The Grade Working Group: Grading the Graders

Welcome to the  Grade Working Group: From evidence to recommendations – transparent and sensible

The Grading of Recommendations Assessment, Development and Evaluation (short GRADE) working group began in the year 2000 as an informal collaboration of people with an interest in addressing the shortcomings of grading systems in health care. 

The working group has developed a common, sensible and transparent approach to grading quality (or certainty) of evidence and strength of recommendations.

So this is a group that’s grading the graders? 

Genetic Polymorphisms and Pain

Genetic Polymorphisms: Understanding Their Relationship With Cancer Pain – Clinical Pain Advisor – by Vicki Moore, PhD – June 2020

Cancer pain is no different than any other pain and this article explains why and how genetic factors are critical in determining opioid doses.

The Genetic Connection

In addition to genetic polymorphisms associated with the experience of pain, several SNPs have been linked to responses to pain analgesia, such as with opioid therapy.

Although opioids are often an efficacious therapy for pain related to cancer, patients may show varying responses to opioid treatment in association with SNPs in OPRM1, COMT, ABCB1 and other genes.  

N.H. Bill supports doctors treating pain with opioids

Here’s a very positive development in New Hampshire:

HOUSE BILL 1639-FN – AN ACT relative to healthcare.

Section 5
Requires that boards regulating practitioners prescribing, administering, and dispensing controlled substances adopt rules for management of chronic pain.

Section 6:
defines chronic pain for the purposes of the controlled drug prescription health and safety program.  

EBM only works for the mythical “average patient”

Pain-Topics.org News/Research UPDATES: Expect Analgesic Failure But Seek Success – this website is dead, but my post from 2013 still feels pertinent as corporate profit-driven healthcare companies continue their push to standardize our healthcare.

Evidence-Based Medicine (EBM) figures prominently in these efforts and is vigorously pursued and implemented by corporate healthcare (whose prime directive is to create profit for shareholders).

As our healthcare system tries to move toward EBM (evidence-based medicine), it’s critical to remember that there’s no such thing as an “average patient”.

New standards will be created based on statistical evidence – like means and averages – which can be misleading in medicine. This article points out how such statistics may not make sense in the real world (where not one single family has the statistical average of 2.2 children). 

The best treatment(s) for chronic primary musculoskeletal pain

The best treatment option(s) for adult and elderly patients with chronic primary musculoskeletal pain: a protocol for a systematic review and network meta-analysis –  free full-text /PMC6842192/ – Nov 2019

When researchers try to design studies about pain without differentiating between different kinds of pain, which I think invalidates those studies right away.

For myself, I’ve noticed several types of pain and each requires a different treatment:

• For the pain from subluxations in joints, opioids work.
• For my cervicogenic headaches, neck exercises work (and opioids initially).
• For muscle spasms along the spine, muscle-relaxants are effective.
• For the burn in muscles being used, nothing has worked.

Different pain requires different treatment, and I haven’t seen any studies about “pain” that rigorously control what kind of pain subjects have. 

Profit Motive as Cause of Previous Over-Prescribing

I keep reading about studies that show opioids to be no more effective for pain than non-opioid medications or other therapies. I still cannot believe that.

At first, I was convinced the studies had been corrupted, then I thought that the statistics were improperly manipulated, then I thought the patients had been poorly selected, but now I’m running out of excuses to insist those studies are wrong.

Still, it makes no sense to me that the only medication or treatment or therapy that has reliably reduced my pain for decades can be “proven” to be no better than drugstore pills (NSAIDs). 

Stanford finds personalized approach to opioids better

Opioids: Stanford researchers find personalized approach a better way to prescribe painkillers – By Denise Dador – Dec 2019

This article demonstrates the importance of personalization for quality healthcare and shows that standards are inappropriate for medication choice and dosing.

Why do some people get addicted to opioid painkillers and others don’t?

Stanford School of Medicine researchers have developed an innovative program called the Humanwide Project. Through wearable technology, genetics, and other tools, it aims to personalize care and take the mystery out of how we work.

Debbie Spaizman was nearly sidelined by a health concern. Surgery was needed, but she hesitated due to how she reacted to pain medication.  

Pain Needs Patient-Centered and Individualized Care

The HHS Pain Management Best Practice Inter-Agency Task Force Report Calls for Patient-Centered and Individualized Care – Jianguo Cheng, MD, PhD, FIPP, Molly Rutherford, MD, MPH, FASAM, Vanila M Singh, MD, MACM – January 2020

At least these folks see the reality: for pain, both acute and chronic, standard treatment with standard doses of standard medications is simply not medically appropriate. Pain treatment is not suitable for standardization.

Some healthcare services must be personalized to be effective, even when they become much more complicated and difficult (meaning, expensive).

The same people insisting on standard dose limits for opioids wouldn’t think of suggesting standard dose limits for blood thinners or insulin or cancer treatments.

The Pain Management Best Practices Inter-Agency Task Force (Task Force) was convened by the US Department of Health and Human Services (HHS), in conjunction with the Department of Defense, the Department of Veterans Affairs, and the Office of National Drug Control Policy.

Guidelines should allow for individual decisions

National Academies outlines new guidelines for opioid prescribing – By Andrew Joseph @DrewQJoseph – Dec 2019

 A new report issued Thursday by the National Academies of Sciences, Engineering, and Medicine outlines a framework for prescribers and others to develop their own plans for acute pain, without offering any direct recommendations itself. 

Here is finally a sensible “guideline” that essentially says to ignore specific “rules” and work with individual patients to find what works best for them.

But I expect the simplistic anti-opioid rules fabricated by non-medical “experts” will continue to override any thoughtful guidance from respected scientific groups like the National Academies of Sciences, Engineering, and Medicine.

After all, what could scientists possibly know that PROPagandists don’t?  

CDC Guideline Harms Pain Patients

CDC Guideline Harms Pain Patients, Panel Says – by Judy George, Contributing Writer, MedPage Today – March 11, 2019

The CDC’s 2016 opioid guideline is being implemented in ways that harm chronic pain patients, a panel of physicians said here.

I agree that the problem isn’t with the guidelines themselves.  They were just

1) suggestions,
2) for primary care providers and
3) first-time opioid prescriptions.

The problem is that they have been weaponized by anti-opioid crusaders to make laws and rules that force opioid tapers even when not medically indicated.