AAPM defends opioid use against PROP petition

American Academy of Pain Medicine Response to PROP Petition to the FDA That Seeks to Limit Pain Medications for Legitimate Noncancer Pain Sufferers  – | August 15, 2012

This is a letter sent by the AAPM to the FDA in 2012, rebutting a petition to restricts opioids submitted by PROP. It explains why the proposals are scientifically and statistically invalid, based on unrealistic assumptions, and in some cases, are even irrational.

Here is the complete text of the letter (with my emphasis):

Dear FDA Officers:  We write to respond to the petition submitted by Physicians for Responsible Opioid Prescribing requesting label changes from the FDA in connection with certain opioid products. 

The American Academy of Pain Medicine shares the commitment of the petitioners to find ways to curb prescription pain medication harm. However, we have serious concerns about the petition and believe that the rationale for the requested changes is seriously flawed, potentially harmful to patients with debilitating pain conditions for whom opioid therapy is indicated and without substantive scientific foundation.

Limit to Severe Pain

The petitioners request that the Food and Drug Administration (FDA) strike the term “moderate” from the indication for noncancer pain.

The American Academy of Pain Medicine (AAPM) believes that there is no clinical method to differentiate moderate from severe pain other than patient report.

Further, there is often substantial variance over minutes, hours, and days in pain intensity reports; pain is not a static condition, nor is there any scientific evidence to show that moderate pain has any more or less adverse outcomes than the labeling of pain as “severe.” Further, for years, clinical trials leading to the approval of many of the currently available opioid formulations have used “moderate-to-severe pain” as the criterion in opioid efficacy studies, not severe pain only. As the petitioners are basing their recommendations on what they believe is a lack of evidence, it seems reasonable to call for evidence to support this recommendation that the moderate-to-severe criterion now be changed to “severe pain.”

Limit Dose to Less than 100-mg Morphine Equivalent

The petitioners also suggest the FDA restrict labeled indications for the designated opioids to a maximum daily dose of 100 mg of morphine equivalents for noncancer pain.

This dose limit is an arbitrarily chosen number that disregards pharmacokinetic, pharmacodynamic, and pharmacogenetic differences among patients and interindividual variability in opioid response and analgesia.

As well, setting a 100-mg ceiling dose could be dangerously misleading, implying that doses below 100 mg are inherently safer than higher doses in any given individual or population of patients. The petitioners present as support for this restriction studies showing higher doses contribute to more deaths. Although these studies have flaws that are addressed later, it is certainly likely that there is an overall correlation between dose and morbidity. However, this correlation is not a simple one, with several likely confounding variables including medical and psychiatric comorbidities, and drug–drug interactions, among other factors.

These elements of clinical assessment, dose titration, monitoring, and structured follow-up cannot be managed by designating an arbitrary dose ceiling. Rather, appropriate dosing requires education, training, and experience consistent with the larger sphere of complex chronic disease management.

It is our respectfully stated view that the petitioners are seeking a simple solution to a complex problem and, in so doing, misdirecting the more appropriate course of action that is needed to rectify gaps in prescriber capacity to prescribe safely.

Very important additional factors that have been recognized to be associated with unintentional overdose deaths have not been addressed by the petitioners’ requests.

Initiating and/or rotating to methadone and other long-acting/extended-release opioids present key principles of prescribing not recognized in the 100-mg ceiling limit [1,2]. The Centers for Disease Control and Prevention (CDC) reports that a third of opioid-related overdose deaths involve methadone [3]. For instance, if every prescriber knew how to safely prescribe methadone, which has been associated with a disproportionate number of opioid-related deaths during the last decade, we could rapidly reverse the incidence of prescription opioid deaths. Similarly, there is substantial evidence that benzodiazepines— and perhaps coadministration of other central nervous system depressants—are major contributors to the deaths associated with opioids.

The petitioners’ recommendations fail to address this evidence and thus may lead to a false sense that dose is the issue not the problematic interactions of various drugs throughout a range of doses.

Limit FDA Approval for Noncancer Pain

The petitioners request a maximum duration of 90 days for continuous (daily) use of opioids for noncancer pain.

Pointedly stated, this change effectively eliminates the use of opioids for chronic noncancer pain.

This is a radical position that would leave an untold number of pain sufferers with few treatment options given the on-label restrictions imposed by many insurers, including Medicare/Medicaid.

