Thread by @JillPiggott

Late in CDC's 2016 Guideline, a table reveals the Agency had no solid evidence for its claim that reducing rx #opioids would reduce ODs without harming people in #pain. In fact, ODs & suicides have spiked in their wake.

Thread: What did CDC know & when did they know it?

In a spring 2016 research paper, the Guideline's authors report that no "rigorous" studies had been conducted on whether dose reductions lower ODs, tho "preliminary results" suggested that high doses are less risky than low doses.

(All references at end of thread.)

CDC conducted its own study using VHA data about vets taking rx opioids. They matched 221 vets who died of OD (some of whom "likely" committed suicide) with 221 vets still living.

They found "dosage was a moderately good ‘predictor’ of opioid overdose death."

"On average, overdose cases had a prescribed opioid dosage higher than 71% of controls.”

CDC found no “clear cut-point” or threshold dosage “to distinguish between overdose cases and controls.”

Because dosage is a "moderately" good predictor of OD and because lower dosages are generally safer than higher dosages, CDC decided to recommend that PCPs (their target audience) initiate opioid therapy at "lower" dosages.

CDC suggested 100 MME because it “would affect proportionately few patients not at risk for #overdose while potentially benefiting many of those at risk for overdose.”

In their study, "fewer than 25% of control patients would have to be tapered if a dose cap were set at 50 MME."

I taught ethics for decades. The "few vs many" formula shows CDC justifies rationing access to analgesics on utilitarian grounds: that is, the greatest good for the greatest number.

In fact, opioid limits fail this test and are medically unethical.

Requiring a prescription for controlled substances provides the greatest good for the greatest number.

Bans & arbitrary dosage caps condemn people who are "not at risk for overdose" to uncontrolled pain & unnecessary disability, as FDA warned in 2019. Suicide is too common.

CDC's Guideline is based on studies that found "the many" are the average 96% of patients who take rx #opioids without incident. The 4% includes non-addictive dependence & long use.

Multiple large studies (see below) find the rate of new addiction in medical use is under 1%.

Neither evidence nor ethics justifies CDC's promotion of a policy that denies safe, effective treatment to at least 1 in 4.

CDC knew from the start that all patients "are not at risk of overdose," yet they urged doctors to harm actual patients to "potentially" benefit others.

CDC warned that “caution should be taken in drawing causal inferences from this observational study." In a table late in the Guideline they acknowledged that they had no or "very low quality" evidence for their recommendations (see below).

But when states, insurers, providers, & policymakers indeed drew "causal inferences" from their research & hardened into law recommendations made without evidence, CDC didn't "clarify" the intent of the Guideline until 2019 & only after pressure from patients & experts.

In 2017-18, CDC conducted research to assess #opioid prescribing before & after the Guideline. They acknowledged that prescriptions were already in decline before the Guideline “accelerated” them. And they identified ODs as the outcome of “of greatest interest to public health."

Buried late in the paper & discussed at no other point, CDC reports that "declines in...opioid prescribing metrics...have not been followed by decreases in opioid overdoses. Instead, overdoses due to illegal opioids (heroin, illicitly manufactured fentanyl) have increased.”

As CDC acknowledged in 2018, prescription #opioid restrictions are associated with a dramatic acceleration of opioid overdose deaths. Spikes in suicide among people forced off or denied safe, effective pain medicine are a manufactured & horrifying public health crisis.

Thread primarily discusses this CDC research:

Bohnert AS, Logan JE, Ganoczy D, Dowell D. A detailed exploration into the association of prescribed opioid dosage and overdose deaths among patients with chronic pain. Medical Care. 2016 May;54(5):435. ncbi.nlm.nih.gov/pmc/articles/P…

Find CDC's admission that OD deaths went up after prescriptions went down at the end of the 8th paragraph in the Discussion here:

Bohnert et al. Opioid prescribing before/after the Guideline. Annals of Internal Medicine. 2018 Sep 18;169(6):367-75.
ncbi.nlm.nih.gov/pmc/articles/P…

Table 1 of the 2016 CDC Guideline shows the Agency didn't have evidence about whether lowered doses of rx #opioids would reduce ODs (they did not) or whether they could kill patients (they do). cdc.gov/mmwr/volumes/6…

References for all other stats cited in the thread can be found in @headsUPmigraine's Quick Facts on Opioid Restrictions: docs.google.com/document/d/e/2…

I direct @headsUPmigraine with my colleague Dr @NitaGhei. headsUPmigraine has a public facebook group. No rules! You don't even have to have #migraine to team up!

@threadreaderapp unroll

Infuriating CDC papers. Figured I'd take 1 for #TeamPain & post a thread to save others from the pain of reading every damn page. STAY SAFE! @PROPkills @hope411adcock @Irishbrat1966 @JSG_54 @StopBadDocs @amylorrainelong @TheDarkGift_ @NickCarlin6 @FollowingForFu2 @LelenaPeacock