Evidence? We don’t need no stinkin’ evidence.

The Opioid Crisis Requires Evidence-Based Solutions, Part I: How the President’s Commission on Combating Drug Addiction Misinterpreted Scientific Studies | Bill of Health | law.harvard.eduBy Mason Marks – Dec 2017

Despite the Opioid Commission’s justifiable recommendations, it drew many conclusions that lack empirical support or are contradicted by scientific evidence.

the Opioid Commission was convinced that pain-related questions are driving inappropriate prescriptions.

PROP has really outsmarted all of us patients and doctors who rely on opioids to ease pain. Early on, they framed the discussion as a simplistic opioid addiction issue and ever since, we’ve been stuck trying to defend ourselves against this ignorant tide of drug-war-based policies. 

In its final report, the Commission cites a 2016 study published in the Journal of the American Medical Association as evidence that “savvy providers have figured out that opioids are a way to manipulate satisfaction.”

However, the cited study did not reach this conclusion.

Instead, it reports a mere correlation between a hospital’s rate of new post-discharge opioid prescriptions and patient reports that their pain was well-managed (as measured through the HCAHPS survey). This result is not surprising, and does not necessarily reflect excessive or inappropriate opioid prescribing.

One potential explanation for the observed association is that opioids were appropriately prescribed, which prompted patients to report that their pain had been addressed.

the study identifies only a moderate correlation between data points and makes no claims that they are causally related.

Throughout the cited article, the authors emphasize their inability to distinguish between appropriate and inappropriate opioid prescribing.

They advise readers to use caution when interpreting the observed correlation between satisfaction scores and new opioid prescriptions. 

Others studies found no correlation between prescriptions for pain medication and patient satisfaction. However, these studies were omitted by the Opioid Commission’s report.

The Opioid Commission’s misinterpretation of study data is careless and could negatively impact public health.

Removing questions related to pain management would reduce transparency and equates to throwing the baby out with the bath water. During the opioid crisis, we need more information on how well doctors are managing pain, not less.

In another section of its final report, the Commission recommends the use of enhanced prescription drug monitoring programs (PDMPs), yet it makes no mention of potential privacy and public health risks associated with these systems

there is growing concern that law enforcement access to patient prescription information through PDMPs constitutes an unreasonable government search under the Fourth Amendment. Unrestricted law enforcement access to prescription records could affect the quality of care received by patients.

In a recent federal court case, the Oregon State PDMP sued the U.S. Drug Enforcement Agency (DEA) to determine whether it was obligated to comply with DEA-issued subpoenas for prescription data presented without a search warrant.

Under state law, the PDMP was prohibited from releasing records to law enforcement without a valid warrant. The American Civil Liberties Union (ACLU) intervened in the case on behalf of several anonymous patients who routinely use legally prescribed controlled substances.

Judge Ancer L. Hagerty concluded, “It is difficult to conceive of information that is more private or more deserving of Fourth Amendment protection. He concluded that the subpoenas violated the Fourth Amendment because they demanded records without obtaining a warrant based on probable cause. However, on appeal, the 9th U.S. Circuit Court of Appeals reversed Judge Hagerty’s ruling.

the Court argued that the U.S. Controlled Substances Act (CSA) preempts the Oregon law prohibiting the PDMP from sharing sensitive patient data without a warrant.

The American Medical Association, and the medical associations of eight U.S. states, emphasized that the primary purpose of PDMPs should be to inform healthcare not law enforcement decisions.

Their brief advised the Court that unlimited access to PDMP data could adversely impact public health. Yet the Opioid Commission advocated for expansion of state and federal PDMPs without discussing the risks to public health.

How could the Commission misinterpret the results of numerous studies and make recommendations without discussing the associated risks?

This is the common drug-war tactic: select only data showing negatives about the drug in question, make sweeping pronouncements free of facts, implement prohibition policies without the slightest concern for collateral effects, and then double down when these draconian policies don’t work.

It seems that Drug Warriors can justify just about any intrusion into any data repositories to get whatever information they want and then persecute with impunity.

One potential cause is the conspicuous lack of healthcare professionals on the Commission.

The DEA and government agencies are reacting as though every opioid were illicit fentanyl.

the Commission should have been filled with scientists, physicians, and public health professionals.

The fact that opioids are a medication with legitimate medical uses is simply ignored to make the “opioid crisis” a simple black and white problem to be addressed by inexperienced, non-scientific people who have bought into the opioid hysteria.

With hundreds of American lives at stake each day, the public deserves only the most careful and responsible use of data. Without more scientific voices anchoring the conversation, the Commission may have succumbed to less rational forces.

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