Pain management, prescription opioid mortality, and the CDC: is the devil in the data?

Transparency, freedom from bias, and accountability are, in principle, hallmarks of taxpayer-funded institutions. Unfortunately, it seems that at least one institution, the Centers for Disease Control and Prevention (CDC), continues to struggle with all three. What began with a prescribing guideline created in secrecy has now evolved to the use of statistical data and public statements that fail to capture not only the complexity of the problem but also the distinction between licit and illicit opioids and their relationship to the alarming increase in unintentional overdose. This is unfortunately consistent with Mark Twain’s assertion that “There are lies, there are damn lies, and then there are statistics.”1 For instance, when the CDC was in the process of drafting guidelines for the use of long-term prescription opioids to treat chronic pain, the identities of the project’s Core Expert Group members remained a secret until they were leaked.2,3 When its members were eventually identified, many were concerned that the group’s composition was not balanced and had an inherent bias against the use of prescription opioids to treat pain.4 Then, when the time came for public input on the draft of the prescribing guideline, the CDC’s invitation for meaningful comment can be best described as somewhere between a charade and a comedy of errors. For example, the only way the public could view the draft was during a one-time internet webinar. The actual guideline itself was not publicly available and was not posted on the CDC website, and admission to the webinar was limited. Those fortunate enough to gain entry were sometimes able to see the actual recommendation as it flashed on the screen, and while attendees were permitted to ask questions, the CDC stated that they would not provide any answers. At the end of the webinar, attendees could then email their comments to the CDC, but they only had 25 hours to do so.5 Due to the many technical problems associated with the first webinar (which was reminiscent of Get Smart’s Cone of Silence),6 the CDC decided to repeat the webinar on the following day and allow an additional 24-hour comment period. 4 But the controversy did not end there. Following the webinar, allegations of unlawful behavior by the CDC in the creation of the guideline were made, specifically that the CDC had violated the Federal Advisory Committee Act.7 The United States Congress eventually stepped in, and the CDC caved under pressure and permitted a 30-day open comment period8 during the Christmas holidays. Although the new open comment period yielded several thousand comments in the Federal Register, there was little change between the draft guideline and the final guideline. And while the CDC had asserted that they would be open to revising the guideline, and one of their own consultants had notified them that the guideline may be negatively impacting prescribing and pain treatment, there is no evidence that the CDC intends to do so.9 Remarkably, the actions of the CDC in the creation and publication of the prescribing guideline appears to violate every single standard that the Institute of Medicine recommended whenever clinical practice guidelines are created.10 Consequently, the authors of this commentary fear that the CDC’s earlier lack of transparency, freedom from bias, and accountability in the creation of a prescribing guideline has now infected the way they characterize statistical data to the public regarding the relationship between opioids (licit and illicit) and unintentional overdose.