Predicting Our Way Out Of A Crisis
The belief that we can “Minority Report” our way out of a crisis of overdose deaths is not only wrong, it’s deeply dystopian.
A new product called AvertD has recently been approved by the FDA.
As an emergency and addiction medicine physician, this worries me a lot, actually.
These developments can have disastrous unintended downstream consequences and can very easily lead to increasing stigma and under-treating pain. We cannot adequately predict future outcomes, even with genetic testing, and I don’t believe tools like this have significant validity. As noted on MedPage Today, the company which created the test, SOLVD, presented results of a single observational study that utilized machine learning as a predictive algorithm to the FDA which demonstrated a sensitivity of 82.76% and a specificity of 79.23% for detecting opioid use disorder. This level of specificity for what should be considered a critical clinical decision instrument would be considered unacceptable by most standards for predicting bad outcomes.
For example, we use risk stratification clinical decision instruments all the time in emergency medicine to aid our decision making. Do you think discharging someone having chest pain with less than 80% certainty that they were not having a heart attack would be acceptable? No, absolutely not.
Then why would we be willing to accept less than 80% certainty in an observational study to appropriately predict if someone might develop opioid use disorder? How will that solve for anything other than stigmatize patients, lead to misdiagnoses and under-treatment?
Regardless, even with 100% accuracy, this would not and will never “solve” the crisis of overdose deaths.
The reason is because we do not have an “opioid crisis” we have a crisis of failed policies.
In the end, the fact remains that the use of psychoactive substances or means to alter our perception of reality is a natural response to existing, and substance use disorders always have and always will be a potential future consequence of the complex web of genetic plus environment plus exposure. We cannot control our own genetics, and while we can seek to appropriately avoid harmful exposures, we will never be able to eliminate them. What we really need to focus on is correcting to correct the other part of that equation and seek to improve upon the environment — socially, clinically, and politically. Changing the clinical environment to improve care for people with substance use disorder includes a non-stigmatizing treatment of all of our patients, whether with pain and potentially treating them with opioids, and taking a harm reduction approach to ensure that if they do develop a substance use disorder, that the recognition of their medical condition does not impede their life or their care and that they can adequately access treatment, just as we should believe for all other medical conditions.
I come from a strong family history of addiction, including alcohol and opioid use disorder. I can all but guarantee that I would flag any and all of these sorts of tests for just about everything. Yet, I’ve had 10 operations including multiple neurosurgical operations and have been given opioids plenty of times. I drink alcohol socially. I have developed neither alcohol nor opioid use disorder.
Of course, another factor of the complex web that is “addiction” includes the environmental factor. While I might flag every other aspect of genetics and exposure, I wouldn’t raise any flags for any environmental factor for any test of addiction, because as a rich white kid from the suburbs of San Francisco, I was playing on easy mode, I already had a lead off third base. That’s also why my father, who was a prosecutor for San Mateo county, could manage to have alcohol use disorder, return to use and seek treatment a few times over his career, and even while successfully maintaining abstinence from alcohol could instead end up railing lines of oxycodone while not suffering legally, financially, or occupationally.
I understand the impetus to want to be able to predict bad outcomes and stop problems before they start. Dystopian science fiction the likes of “Brave New World” through “Minority Report” wouldn’t exist if not for that motivation. However, the descriptor “dystopian” wouldn’t apply if the context of that science fiction environment were not deeply concerning or unjust or malevolent. We can either seek to recreate that dystopia, or actively fight against that trajectory. We have a choice, and that is based on the environment we choose to create.
The fact is that we don’t have an “opioid crisis,” we have a crisis of overdose deaths due to failed policies. Instead of understanding and addressing the root causes, our governmental agencies appear to prefer to double down on the drug war and seek to Minority Report their way out of a problem of their own creation.
You can find me at tnicholsmd.com or find my podcast as well as harm reduction and recovery resources at RecoveryReform.com.