The Washington Legal Foundation, a nonprofit organization based in Washington, D.C., recently published an article predicting an exodus of physicians from the pain management specialty and a disproportionate negative impact on poorer citizens who need pain care as a result of new stricter opioid regulations in Washington State. The following paragraph is a quote from that article:

Washington Department of Health officials, recognizing that opioid therapy will become increasingly difficult to obtain, proposed that chronic pain patients should explore alternative treatments for relieving pain, such as “physical therapy, yoga, massages or acupuncture.”

Unfortunately (and ironically), a majority of these alternative medicine options are not covered under Washington’s Medicaid program because they are not clinically proven, rendering these “choices” financially unrealistic for many patients who suffer from chronic pain [4].

Further, the Foundation averred that the regulations impose a strong prejudicial bias, as they aim to deter opioid-related harm by targeting those with chronic noncancer pain, while ignoring problematic consequences of opioid prescribing in acute care venues, emergency departments, surgical settings, cancer pain treatment centers, and in palliative care.

While we believe that there is a need to balance risks to patients with pain and potential harms to the general public, we construe the terms requested by the petitioners as weighing excessively against the target population (patients with moderate-severe chronic debilitating pain) for whom the currently approved long-acting opioid analgesics are indicated, insofar as prescribers will seek safe harbor for prescribing within these limits (dose and duration) as labeling has become the de facto standard of care defining “legitimate practice.”

Under the highly interpretable language of the Controlled Substances Act, which speaks of “legitimate medical purpose,” it creates additional risk for prescribers to deviate from language within 1260 Fine and Webster the labeling. Therefore, even though neither the FDA nor the Drug Enforcement Administration regulates the practice of medicine in this particular sphere, they powerfully and pointedly affect the practice of medicine

Prevalence of Opioid Addiction in Patients Treated for Pain

The petitioners cite that over the past decade, a fourfold increase in the prescribing of opioid analgesics has been associated with a fourfold increase in opioid-related overdose deaths and a sixfold increase in individuals seeking treatment for addiction to opioid analgesics.

We acknowledge the problem with opioid-related harm and agree that more must be done to reverse these problems. However, there are two separate populations that need different solutions: the population of patients treated with opioids for pain and the population of nonmedical users of opioids.

Evidence from the National Survey on Drug Use and Health suggests more than two thirds of nonmedical users get opioids from family or friends [5]. Much of society’s problem with nonmedical use is due to leftover medication stemming from the prescribing of more opioids than necessary for acute and trauma pain, not chronic noncancer pain [5,6]. The measures proposed by the petitioners will not address this problem. It would be an error to try to solve the problem of nonmedical use by denying people with pain access to medication.

Industry Marketing of Opioids

The petitioners state that the prescribing of opioids increased over the past 15 years in response to marketing efforts that minimized risks of long-term use for chronic noncancer pain and exaggerated benefits.

AAPM believes the marketing issue needs ongoing vigilance, but making medications more difficult to obtain by people who benefit from them will not address the marketing issue. A clear distinction must be made between the very important public health campaign over recent years to increase awareness about the adverse consequences of undertreated chronic pain and the critical elements of assessment and optimal management vs marketing and promotion of opioids by pharmaceutical companies.

These issues are sadly conflated in the petition and, as the foundation for the requested changes in labeling, lead to specious conclusions and solutions. Theirs is truly a “throw the baby out with the bathwater” approach. We suggest that there are better means to the mutually agreed-upon salutary ends of safe and effective use.

Opioids and Long-Term Safety and Effectiveness

The petitioners contend that long-term safety and effectiveness of managing chronic noncancer pain with opioids has not been established.

Indeed, little research has focused on the question of long-term effectiveness of opioid therapy for chronic noncancer pain. The majority of recommendations from a practice guideline endorsed by the American Pain Society and the AAPM are based on lower quality evidence [7]. At best, the literature has shown inconsistent effectiveness of opioids for chronic pain [8].

A systematic review of patients with chronic back pain by Martell et al. found opioids relieved pain for up to 16 weeks but that long-term benefit was uncertain; furthermore, patients exhibited a high incidence of substance use disorders [9].

