Concerns about Equity and Bias in New Revised CDC Guidelines

[drusso]

See attached.

Observations on CDC Guideline for Prescribing Opioids – United States, 2022

This document outlines the observations of the Opioid Workgroup on the updated CDC Guideline for Prescribing
Opioids. CDC recommendations for prescribing opioids for outpatients with pain outside of sickle cell disease-related
pain management, cancer pain treatment, palliative care, and end-of-life care. The observations presented here follow
the ordering of the draft Guideline.

Overall Observations

Overarching Themes

• Overall, many workgroup members felt that much of the supporting text of the guideline was not balanced and was
missing key studies. Many workgroup members felt that the guideline focused heavily on the risks or potential
harms of opioids, while less attention was focused on the potential benefits of opioids, or the risk of not taking
opioids or undertreating pain. In addition, some workgroup members felt that the language of the recommendation
statements or supporting text conveyed more certainty or was more absolute than warranted by the evidence.

• Much of the discussion of the recommendations centered around the concern for misapplication of the guideline.
Because of the consequences of misapplication of the 2016 guideline, many workgroup members were concerned
about how the recommendation could be misapplied, leading to potential harm to patients. The workgroup
discussion thus focused on how best to mitigate against this valid concern while preserving the benefits of the
guideline. However, some were concerned that the workgroup may have been over-correcting and so much concern
about future misapplication could potentially be detrimental to the greater good.

• Many workgroup members felt the guideline paid too little attention and had minimal discussion about racial/ethnic
disparities and inequities in how pain is perceived, valued, and managed, and the potential implications of these
disparities on implementation of the guideline, including disparities in access to recommended treatments, along
with how the guideline could impact disparities.

• Many workgroup members noted how the guideline has a constant tension between public health benefits versus
patient benefits. This issue is minimally addressed in the guideline and comes very late. Workgroup members felt it
is important to directly address this tension between risks and benefits to public health versus individual patients,
and to contextualize how individual providers should use this guideline in caring for their patients versus considering
potential public health consequences. In addition, several workgroup members felt that overall, the guideline was
not sufficiently patient-centered.

• Many workgroup members were cautious about including specific opioid dose thresholds in the recommendations.
Workgroup members acknowledged the importance of having benchmarks, but many felt that specific opioid doses
would be misapplied as absolute cutoffs or thresholds for policies or practices. Many workgroup members felt the
specific opioid dose thresholds belonged in the supporting text where the discussion could be more nuanced. In
addition, there is no single standard formula for calculating MMEs.

• Many workgroup members noted a sense of exceptionalism throughout the guideline. Specifically, certain
conditions were named in the text, while others were not. Naming of specific conditions may lead to interpretation
regarding whether pain is “real” or “worthy” of certain types of treatment. In addition, while the guideline states it
does not apply to sickle cell disease, cancer, palliative care, or end-of-life care, palliative care is not clearly defined.

• Many workgroup members felt that the recommendation category A was overutilized (11 of the 12 statements had
recommendation category A). Members felt that this type of grading likely contributed to the misapplication of the
2016 guideline.

• Many members of the workgroup developed a document that described the workgroup’s guiding principles when
providing observations on the guideline. Guiding principles include: minimize bias, ensure scientific integrity,
enhance inclusivity, establish patient- and clinician-centered guidance, and mitigate harms from unintended
consequences. The document is included as Appendix A.

---

Members don't see this ad.

 

[Laryngospasm]

🍿

 

[Ferrismonk]

Glad there is a chiropractor on this "panel".

 

[drusso]

In the same health system, Black patients are prescribed fewer opioids than white patients

“ get fewer pills, lower dose, lower potency — they just are getting less,” says family medicine specialist and health services researcher Nancy Morden.

www.statnews.com

"Morden hopes that, in addition to sparking more studies, her research will impact policy and future public health guidelines. The 2016 CDC guidelines, for instance, while well-intentioned, may have yielded a one-size-fits-all approach that didn’t take individual patients’ circumstances into account, some experts have argued."

 

[kstarm]

In the same health system, Black patients are prescribed fewer opioids than white patients

“ get fewer pills, lower dose, lower potency — they just are getting less,” says family medicine specialist and health services researcher Nancy Morden.

www.statnews.com

"Morden hopes that, in addition to sparking more studies, her research will impact policy and future public health guidelines. The 2016 CDC guidelines, for instance, while well-intentioned, may have yielded a one-size-fits-all approach that didn’t take individual patients’ circumstances into account, some experts have argued."

