Is the whole concept of MME's pharmacologically unsound? Implications for pain...

[drusso]

Should pain MD's be commanding "Show me the data" on MME conversion?

Comments to the FDA: Opioid Dosing Based on Milligram Morphine Equivalents Is Unscientific

The FDA is conducting a workshop to discuss the science (lack thereof, really) of Morphine Milligram Equivalents as it applies to the atrocious CDC 2016 Opioid Prescribing Guidelines. Public comments have been solicited. Here are mine.

www.acsh.org

"Bottom Line

It is incomprehensible that the CDC would put out a series of guidelines without bothering to consider even the most fundamental tenets of pharmacology. But this is what happens when a woefully uninformed group like PROP feeds advice to an equally clueless CDC and lawmakers pick up the baton – a shameful and disastrous chapter in American medical history.

The failure to consider even these simple metabolic differences is a primary reason why the CDC table fails as a useful guide and why the concept of morphine milligram equivalents is scientifically faulty."

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[Orin]

Should pain MD's be commanding "Show me the data" on MME conversion?

They're not wrong, but the data these recommendations are based on use an MME conversion to show increased morbidity/mortality in the aggregate population as a function of increasing exposure. The underlying issue of increased risk at increased MMEs is not invalidated, although as the author is suggesting, the exact value for an individual may be different.

This is a broader problem with guidelines though, as they are meant for the population aggregate, but hold little meaning for an individual's risk profile.

 

[callmeanesthesia]

Motivated reasoning by an organization that has clearly set forth its predetermined conclusions as “skepticism”. Dime a dozen. Same argument could easily apply to statins. “Because there is variability in metabolism standards for dosing are useless! People need their pain pills to function and are being tortured by the mean government!” He’s an organic chemist, not a physician. He gets no say. As an anesthesiologist who has actually used MME equivalents, to treat actual patients, I can tell you definitively they are useful.

 

[drusso]

Motivated reasoning by an organization that has clearly set forth its predetermined conclusions as “skepticism”. Dime a dozen. Same argument could easily apply to statins. “Because there is variability in metabolism standards for dosing are useless! People need their pain pills to function and are being tortured by the mean government!” He’s an organic chemist, not a physician. He gets no say. As an anesthesiologist who has actually used MME equivalents, to treat actual patients, I can tell you definitively they are useful.

I can't believe the CDC didn't catch this kind of formal fallacy in a guideline that affects so many people.

Ecological fallacy - Wikipedia

en.wikipedia.org

An ecological fallacy (also ecological inference fallacy[1] or population fallacy) is a formal fallacy in the interpretation of statistical data that occurs when inferences about the nature of individuals are deduced from inferences about the group to which those individuals belong.

 

[callmeanesthesia]

I can't believe the CDC didn't catch this kind of formal fallacy in a guideline that affects so many people.

Ecological fallacy - Wikipedia

en.wikipedia.org

An ecological fallacy (also ecological inference fallacy[1] or population fallacy) is a formal fallacy in the interpretation of statistical data that occurs when inferences about the nature of individuals are deduced from inferences about the group to which those individuals belong.

Anyone who’s ever seen an opioid patient can smell the BS in that argument. “All those other people abusing it ruined it for people like me who really need it! I only take it when I really need to (five times a day). They did a genetic test on me and said I should have dilaudid because I don’t metabolize the Norco or tramadol well enough.”

 

[callmeanesthesia]

Sorry, maybe I’m being too harsh but these hypocritical “think tanks” that shill corporate and special interest sponsored antiscientific viewpoints using a veneer of skepticism and libertarianism really bother me. Unfortunately very effective on certain people.

 

[Ducttape]

yes this is the same old drivel in a different form.

please don't tell me that an oxycodone 30 mg is equivalent in potency to a hydrocodone-acetaminophen 5 mg...

I also do not believe your ecological fallacy argument applies. same old trope I hear all the time - what applies to everyone "doesn't apply to me! ill never get tolerant/dependent/get low T! wait. low T?"



again - what is the medical proof that using any substance with high addictive potential is beneficial long term for the purely subjective phenomenon that is chronic non-palliative pain?

 

[BobBarker]

Pain is relative. My two year old broke his foot, the first three metatarsals. Tylenol and ibuprofen for two days. He has been fine since. And we are on vacation at the beach.