However, comorbid conditions are frequent with chronic back pain, including major depression in 18–32% of patients [10]. Therefore, it may be unwise to use these patients as a yardstick by which to measure the likelihood of success with opioids in all patients. Some evidence suggests that patients with depression, regardless of pain condition, do not respond as well to opioid therapy as nondepressed patients [11]. Perhaps, it is patients without comorbid disorders who achieve the most benefit from opioid therapy. Therefore, screening of patients for mental health and substanceuse comorbidities may be the most important step in assuring proper candidate selection for long-term opioid therapy.

*However, it is clear from clinical experience and the literature that there are many patients who do benefit.

*Even though opioid trials are plagued by high dropout rates due to adverse effects or ineffective analgesia, a subset of patients continues to achieve meaningful pain control long term [12].

In patients who had been taking opioids for chronic pain for an average of 2 years, when the treatment was suddenly stopped, the patients experienced more pain and a reduced quality of life—not an uncontrolled craving for drugs [13].

Furthermore, the degree of pain relief that is meaningful to the patient must be taken into consideration. If patients do not achieve effective pain relief with one opioid, rotation to another frequently produces greater success [14].

For many of these patients, other treatments have failed, and restrictions on the availability of opioids within a full potentially therapeutic range sentence them to suffer needlessly. In other words, it is equally detrimental to generalize from successes as it is from failures.

In the absence of highly sensitive and specific predictive factors, clinicians must rely on well-defined risk mitigation practices that have emerged in order to create the most propitious benefit-to-harm ratio for each patient under treatment. This cannot be adjudicated through a priori constrained dose and duration parameters.

The petitioners cite recent surveys of chronic noncancer pain patients receiving chronic opioid therapy showing that many continue to experience significant chronic pain and dysfunction.

The same could be stated about the plight of most patients with chronic progressive conditions treated with well-accepted therapies, including those with chronic obstructive pulmonary disease, heart failure, or neurodegenerative diseases, among many others.

For patients living with chronic pain, the goal of opioid therapy is not to eliminate all pain—which is currently impossible in most instances—but to help improve 1261 Editorial and restore function and optimize quality of life to the greatest extent possible.

Expecting any treatment, including opioids, to eliminate intractable pain is unrealistic, as much so as expecting miraculous recovery of muscle control in multiple sclerosis patients given the limitations of current treatments.

Iatrogenic Addiction from Opioids Used to Treat Chronic Noncancer Pain

The petitioners argue that recent surveys using Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria found high rates of addiction in chronic noncancer pain patients receiving chronic opioid therapy.

However, the interpretation of the data depends on the definitions and meanings of aberrant behaviors, misuse, use, and addiction. All of these terms do not have the same clinical implications. Boscarino et al. compared diagnostic criteria for opioid dependence contained in the fourth edition of DSM (DSM-IV) with those in the updated DSM-V for an opioid-use disorder [15]. This analysis was accomplished by combining the prior categories “abuse” and “dependence” into a single opioid-use disorder category and then grading the severity. This move away from indistinct categories, such as “abuse,” reflects evolution in neuroscience and empirically based understanding of the relationships among a given chemical, an individual’s genetic and environmental circumstances, and the disease of addiction.

However, many of the criteria investigators used to identify opioid-use disorders resemble common behaviors of patients with uncontrolled pain (e.g., taking more than intended, unsuccessful attempts to cut down intake), casting doubt on the reported signs of “addiction.” Each of the criteria in the DSM-V could result from an entirely different cause or motivation when observed in patients with pain than in nonmedical users seeking the same drugs.

If the study is interpreted to say 35% of patients may have trouble managing opioid intake, it is consistent with prior studies assessing problematic opioid-use behaviors. Some of these behaviors can be managed with structured approaches to care and appropriate monitoring.

But, it is false to conclude that this number equates with the prevalence of “addiction” or that addiction is an inevitable consequence of chronic opioid therapy in patients without predisposing factors. This distinction is of great importance because it implies very different approaches to care in distinct populations of patients (based upon risk assessment) and prognoses.

Fleming and colleagues conducted 2-hour interviews with 801 patients receiving long-term opioid therapy who were being treated by 235 Wisconsin physicians:

They found rates of

  • 26% for purposeful oversedation,
  • 39% for increasing dose without prescription,
  • 8% for obtaining extra opioids from other doctors,
  • 18% for use for purposes other than pain,
  • 20% for drinking alcohol to relieve pain, and
  • 12% for hoarding pain medications” [16].

The sum of these aberrant behaviors is troublesome. Yet, the study cited in the excerpt by Fleming et al. has also frequently been cited as showing that opioid-use disorders—a term usually equated with “addiction”—were 3.8% in the sample studied [17].

