Thread by @funchefchick

Historical data about annual prescription opioid overdose deaths in the United States has been wildly inaccurate for every year reported prior to 2018, and everything you've read about the cause of the 'overdose crisis' before then is wrong and bad: a thread. With sources. 1/20

First: Long before illicit fentanyl and the 'overprescribing of opioids' in this country, we had heroin as the primary related opioid in misuse/overdose deaths. Heroin deaths were often reported -inaccurately- as generic morphine fatalities or 'RX opioid deaths' nationwide. 2/20

Why? Because heroin rapidly metabolizes to morphine post-mortem. Standard toxicology screens reported many heroin overdose deaths as 'morphine' when really, they were undercounting heroin fatalities. 3/20 ncbi.nlm.nih.gov/pmc/articles/P…

Today, toxicology looks for the presence of 6-MAM (6 mono acetylmorphine) to definitively prove the presence of heroin post-mortem. This metabolite is a specific byproduct of heroin which is left behind after use. 4/20 forensicfluids.com/what-is-6-mam/

So heroin deaths were reported as prescription opioid deaths for .. a real long time. Not ALL, obviously, but enough to corrupt the data on prescription opioid deaths (and heroin) to be sure. But that's not all. Next we get to some unforced errors by the CDC ... 5/20

CDC announced in 2014 that historically they’d characterized ALL opioid PR deaths (natural and semisynthetic opioids, methadone, and other synthetic opioids) as ‘prescription’ opioid overdoses. Prior to 2014 ANY opioid could be considered RX. Just . . d'oh. How do we know? 6/20

CDC quietly mentioned it, buried in a 2014 report: 'Historically, CDC has programmatically characterized all opioid pain reliever deaths (natural and semisynthetic opioids, methadone, and other synthetic opioids) as "prescription" opioid overdoses" 7/20
cdc.gov/mmwr/preview/m…

Cool cool cool. Reporting heroin deaths as RX opioid deaths because of toxicology limitations, but also - the CDC had failed to notice - and account for - the rise of illicit fentanyl until 2014. So all of the data pre-2014 on 'prescription opioid deaths'? Suspect. 8/20

But after 2014 the CDC knew about illicit fentanyl so the data was accurately reported after that, right? Um, no. It turns out not. The CDC admitted in *2018* that they’d still been miscounting illicit fentanyl deaths and reporting them as RX overdose fatalities all along. 9/20

Where did the CDC choose to come clean? On the CDC website where they've been touting their "2016 Opioid Prescribing Guidelines". Nope. JAMA? Lancet? NEJM? BMJ? AIM? Nah. They chose: the American Journal of Public Health. With a super clear title. 10/20 ncbi.nlm.nih.gov/pmc/articles/P…

Meanwhile, others used far clearer titles and were .. . far more direct. You totally saw that huge wave of media coverage though, right? No? Me either. 11/20
ncbi.nlm.nih.gov/pmc/articles/P…

acsh.org/news/2018/03/1…

painnewsnetwork.org/stories/2018/3…

How - and why - did the CDC keep counting illicit fentanyl drug poisoning fatalities as 'prescription opioid-related' deaths as recently as 2018, when they were clearly aware that illicit fentanyl had arrived nationwide as early as 2014? That's a fine question. 🤷🏽‍♀️ 12/20

Every news headline you HAVE read about the 'prescription opioid crisis' is WRONG. CDC has known it, quietly admitted it, and allowed the inaccurate media narrative to continue unabated. State and federal agencies nationwide ran with it and destroyed pain care in America. 13/20

CDC's inaccurate data abt RX opioid deaths led to draconian prescribing rules, policies, regulations, HEDIS measures, insurance prior auths & coverage limits, insufficient pain mgmt in hospitals, surgery patients, traumas, crippling pain dx like Sickle Cell, etc. IT'S BAD. 14/20

Further, well-intended people are trying to measure TODAY's drug poisoning & opioid RX rates & other data against historical data which is pure fiction. We do not have accurate data to measure against. We can only measure accurately moving forward. 15/20

Because it's complicated and the data is older most people don’t realize that we’ve been relying on wildly inaccurate RX opioid fatality numbers all along. And there’s not really any interest (or funding) to try to go back and correct it, even if we could. (We can't) 16/20

Best we can do NOW is to accurately collect data going forward and try to move the trends in the right directions: fewer OD deaths (of all kinds) and appropriate RX'ing of opioids for pain (of all kinds) w/cautious & careful weighing of risks and benefits for EACH PATIENT. 17/20

Each individual patient should be individually assessed for risks/benefits of opioids not by some blanket set of metrics or policies. Every patient deserves individualized care and we need to empower and educate providers to resume treating pain again. Everywhere. Now. 18/20

P.S. Don't think I haven't seen you @CDCgov w/the new draft guideline. WE SEE YOU. You kept in MMEs you just hid them behind walls of text AND lowered them! You say providers should use clinical judgement then say opioids do not work, period. We see you. This isn't over. 19/20

The corruption among the guideline's key authors and the bias and undue influence among anti-opioid zealot groups involved with writing this draft w/no concern for the harms they have caused to patients and providers nationwide? Your day is coming. Fin.

pallimed.org/2021/09/roger-…