 

[drusso]

yes this is the same old drivel in a different form.

please don't tell me that an oxycodone 30 mg is equivalent in potency to a hydrocodone-acetaminophen 5 mg...

I also do not believe your ecological fallacy argument applies. same old trope I hear all the time - what applies to everyone "doesn't apply to me! ill never get tolerant/dependent/get low T! wait. low T?"



again - what is the medical proof that using any substance with high addictive potential is beneficial long term for the purely subjective phenomenon that is chronic non-palliative pain?

The validity of the ecological fallacy is undisputed.

 

[callmeanesthesia]

The validity of the ecological fallacy is undisputed.

But it’s relevance to high dose opioid prescription is.

 

[drusso]

But it’s relevance to high dose opioid prescription is.

Explain how hazards of the ecological fallacy impact population-based treatment guidelines highlighting the role of bias, ideology, and conflict of interests.

Beliefs Aren't Facts

Academics who hold that it is sacrilege to question their ideas are putting free inquiry in danger, argue the president of Northwestern and one of his colleagues.

www.persuasion.community

"Academic freedom means subjecting ideas to fearless criticism; only then can mere assertion be distinguished from tested knowledge. Without such criticism, the very reason for research—finding more truthful ideas—is lost, and education becomes the inculcation of dogma rather than the quest for understanding."

 

[callmeanesthesia]

Explain how hazards of the ecological fallacy impact population-based treatment guidelines highlighting the role of bias, ideology, and conflict of interests.

Beliefs Aren't Facts

Academics who hold that it is sacrilege to question their ideas are putting free inquiry in danger, argue the president of Northwestern and one of his colleagues.

www.persuasion.community

"Academic freedom means subjecting ideas to fearless criticism; only then can mere assertion be distinguished from tested knowledge. Without such criticism, the very reason for research—finding more truthful ideas—is lost, and education becomes the inculcation of dogma rather than the quest for understanding."

“It pays to keep an open mind, but not so open your brain falls out” (attributed to various scientists)

 

[SeniorWrangler]

I've been reading "Empire of Pain" by Patrick Keefe about the Sacklers, Purdue Pharma and the Oxycontin disaster, and it's pretty clear to me that most of the pro-opioid arguments were dreamed up by Purdue marketing people a long time ago and are still rattling around in people's heads.

Empire of Pain by Patrick Radden Keefe: 9781984899019 | PenguinRandomHouse.com: Books

NEW YORK TIMES BESTSELLER • A NEW YORK TIMES NOTABLE BOOK OF THE YEAR • A grand, devastating portrait of three generations of the Sackler family, famed for their philanthropy,...

www.penguinrandomhouse.com

ALSO, the "American College of Science and Health" is a bogus lobbying group set up by industry; it advocates for the safety of things like pesticides, fracking, bisphenol-A, sugar in soda, etc. etc. They are funded by industries that make products with bad reputations, as seen in the movie "Thank You for Smoking." Here's an example from some leaked documents:

ACSH donors in the second half of 2012 included Chevron ($18,500), Coca-Cola ($50,000), the Bristol Myers Squibb Foundation ($15,000), Dr. Pepper/Snapple ($5,000), Bayer Cropscience ($30,000), Procter and Gamble ($6,000), agribusiness giant Syngenta ($22,500), 3M ($30,000), McDonald’s ($30,000), and tobacco conglomerate Altria ($25,000). Among the corporations and foundations that ACSH has pursued for financial support since July 2012 are Pepsi, Monsanto, British American Tobacco, DowAgro, ExxonMobil Foundation, Phillip Morris International, Reynolds American, the Koch family-controlled Claude R. Lambe Foundation, the Dow-linked Gerstacker Foundation, the Bradley Foundation, and the Searle Freedom Trust.

None of this is to say that Josh Bloom is wrong, but he's a lobbyist, and he has as much credibility as a drug rep, but without the pens and pizza.

Leaked documents reveal the secret finances of a pro-industry science group

The American Council on Science and Health defends fracking, BPA, and pesticides. Guess who their funders are.

www.motherjones.com

 

[Laryngospasm]

So much of what we have been fed about opioids has been influenced or directly put out by these companies. I think deep down we all know that in most cases opioids especially higher doses not only don’t help but actually cause harm. You have to see the man behind the curtain. I broke a bone in my foot and kept working with no medication, I have back pain herniated discs and facet disease. I take no medication nor do I want any.