in-person contact instead by telemedicine beginning in the months of late March and increasing through the following year resulted in increases in high-risk opioid use including use by injection – when would we predict to see the associated increases in medical encounters for infectious injection-related disease?
I’m not medically trained, but can somewhat confidently surmise that any such increase in high-risk use including by injection – associated with increasingly relaxed prescribing safeguards over the pandemic calendar year 2020 – would evidence some lag in time over which increasing high risk use with some probability of new infection, then development of disease state, then development of symptoms would result eventually in an increase in medical encounters for the condition.
That appears to be what we see, as described in this recent post and illustrated here –
Those are pronounced surges by 2021 and into 2022 following the initiation and ramp up of increasingly uncontrolled and unguarded MAT opioid medical dispensing in 2020.
Equally invalidating of conclusions drawn in this study is the flaw of selection bias determined by patient choice.
Patients who are accessing doctor-dispensed controlled, addictive opioids as a way to engage in high-risk use to alter mood rather than eliminate high-risk use are differently motivated than patients accessing prescribed opioids to avoid high-risk use to reduce dependence and improve functioning and wellness. The former would need to minimize medical and other encounters that risk detection and interruption of their no-cost supply of opioids commonly mixed with illicit or other drugs for euphoric effect or as currency to get other more euphoric or potent drugs including fentanyl. The former would be strongly motivated to access the opioids with minimal risk by choosing prescribers using telemedicine. To decline medical attention after a community, social, or bystander revival of overdose by naloxone. To stay under the radar.
This study, spun in America’s top medical journal to support the continued use of telemedicine to supply to problem opioid users the controlled opioids established as fueling crisis provides no basis and no evidence supporting its conclusions.
Excepting one conclusion that strikes as fitting and congruent in an ironic, tragic, pathological way.
Meeting doctors by video or telephone “largely replicated the standard model for care delivery,” said lead researcher Michael L. Barnett, a professor at the Harvard T. H. Chan School of Public Health.
That may well be true, for the “standard model of care delivery” represented by the responses and practices of the medical prescribers described in the Quest survey – in a public health crisis, continuing to dispense controlled, addictive, abused opioids posing risk of harm and death believing they were by using telemedicine missing important clinical signs indicating increased patient risk.