For patients who are able to sustain long-term benefit from opioid therapy, the risk of addiction appears low in some studies. In a review of 26 studies (total enrollment of participants: 4,893) that reported data after 6 months of chronic pain treatment with opioids, signs of iatrogenic addiction were reported in 0.27% of participants [12]. Such results suggest that chronic opioids cannot be assumed to be the wrong treatment for all patients at the start.

Again, we conclude that the changes requested by the petitioners do not address the far more salient issue of prescriber education and adherence to principles of practice, including ongoing monitoring for aberrant behaviors and early signs of addiction, while it provides a false sense of security for patients and practitioners that lower doses or durations of treatment are protective.

The Question of Curing Chronic Pain and Complicating Comorbidities

The petitioners also argue that patients who remain on opioids for extended periods justify a need to change the label.

They cite a large sample of medical and pharmacy claim records showing that two thirds of patients who took opioids on a daily basis for 90 days were still taking opioids 5 years later. [duh, that’s why it’s called chronic pain]

It is unclear what this statement of finding is meant to indicate. How does this differ from patients on insulin, statins, antihypertensives, etc.?

Chronic pain is in most cases just that: a chronic disorder that may be life long often due to damage sustained to tissues or the nervous system. We fail to see the rationale behind a delimiting label change for the specific treatment of any chronic condition in patients who are using their prescribed medication safely and effectively (i.e., meeting defined goals of treatment), regardless of the chronic condition, including chronic pain.

It is correct, as the petitioners argue, that some evidence shows that patients with mental health and substance abuse comorbidities are more likely to receive chronic opioid therapy than patients who lack these risk factors, a phenomenon referred to as adverse selection.

However, people with pain and mental health disorders also deserve to have their pain treated.

This is an increased risk population that requires vigilance and more medical involvement, not less. It is acknowledged that this population is more difficult to treat largely because it is hard to know when the drug is being used for pain or for the mental disorder or both.

Some of these patients need strict monitoring, and some should not receive long-term opioids. This is where we need more research and medical training, but it is not a reason to deny people with pain an opioid if it is appropriate

Role of Opioid Dose in Overdose Risk

The petitioners cite three large observational studies published in 2010 and 2011 that found a dose-related overdose risk in chronic noncancer pain patients on opioid therapy.

Close examination of these studies fails to show evidence that dose alone was the reason for overdose deaths.

In one of the cited studies, Bohnert et al., investigators retrospectively studied the Veterans Health Administration (VHA) database and reported that the rate of fatal overdose among patients treated with opioids was 0.04%, with a higher risk among patients prescribed doses of 100 mg per day compared with those prescribed 1 to <20 mg per day [18].

In Gomes et al., a study of Canadians on public assistance, doses of >200 mg morphine equivalent per day were associated with nearly three times the risk of opioid-related mortality compared with doses of <20 mg [19].

These reports contain a high number of confounding factors that include a high prevalence of benzodiazepine involvement in fatalities in the Gomes study and a heterogeneous population with many comorbid psychiatric and substance-use disorders in the Bohnert study [20]. In criticizing the “data mining” approach used by investigators, Leavitt wrote, “It also is curious in the [Bohnert] study that the greatest absolute number of overdose deaths (43.5%) occurred when the maximum prescribed daily opioid dose was listed as 0 mg/day. The authors had little explanation for this, other than many patients might have obtained opioids from non-VHA healthcare providers, and some might have saved opioids from a prior prescription or obtained them from illicit sources” [20].

Methadone and Suicide Contribution to Overdose Deaths

Furthermore, the studies failed to analyze methadone as a medication shown by the CDC to contribute to a disproportionate number of overdose deaths when compared with the quantity of methadone prescriptions [3]. Both studies specifically excluded methadone from analysis, explaining that methadone equates poorly to morphine equivalents and that it is used more frequently (in Canada, the setting of the Gomes study) for addiction treatment than pain. Importantly, there is no comparative data presented on the risk or incidence of suicide resulting from inadequate pain control recognizing that this risk in patients with chronic pain is double the control population rate.

We infer that it is premature to conclude that an arbitrary dose limitation in opioid labeling will beneficially reduce mortality, but there is good cause for concern that such a maneuver, well intended as it may be, could have serious unintended consequences, including inciting morbidity and mortality among chronic pain sufferers due to uncontrolled pain. This remains an important area for much needed research and professional education.

