How Opioid Prescribing Guidelines Use Pseudoscience — Pain News Network – By Michael Schatman and Jeffrey Fudin, Guest Columnists – March 30, 2016
Recently, we (along with our colleague, Dr. Jacqueline Pratt Cleary) published an open access article in the Journal of Pain Research, entitled “The MEDD Myth: The Impact of Pseudoscience on Pain Research and Prescribing Guideline Development.”
In this work, we address the issue of how governmental and managed care opioid guideline prescribing committees use the flawed concept of morphine-equivalent daily dose (MEDD or MME) to arbitrarily place limits on the amount of opioids that a clinician “should” prescribe to any patient with chronic pain — as if all patients were identical.
We believe that by arbitrarily limiting the “appropriate” amount of an opioid that a physician should prescribe to a patient (which all recent guidelines – including the CDC’s guideline – call for), physicians feel compelled to limit the amount of opioid analgesic therapy that they prescribe – irrespective of the amount of relief that a patient with chronic pain receives.
Is this good pain medicine practice? Hardly. However, in the eyes of the anti-opioid zealots who have dominated recent opioid prescribing guideline committees, their agenda of taking opioids out of the picture altogether for patients with chronic pain is evidently more important than is patient well-being.
Aside from the pharmacogentic issues, we also have conversion issues because of simple mathematics. We cite data that clearly shows there are no universally accepted opioid equivalents. Even if there were no issues with genetic variability, there is still no consensus on how to mathematically convert one opioid to another.
Will the anti-opioid zealots admit that they have a non-scientifically-based agenda to take opioids out of the American chronic pain management discussion? No – because if they were to do so, they would be seen as cruel or uncaring. Rather, they emphasize that their concerns are for the well-being of patients and society. Their logic suggests that if clinicians stop prescribing opioid analgesics altogether, then the unfortunate number of opioid-related overdoses and deaths will decrease dramatically.
As scientists and practitioners who work with patients with chronic pain every day, we see the damage in which these guidelines result.
Despite being touted as voluntary, physicians fear regulatory sanction should they disobey them, and accordingly are taking opioids out of their treatment armamentaria.
Are we suggesting that opioid therapy be considered the first-line treatment for chronic pain? Certainly not.
Chronic opioid therapy should be considered only when other available treatments have proven ineffective.
However, given the for-profit health insurance industry’s business ethic of cost-containment and profitability, insurance access to many treatments that may be superior to opioid therapy are out of reach for the vast majority of Americans. We also have to remember that 20% of Americans live in underserved areas in which more sophisticated and safer treatment options are completely inaccessible.
We are concerned about this ethical imbroglio, as it is extremely damaging to our patients who suffer from the disease of chronic pain. To quote from our article, opioid prescribing guideline committees’ continued utilization of the antiquated and invalid concept of MEDD is “scientifically, ethically, and morally inexplicable.”
As a result of this highly unethical practice, “impressionist lawmakers and anti-opioid zealots are basing clinical policy decisions on flawed concepts that ultimately could adversely affect positive outcomes for legitimate pain patients.”
It’s difficult enough to suffer from chronic pain under the best circumstances. What patients with pain and society in general certainly don’t need is a group of smug inexperienced pain policymakers, politicians, and managed care administrators impacting public policy by evoking pseudoscience.
There is sufficient good science being published that demonstrates that their reliance upon the MEDD myth is highly disingenuous.