American Council friend, opioid advocate, and prolific writer Red Lawhern, Ph.D is at it again. The CDC left us with a huge mess last year with its Guidelines for prescription of opioid medications to adult non-cancer chronic pain patients. But, if you look deeper, it wasn't a simple mess. It would seem that the agency's conclusions, supposedly based on sound studies, were decided in advance and preordained. This would then add malfeasance to the stupidity that they have already displayed in spades. Red explains.
In recent months, a rising chorus of complaints has sounded on the March 2016 CDC Guidelines for prescription of opioid medications to adult non-cancer chronic pain patients. As one group of medical professional critics phrased the issues, the Guidelines are “Neat, Plausible, and Generally Wrong”. [Ref 1] Their piece and many others have enumerated a profound lack of balance, science and medical evidence behind the guidelines.
As a wise writer once informed us, “you can get data to say almost anything if you torture them for long enough”. This is precisely what the CDC has done.
Now comes yet another paper in the November 2016 issue of Pain Medicine which goes even further, to demonstrate what may be deliberate malfeasance and bias. The work is titled “Durations of Opioid, Nonopioid Drug, and Behavioral Clinical Trials for Chronic Pain: Adequate or inadequate?”
Extensively researched and referenced, the mission of this paper is to assess the validity of the literature review conducted by the CDC Consultants Working Group which wrote the Guidelines. The finding of this independent assessment is that CDC writers applied a criterion for weeding out studies of opioid effectiveness that they did not apply to non-opioid and behavioral treatments which they recommended in preference to opioids.
CDC eliminated all studies of opioids which lasted less than a year, but failed to apply the same criterion to non-opioid therapies. The disqualifying imbalance incorporated in this literature review is revealed in an extract from the abstract of the paper [Ref 2]
A recent US federal review and clinical guideline on opioids for chronic pain asserted that the literature contributes no evidence on efficacy because all trials had "inadequate duration." To explore the evidence, we examined durations of studies on opioid, nonopioid drug, and behavioral therapies for chronic pain….”
No common nonopioid treatment for chronic pain has been studied in aggregate over longer intervals of active treatment than opioids. To dismiss trials as "inadequate" if their observation period is a year or less is inconsistent with current regulatory standards. The literature on major drug and nondrug treatments for chronic pain reveals similarly shaped distributions across modalities. Considering only duration of active treatment in efficacy or effectiveness trials, published evidence is no stronger for any major drug category or behavioral therapy than for opioids.”
As they now stand, the Guidelines seem designed to deliberately confuse an artificially created “absence of proof” for opioid effectiveness, with “proof of absence” for effectiveness. It appears that the CDC set out to discredit the effectiveness of opioids in long term use -- regardless of the available evidence -- using a scientifically invalid process called "cherry picking."
What is especially damning in this finding is that the principal writer of the CDC guidelines clearly knew better. This investigator had also contributed to an earlier 2014 “evidence report” to the CDC. The earlier systematic review of the effectiveness and efficacy of opioids was based upon the best available evidence, and identified dozens of clinical trials and systematic reviews of this topic. Although conclusions were guarded due to the poor overall quality of the literature… earlier reviews concluded that selected, carefully monitored patients might benefit from such therapy. [Ref 3]
However, this conclusion was totally absent from the 2016 guidelines.
In other words, the writers of the CDC standards appear to have biased their report to support a political agenda. When the data didn’t support their preconceived position, they down-selected the data until it could be construed to label opioids as both dangerous and ineffective treatments for pain.
This is more than a scientific quibble. The Guidelines are being incorporated into highly restrictive State laws that are forcing tens of thousands of patients into agony by withholding the only medical care that has worked for them. Fear of malicious prosecution by the DEA is causing US doctors to leave pain management practice in droves. Suicides by people unable to bear their unbearable pain have already happened and more should be anticipated.
It is time for the CDC to withdraw a fallacious opioid treatment standard which is causing great harm, and to start the project over. This time, a wider range of professional stakeholders as well as chronic pain patients themselves should be among the writers group. And all treatments for chronic pain should be compared on a common baseline.
- “Neat, Plausible and Generally Wrong – A Response to the CDC Recommendations for Chronic Opioid Use, Stephen A Martin MD, EdM, Ruth A Potee, MD DABAM, and Andrew Lazris, MD https://medium.com/@stmartin/neat-plausible-and-generally-wrong-a-response-to-the-cdc-recommendations-for-chronic-opioid-use-5c9d9d319f71
- PubMed database at the US National Library of Medicine -- from “Durations of Opioid, Nonopioid Drug and Behavioral Clinical trials for Chronic Pain” Citation: Pain Med. 2016 Nov;17(11):2036-2046, BO, Barreiro AE1, Bradshaw YS, Chui KK, Carr DB. https://www.ncbi.nlm.nih.gov/pubmed/27880651
- “CDC Manipulated Data to Deceive” – by Zyp Cyk, in “EDS Info (Ehlers-Danlos Syndrome)”, quoting at length from “Durations of Opioid, Nonopioid Drug and Behavioral Clinical trials for Chronic Pain” https://edsinfo.wordpress.com/2016/11/29/cdc-manipulated-data-to-deceive/#comment-7816