Opioids and Seniors

Finally, the petitioners cite studies reporting that at high doses, opioids are associated with increased risk of overdose death, emergency room visits, and fractures in the elderly.

Indeed, higher doses of opioids are associated with increased risk of harm in a subset of the pain population. However, as we have cited earlier, dose is only one factor contributing to the harm associated with opioids.

In the study the petitioners cite, associating high dose to increased risk of fractures in elderly, propoxyphene was the opioid most commonly prescribed. This opioid is not considered highly potent and is no longer on the market.

In addition, the study cited by the petitioners has been aptly criticized for serious flaws in the analysis of the data [21]. On balance, great caution should be exercised in interpreting conclusions.

We advocate opioids generally be limited to patients that have failed other safer and more effective therapies.

But specifically, physicians involved in the care of older individuals need to understand the unique aspects of geriatrics and pharmacotherapy, and through this understanding provide informed, salutary treatment options and monitor appropriately to prevent adverse events.

This is a population at risk for falls and fractures, including as a result of undertreated pain. It is the compact between physician and patient (or proxy) to determine how best to strike the optimal balance in ascertaining treatment decisions. When an approved drug is deemed appropriate based upon a patient’s specific circumstances and in the absence of any contraindications, the treating physician must have the latitude to determine what serves the best interest of her patient. This is the essence of the practice of medicine.

We welcome the opportunity to participate in a dialogue with FDA and other interested parties, including prescribers, pharmacists, behavior health practitioners, other healthcare professionals, the scientific community, government agencies, and patients, in reaching a positive outcome for those Americans who suffer unnecessarily with chronic pain.

 

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6 thoughts on “AAPM defends opioid use against PROP petition

  1. Kahty C

    Thanks Zyp!

    It is about time they came out with an Evidence Based Scientific Response. The Hysteria has created a climate of fear that won’t be fixed in years.

    Liked by 1 person

    Reply
    1. Zyp Czyk Post author

      Re “won’t be fixed in years.” – that’s what’s so frightening. Many of us cannot tolerate waiting for years without pain relief.

      Sadly, even “evidence” can be manipulated to show bias these days. How facts are portrayed is critical and seems to be influenced by various powers, usually money, to support the desired or popular bias.

      Like

      Reply
      1. Kahty C

        Exactly Zyp.

        We are all being sold out by Corporate Media. The Corporate Interests are pretty clever. They got together, in response to the A.C.A, they had to ensure their profitability, by misleading the Public. These people are pretty clever, because that is all that they do. They found that the “Facts” were inconvenient. One was to obscure the Data, was to ensure it could not be collected. They rewrote the ICD-10, and the DSMV-IV to obfuscate the collection of Data. The Corporate lobbyists and Dark Money groups, even told Congress that using Data to keep the costs of the A.C.A down, was “Government Overreach” They sold us on the idea that technology was going to improve our lives. That all of that Medical Data was going to usher in a “Modern Age of Miracles”.
        The industry could not have that, their current Marketing tactics depends on a misinformed Public. Data does not lie but people do. There was an old saying “Garbage in, garbage out.” The Medical and Pharmaceutical Industries knew, that the “Jig was up.” The only way they could continue their operations was to control the Data input, because numbers don’t lie. They made sure that the Billing was narrowed to the DSMV-IV and the ICD-10, it made sense to standardize the billing. The DSMV-IV was rewritten not to better describe Psychiatric Conditions, but to obfuscate Facts, and facilitate billing. The rewritten DSMV-IV expanded the Categories and descriptions, so that even a person dealing with Medical Malpractice now has a “Mental health Condition.”
        The DSMV-IV is the Bible for Psychiatric Practitioners. The Language is deliberate vague. Every word, phrase and inference was gone over by the Industries. The Conflagration of “Opiate Use Disorder” with “Chronic Pain” was deliberate. Every change in the wording was gone over by Industry groups, Each deliberately vague phrase was written that way, to allow a biased Interpretation. The wording had nothing to do with Science or Facts, it had to do with a “Reasoned Professionals Interpretation.” That was how they explained the wording. They Marketed the “idea” that “Professionals” with a background in Psychiatry would know what they meant. When the DSMV was first written, it was meant to help describe these Conditions. Somehow it became the Billing Manual. It was already in use as a reference. Big Pharma and the Medical Industry knew that as the only reference for Billing, the wording is very important. Not only was the billing important to practitioners, the language could facilitate the Marketing of Pharma Products.

