Tuesday, December 6, 2016

Confirmation Bias: A Critique of Opioid Guidelines

If you've bothered to keep track of the drama that's unfolded since the election last month (no one would blame if you haven't...), you've no doubt heard the phrase "confirmation bias."  We tend to seek out, the theory goes, news and information that confirms our current view of the world. Opposing views create cognitive dissonance, making us feel less sure about ourselves and forcing us to confront the possibility that we might be wrong (perish the thought). Confirmation bias is something we should all strive to avoid.  Whether its a citizen consuming political news, a fund manager picking a stock, or a GM signing a player... when we pick and choose our data set, we're more likely to make bad decisions.  

I suggest we take a similar approach in the fight against prescription drug misuse and abuse.  

If one truly believes that the best available research, data, studies, and thinking should guide our approach to this public health issue, then one cannot be offended by alternative points of view offered by those who share the same goal.  If one wants to solve the problem, one must consider the other side's view.  There may be more in Health Affairs and JAMA than is dreamt of in our philosophies.  And it's in understanding the critique of our position that we find the nuanced, balanced, and sustainable solutions required to mitigate prescription drug misuse and abuse.  

With this in mind, I recommend reading "Neat, Plausible, and Generally Wrong: A Response to the CDC Recommendations for Chronic Opioid Use" by Stephen Martin, MD, a practicing family physician in Massachusetts who treats chronic pain patients (in other words, the very target of the new CDC guidelines).  Dr. Martin lays out a case against the CDC guidelines that is well written, well researched, and likely to be not well received by readers of this blog.

And that's the point.  If we're going to make progress, let's engage with the sharpest and most well-reasoned points our critics have to offer.  Dr. Martin's arguments boil down to three main bones of contention: First, that the CDC is inappropriately conflating public health initiatives and individual treatment decisions.  Second, that with respect to studies regarding long term use of opioids for chronic pain, "absence of evidence is not evidence of absence."  And third, that opioids can be used safely, even over the long term, in the context of what Dr. Martin calls a "skilled, longitudinal, patient-clinician relationship."

Disagree?  Good.  I mostly do, too.  But I'm not going to do your homework for you.  Read the article, think through his positions, examine his data.  Then develop rational, data-driven responses.  Be prepared to listen to an equally rational and data-driven response back.  And before you know it, you'll be engaged in a legitimate, fruitful dialogue that may, in fact, identify common ground and lead to better solutions than either position might have achieved on its own.

For those that perceive a broader theme to this post, I admit an ulterior motive.  Let's practice data-driven dialogue across our professional, personal, and political spheres and see if we can't mend some broken fences.

On Twitter @PRIUM1

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