In the hotly contested "worst opioid information " contest we may have a new leader: Derek Rose, an "investigative reporter" for WISN, an ABC affiliate in Milwaukee. Although Rose's story would seem to make him the front-runner for this year's MVP (Most Valueless Piece) we should not ignore the contribution of Dr. Michael McNett, a "pain management physician and leader of the Comprehensive Pain Program team" at Aurora Health Care in Milwaukee.
Let's start with the headline:
"CDC: Tylenol, Advil more effective than prescription opioids."
If that's bad, the first sentence is much worse:
"For families across Wisconsin, there is a new and chilling dose of reality: CDC researchers found less addictive over-the-counter drugs, like Advil and Tylenol, are three times more effective than some of their opioid counterparts."
Derrick Rose, WISN, 2/4/19
Here's a chilling bit of reality: All of that is dead wrong. As in, "Three Stooges Fact-checking Inc." wrong.
First, Advil and Tylenol are not less addictive. They are non-addictive. How can a reporter covering health possibly make this statement?? Good thing he wasn't covering this...
Second, Advil and Tylenol are three-times "opioid counterparts??" There is NO evidence behind this crazy claim. Zero. Things go from bad to worse when Rose brings in McNett.
When asked why doctors had not always approached pain management with a less addictive medicinal approach all along, [McNett] said doctors had always been taught to pursue an opiate-first solution.
"I think a lot of it was misinformation," he said. "I think ignorance is to blame too. We just didn't know better."
(Left) Michael McNett, M.D. (Right). It is difficult to imagine how both of them could possibly get it so wrong. WISN reporter Derrick Rose
McNett, who somehow ended up assisting the Wisconsin Medical Examiner's Board in formulating new prescription guidelines (1), makes some interesting statements in his interview with Rose.
"The benefit you get from one Advil and a Tylenol is greater than the amount of benefit from oxycodone."
Whoa! Did he really say that?
Perhaps that explains this...
Perhaps it's based on a garbage study that I wrote about in 2017 (See Advil Works As Well As Opioids For Acute Pain? Not So Fast). The conclusion of the JAMA article was:
"For adult ED [Emergency Department] patients with acute extremity pain, there were no clinically important differences in pain reduction at 2 hours with ibuprofen and acetaminophen or 3 different opioid and acetaminophen combination analgesics."
Buried in the paper was a "trivial" little point - dose. The opioid patients received 5 mg - the lowest (damn low) therapeutic dose of Vicodin, the weakest of the commonly used prescription opioid analgesic combined with 325 mg of acetaminophen. But the others received 400 mg - the maximum recommended single dose - of Advil (ibuprofen) plus 1000 mg - the maximum recommended single dose - of Tylenol (acetaminophen).
Well, that's not fair, is it? Why not just use this headline instead?
"One Advil Works Better Than One-Billionth of a Vicodin."
Or maybe this garbage study by Erin Krebs from the Minneapolis Veterans Affairs Health Care System, which concluded:
"Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months."
Plenty of problems here (2)
- It used patient questionnaires, which are notoriously unreliable.
- Only 240 patients were in the study, almost all male.
- Pain was measured only at two time points: t = 0 and t = 1 year.
- You must be kidding.
- There was no real difference in the pain of opioid and non-opioid groups, just a weak statistical significance of one
- The protocol of the 12-month trial was changed (after the trial started) eight times.
- You must be kidding
- And saving the best for last...
- Patients on long-term opioid therapy were excluded.
Might there be a slight problem here? If you're comparing two different drug therapies for pain and exclude patients who are already using one of them because it works, you've got a teensy problems hands called "selection bias." Include these patients and this nonsense conclusion becomes something quite different:
"Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months, but only if you exclude the people who are already benefiting from opioid medications."
Which is roughly equivalent to...
"People with penises have bigger penises than people without penises."
Back to Dr. McNett. Let's cut the guy a break. Anyone can make a mistake. It's not like the guy has said anything goofy in the past, right?
“The more an addiction is fed, the stronger it gets. The worse [sic] thing we can do is to continue giving that patient narcotics.”
Michael McNett, Milwaukee Medical Society news release
No, it's not. Junk like this is worse.
- McNett is implying that pain patients are addicts. With rare exceptions, they are not.
- The worst thing "we" can do is call patients addicts.
- Perhaps, even worse, is that the McNetts and Kolodnys of the world are being listened to by the Derek Roses of the world..
- ...so the wrong message is sent to those who make policy.
And then everything gets done wrong. People suffer. People die.
(1) This really isn't all that surprising. Andrew Kolodny, who, if he has any training or knowledge in pharmacology hides it well, ended up giving advice to the CDC, which hides it even better. And I will be the batting coach for the Yankees this season.
(2) For more on what was wrong with the Krebs study read what Jacob Sullum over at Reason has to say. There is plenty.