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        1. Richard A. Lawhern, Ph.D.

          I would offer one minor quibble: the most recent edition of the DSM is DSM-5 in 2013. I might also suggest that the mess prevailing around this document is somewhat more multi-dimensional than you express, Kahty. The fundamental issues were perhaps less a matter of “corporate money” than of “guild-privilege” in the malfeasance of the American Psychiatric Association.

          During 2010-2013, I was active in opposing most of the new edition’s made-up nonsense pertaining to so-called “psychosomatic medicine”. I’ve been quite public since its publication, in forums like Psychiatric News. My voice has been one of many, some of them professionals in psychiatry itself. Dr. Allen Frances MD (Chair person for the writers’ working group of the much earlier DSM-IV) has been one of the sharpest critics of the newest edition. He accuses the American Psychiatric Association of fundamental malpractice and fraud in its release of a document in which over half of the identified “disorders” have no validated field data to confirm the reality of the disorders themselves. Apparently the US NIH agreed, for they publicly announced that the DSM will no longer serve as a basis for organizing or funding research.

          Professional psychiatry and psychology are now weathering a deep crisis of credibility. The most vexing issues revolve around the characterizations of presumed “causes” for severely disabling mental health issues, and the involuntary confinement of patients. Arguably, the entire “knowledge” base of psychiatry needs to be burned to the ground and started over under rigorous public oversight, for it is clear that most of what psychiatrists once thought they “knew” simply wasn’t remotely true. And the asserted “promise” of psychoactive drugs has turned out to be a nearly uniform disaster, shortening lives and injuring patients on whom the drugs have been forced. As Dr. Frances expresses in his book “Saving Normal”, much of psychiatry is little more than faddish hysteria; US kids are grossly over-medicated for ADHD with meds that cause obesity and affect sexual development; millions of patients are given anti-depressants which work no better than placebos, after ten minute office evaluations by MD General Practitioners.

          For those interested in a deeper investigation of the failures of modern psychiatry, I commend a reading of “Psychiatry Under the Influence — Institutional Corruption, Social Harms, and Prescriptions for Change”, available on Amazon. A useful news media outlet is “Mad In America”.

          Regards, Red

          Liked by 1 person

          Reply
          1. Kathy C

            Thanks Red,
            I had been following the debacle with the DSMV-IV at the time. When it was “improved” There was a lot of talk and disappointment. It is entirely possible that the Psychiatric Community is a Guild Issue. They seem to be losing credibility, while still peddling their wares. The drugging of millions of American should be a bigger concern. Back in the 70’s I attended Workshops at New Paltz, where they were experimenting with Gestalt Therapy. At that time there seemed to be so much experimentation and hope for the future. The Industry has stagnated. There has not been one breakthrough, or discovery since then. People I know with Mental disorders are even worse off than they were back then. Some Practitioners are even returning to older medications, and re selling Shock Therapy.
            It is possible to that Pharma had some influence in the DSMV. I will have to go over my notes from back then. The Mental Health Industry has degraded, to essentially handing out random drugs, with no clear diagnosis. That is unless there is money then there might be talk therapy. I have been following the Reproducibilty Crisis too. The use of these “Studies” that have ruined lives is pretty disturbing. The ability of these stuff to go Viral on the Internet, and justify bad behavior should be criminal. One area where it is most horrible is Education. They actually push this kind of pseudo science on Children.

            We live in interesting times.

            Liked by 1 person

            Reply
  2. Richard A. Lawhern, Ph.D.

    Interestingly, many of the criticisms leveled at PROP’s 2012 propaganda piece on black box labels seem entirely apropos to the proceedings of the CDC “core group” that wrote the opioid guidelines four years later. What I haven’t yet learned is whether the core group ignored or deliberately suppressed those criticisms during its “deliberations” in 2015 and 2016.

    I would welcome some help from other readers, in analyzing the detailed references provided by AAPM in its critiques of the CDC Guidelines. If some of those references and critiques ALSO appear in the earlier response to the PROP petition, then I think we’d have the proverbial “smoking gun” to demonstrate persistent self-serving bias on the part of the writers who rammed through this highly restrictive and unscientific practice standard. I can be contacted by volunteers at lawhern@hotmail.com

    Liked by 1 person

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