By Richard “Red” Lawhern, PhD
I have tracked down some of the “research” behind the so-called CDC practice guidelines published in March 2016. And the research is an absolute CROCK!
Try to hang in here with me as I explain why.
Particularly astounding is the biased and unscientific way that the Consultants Working Group arrived at their recommendation that 90 Morphine Milligrams Equivalent Per Day (MMED) should be established as an upper bound on acceptable prescription practice.
Deborah Dowell, a Senior Medical Advisor in the CDC Division of Unintentional Injury prevention, wrote a briefing of the Consultants Working Group major recommendations that includes a summary chart labeled “Relationship of prescribed opioid dose in MME and overdose risk.”
In that chart, four published studies are compared. Apart from the unexplained protocols behind those studies, the results are internally inconsistent and wildly at variance between the four. One study of reveals a leveling off of overdose risk at 50 mg Morphine Milligram Equivalent Daily Dose, while the others claim a significant further increase in risk at 100 MME or higher.
What we don’t know is HOW MUCH higher the dose increase was in each of the four studies, OR on which opioids.
We also don’t know whether the protocols actually measured what they purport to measure, or were even mutually compatible.
Finally, there is a more than four-to-one spread in outcomes between the three studies at dose levels above 100 MME. That spread of outcomes should be deeply suspicious in a document which is claimed to support a “practice guideline.”
There are literally a whole HOST of unanswered and potentially damaging questions of methodology and interpretation wrapped up in this chart and the guidelines. Among the most fundamental questions is “what is the variability of effects versus MME in large patient populations?”
Anyone who understands the least thing about opioids should know that there is a very wide range of variability in individual patient response to opioids. But that variability isn’t even mentioned in the presentation OR the guidelines. Instead, the CDC is now training thousands of doctors in a fictitious standard of risk that assumes patient responses can be meaningfully averaged — which they clearly can’t.
Medscape has also published an excellent article titled “The Myth of Morphine Equivalent Daily Dosage” which I believe needs to be required reading for anyone who writes in this field.
A strong case can be made that the basic research used by the CDC to justify restrictive guidelines on prescription of opioids is not only scientifically weak but has been cherry-picked by a group of people who were NOT qualified in pain management, to support a totally fraudulent guideline.
In short, if these people were at all qualified, then they lied. And if they weren’t qualified, then they had no business pretending that what they came up with was scientific in any way.
Richard A. Lawhern has volunteered for 20 years as a non-physician author, webmaster, and advocate for chronic neuropathic face pain patients.
Here are the published studies used for this article:
Opioid Dose and Drug-Related Mortality in Patients With Nonmalignant Pain