I never know how to feel about this. I think this bias exists in opioid prescribing and think it is important to address our biases as physicians. And yet we know that opioids have been massively overprescribed and have led to worse outcomes for people on them, thus inadvertently (in this narrow instance about opioids) it is quite possible this group received better care than the group that received higher doses for longer times.

 

[drusso]

I never know how to feel about this. I think this bias exists in opioid prescribing and think it is important to address our biases as physicians. And yet we know that opioids have been massively overprescribed and have led to worse outcomes for people on them, thus inadvertently (in this narrow instance about opioids) it is quite possible this group received better care than the group that received higher doses for longer times.

"Soft Bigotry of low expectations."

Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites

The present work examines beliefs associated with racial bias in pain management, a critical health care domain with well-documented racial disparities. Specifically, this work reveals that a substantial number of white laypeople and medical students ...

www.ncbi.nlm.nih.gov

"Black Americans are systematically undertreated for pain relative to white Americans. We examine whether this racial bias is related to false beliefs about biological differences between blacks and whites (e.g., “black people’s skin is thicker than white people’s skin”). Study 1 documented these beliefs among white laypersons and revealed that participants who more strongly endorsed false beliefs about biological differences reported lower pain ratings for a black (vs. white) target. Study 2 extended these findings to the medical context and found that half of a sample of white medical students and residents endorsed these beliefs. Moreover, participants who endorsed these beliefs rated the black (vs. white) patient’s pain as lower and made less accurate treatment recommendations."

 

[RoloTomassi]

I assume white people will just complain and beg for more pills, so I usually just give them more from the start to avoid that conversation

 

[Ducttape]

In the same health system, Black patients are prescribed fewer opioids than white patients

“ get fewer pills, lower dose, lower potency — they just are getting less,” says family medicine specialist and health services researcher Nancy Morden.

www.statnews.com

"Morden hopes that, in addition to sparking more studies, her research will impact policy and future public health guidelines. The 2016 CDC guidelines, for instance, while well-intentioned, may have yielded a one-size-fits-all approach that didn’t take individual patients’ circumstances into account, some experts have argued."

no offense....

this is old news.

Study Links Disparities in Pain Management to Racial Bias

UVA psychology Ph.D. candidate Kelly Hoffman’s study finds that medical students and residents who held false beliefs about biological differences between blacks and whites were less likely to effectively manage the pain of black patients.

news.virginia.edu

 

[cowboydoc]

So putting this together, was the under treatment of pain in black people during overprescribing of opioids in the few decades an example of bias or racism being protective?

(To be crystal clear, I in no way advocate, support or defend any bias or racism!)

I’m just postulating this could be one of the rare cases where “the system” actually may have benefited, albeit clearly unintentionally, a typically marginalized group. I think we may soon find the popularity of White Claw may have a similar effect.

U.S. Opioid Dispensing Rate Maps | Drug Overdose | CDC Injury Center

There have been several articles and studies on opioid deaths, the impact in the rust belt for example, but looking at exposure to prescription opioids and subsequent complications within different demographics may be interesting.

 

[cowboydoc]

Opioid Overdose Deaths by Race/Ethnicity

 

[Ducttape]

So putting this together, was the under treatment of pain in black people during overprescribing of opioids in the few decades an example of bias or racism being protective?

(To be crystal clear, I in no way advocate, support or defend any bias or racism!)

I’m just postulating this could be one of the rare cases where “the system” actually may have benefited, albeit clearly unintentionally, a typically marginalized group. I think we may soon find the popularity of White Claw may have a similar effect.

U.S. Opioid Dispensing Rate Maps | Drug Overdose | CDC Injury Center

There have been several articles and studies on opioid deaths, the impact in the rust belt for example, but looking at exposure to prescription opioids and subsequent complications within different demographics may be interesting.

you postulate something that would be an entirely unique and completely new scenario.

i know of no other situation where treatment is systematically withheld to protect a minority. no, children dont count. can you name one?

in addition, the optics of doing so are horrible.

 

[cowboydoc]

you postulate something that would be an entirely unique and completely new scenario.

i know of no other situation where treatment is systematically withheld to protect a minority. no, children dont count. can you name one?

in addition, the optics of doing so are horrible.

I can't. I tried to make clear that the study/observation was in no way justifying the action. This just sounds like something from Freakonomics. They made some really interesting observations of correlation by looking at data in a way most others typically don't.

Certain drugs, smoking other things have clearly disproportionate effects on different populations. It would be interesting to see if anything shakes out with the above. Admittedly, the data looking at prescription drugs vs. street drugs, etc. is not that great, so further parsing those numbers may be GIGO. The sociology/public health data seem to be a bit more loose that what we find acceptable for our treatment studies. (Unless it agrees with our bias)