Contradictions in CDC Guidelines

Seedy Sea or CDC? by Jeffrey Fudin – January 12, 2016

This review of the guidelines was written by a professional pharmacist together with his students.

Upon review of the Proposed 2016 CDC Guideline for Prescribing Opioids for Chronic Pain we find various contradicting statements based on the presented evidence and the recommendation strength

According to the National Guideline Clearinghouse, “level A rating requires at least two consistent Class I studies”.

However, all of the 12 recommendations provided are based on case series (level 3 evidence) or expert opinion (level 4 evidence) yet assigned a grade A recommendation

For instance, according to the proposal, providers

“should implement additional precautions when increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should generally avoid increasing dosage to ≥90 MME/ day (recommendation category: A, evidence type: 3)”.

The recommendation is based on one randomized unblinded study8 in 135 patients (94% males; 74% have musculoskeletal pain) who received 40 MME/day compared to 52 MME/day, yet the recommendation was generalized to “chronic non cancer pain” and recommended “to avoid increasing dosage to ≥90 MME/ day” which was not evaluated by the referenced study.

Considering the Rennick study, [Rennick A, Atkinson T, Cimino NM et al. Variability in Opioid Equivalence Calculations. Pain Med. 2015 Sep 9. doi: 10.1111/pme.12920.] it is of particular importance that the standard deviations for fentanyl and methadone “morphine equivalents” will exceed the CDC cut-off by CDC’s own definition of morphine equivalent

Looking at this another way, one clinician’s MME in this case could be 59 MME and another clinician might assign the equivalence of 293 MME, a range spanning 234mg of morphine equivalent.

Just the standard deviation alone is a recipe for death in the untrained professional.

Given

  1. lack of standardization,
  2. potential drug interactions,
  3. patient’s physical features such as height and weight, gender,
  4. end organ (dys)function,
  5. coupled with patient individualized pharmacokinetics due to polymorphism,

we respectfully disagree with utilizing a standard cut-off for morphine dose

instead of improving the knowledge of healthcare professionals, the guideline is placing the burden on patients by reducing opioid access for patients that may legitimately require them

The Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain recommendations may place restrictions on personalized patient care and prevent clinicians from providing high quality of care.

The variability in opioid conversion tools, altered pharmacokinetics; polypharmacy, and drug-drug or drug-food interaction potential, could all complicate medication management within the chronic pain population.

Rennick A, Atkinson T, Cimino NM et al. Variability in Opioid Equivalence Calculations. Pain Med. 2015 Sep 9. doi: 10.1111/pme.12920. [Epub ahead of print]

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3 thoughts on “Contradictions in CDC Guidelines

  1. Kathy C

    There have been zero “Journalists” or Corporate Media outlets explaining this. Even my Congresswoman repeated the same Narrative about the “Opiate Epidemic.” That narrative was untrue in our State, where they have had a drug problem for a while. This country has gone crazy. People should really be scared, not of just the Opiate Guidelines, but the Medical and Pharma Industries. The same kind of misdirection has been used to market a lot of their “Products.” The Opiate Hysteria, has led to more deaths from NSAIDs, and the Prescriptions for various Anti Depressants, muscle relaxers and even Atypical Anti Psychotics. They just won’t be counting the dead, the distress caused or the dead.
    We are in the Post Fact, Post Science Era. I finally got another Surgical Referral, where i found out that i just had “Arthritis.” This is not the first time that the “Specialist” deliberately left out my Imaging and Surgical History. Apparently a Doctors visit is now like “Groundhog Day” the clock resets, and it is as if the last 20 years never happened. The last surgery I had was with one of the Surgeons at that Group. Apparently they can’t even refer to the previous surgery, it might be bad for the HMO’s bottom line. Fortunately I had no expectations, I only wanted and alternate or second opinion. Perhaps the “Back Pain” issue is easier to dismiss, since they believe they are doing us a favor. In a way they are, the Failure Rates at this Hospital or high, along with infections rates, and general incompetence. It seems like Misdiagnosis is the norm now, there is no oversight, or even an expecation of saving money by correctly diagnosing things.
    This is a fairly small town, where the local Hospital, is part of a multi billion dollar national Religious non profit. They have bough off our politicians, health department, and the Medical Board is a protection racket. This hospital is a monopoly here. There won;t be any “local Journalism’ either. The local paper does a lot of Advertising and PR for this hospital, and often gets out in front of National Stories with well placed promotional “Articles” which are just PR spin. This should terrify our local populace, instead they have no idea how dangerous it is. The Misdiagnosis is not limited to pain related issues. It covers every kind of Health issue, form Heart disease to cancer. Of course there haven’t been any studies done on how much this costs. It is most certainly more expensive, not to mention the distress it causes. We should all be scared, due to the loose reporting requirements, they don’t even have to count the dead.

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  2. Pingback: Updated: Evidence Against CDC Opioid Guidelines | EDS and Chronic Pain News & Info

  3. Pingback: Is my doctor’s guideline for my treatment right for me? | EDS and Chronic Pain News & Info

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