I’ve often said the war on prescription opioids is an ideologic war, not a war based on science or facts. Here I make my case for this using some simple laws of physics and while not 100% applicable to the opioid crisis, the fundamental premise for any control system is built on these basic principles and their intended outcomes.
Newton’s third law of motion states that for every action (force) in nature, there’s an equal and opposite reaction. In other words, if object A exerts a force on object B, then object B also exerts an equal but opposite force on object A, or Fa = -Fb. Notice that force is exerted on both objects and in both directions even if one is resting and not in motion. This force is often expressed as work, work is defined as the product of force, so regardless of whether we’re talking about objects moving through space or something more abstract like a healthcare system, the principle remains because the universe, at the level in which we operate, is based on cause and effect. And if we’ve modeled our system completely, the net effect for a force applied to another system is always zero, they cancel each other out.
For complex systems with many inputs and outputs, we may only add up the inputs to see if they equal the outputs, assuming the conversion of all inputs and outputs to a common system of measurement. As long as the two values are equal, we should, in theory, have a good system. But in the context of discussing cause and effect, our mathematical model should always return a zero, this how we know we have accounted for everything on the cause side as well as the effects side. This is an important concept I will come back to so remember, a well-designed system either adds up to what is expected or if all counter forces are accounted for, equals zero.
In our original example, the velocity of object A will be halved following a collision with object B, with the remaining half of the velocity transferred to object B. Adding up the velocity of both objects should yield the velocity of object A before the collision. The better we can measure a cause and effect, the better we can account for all the details in an event and gauge its effectiveness.
This introduces the 3rd component to the process, the ability to measure accurately everything that goes into a system, and everything that comes out. If we fail to incorporate adequate measuring techniques on both sides of the cause and effect, when we try to add up the outcomes or ensure our mathematical equation equals zero, they either won’t add up or won’t equal zero. The measurement problem is also an important concept I will come back to, so remember it.
Now, what if there are three balls of equal mass with Ball A moving at a constant velocity towards balls B and C which are at a resting state. What will be the individual velocity of each Ball after a collision? For the sake of this example let’s assume that Ball A will strike B and C equally, transferring its force and velocity into them. With Balls B and C having twice the mass of Ball A, the forces pushing back on Ball A will be twice that of a single Ball or Fa = -(Fb + Fc) and still the net effect on all three objects will be zero. As most of you probably guessed, the individual velocity of each Ball is 1/3 the original value of Ball A, but by adding a 3rd Ball, we’ve made our system more complex, we now have smaller values to measure for each object. This is why we need a very good system of measurement, for as the complexity of our system grows, so does the problem of measuring its effects.
Regardless of the number of causes and effect, inputs and outputs, or how complex our system is, Newton’s third law remains applicable and true as long as all variables are taken into consideration and this is why it remains a fundamental and foundational law of physics; one which has application across many areas of human effort. Any well-built system, when expressed in terms of forces and outcomes, inputs and outputs, cause and effect, always follows Newton’s third law when all elements of that system are accounted for.
And what happens when you add up all the pieces and they don’t equal the results you expect or cancel each other? Well then, you have to start looking at your system to figure out what you’ve missed and hopefully why you can’t account for all the values going in and coming out. If not, then you have to take a closer look at how your measuring things to ensure you are accounting for every detail no matter how small it may be.
The Scientific Method
This first section has, in a simplistic way, addressed what is known as the scientific method of analysis. Accounting for all details that go into a system as well as what comes out, and having good methods and techniques for measuring cause and effect at the smallest possible detail up to the final results. Good medical research incorporates elements that strive to remove ambiguity and error from the studied results, it often uses mathematical models that employ the methods seen in Newton’s third law, by using controls which are known to produce no effect or double-blind techniques so that those studied and those measuring the results, don’t know the inputs so that they can’t bias the results. The scientific method is what we are taught in school, usually from the fourth grade on up, so we come to expect this type of rigor to be applied to all our efforts which have science at their base.
Good Medical Research
Good medical research is “evidence-based” and built around a formalized method known as a clinical trial. They involve real human subjects based on well-defined criteria, with specified treatments, close observation, and meticulous record-keeping. Even patient selection is limited to prevent the chances of introducing spurious results into the conclusions. Pre-trial criteria are reviewed by multiple committees before protocols are locked in, techniques, as well as interpreted results, are reviewed by a committee for error and omission, or researcher bias. And only when clinical trials performed by multiple independent entities using both identical criteria and methods as well as different criteria and methods produce the same conclusions, do medical facts begin to take shape.
Medical publications using these methods are considered the highest and most reliable forms of medical research, anything less has limited value and its use collectively by the healthcare community is usually suspect on some level. To see what medical professionals think about the current state of medical research in America follow this link, most agree the current state of evidence-based research and publication falls short of what we claim it should be.
Online medical publications are often the worse place for information when seeking knowledge, except for some of the mainstream and long-standing publishers. The standards for publication have dropped considerably over the last fifty years, and a review by a general watch-dog group who grades the quality of scientific research across many areas of modern society concluded recently, that as much as 90% of articles published in online medical journals, had articles that were well below the standards based on a scientific method, lacking objectivity, accountability, rigorous methods, peer review and duplication of results by both the publishers as well as the authors, proving yet again, research publication is no longer about truth and knowledge, but profit.
Generally, medical publications fall into four categories, Original Research aka clinical trials are considered the most reliable form followed by Short reports or Letters, Review Articles and Case Studies.
Original Research is never quoted by the popular media as it remains technically above the average reader, yet it has the most balanced and objective information to consider when reporting on trends and breakthroughs.
Short reports and letters are papers that communicate brief reports of data from original research that editors believe will be interesting to many researchers, and will likely stimulate further research in a field.
Review Articles are, as they say, a review of the publications of other authors. They provide a comprehensive summary of research on a certain topic, and a perspective on the state of the field and where it is heading. They are often written by leaders in a particular discipline after an invitation from the editors of a journal and for this reason, often reflect the bias of the journal and the publishers.
Case Studies are articles reports on specific instances of interesting phenomena, their goal is to make other researchers aware of the possibility that a specific phenomenon might occur and rarely if ever, contain the type of objectivity and accountability attributed to scientific endeavors.
Review Articles and Case Studies are the types of publications most often picked up by the popular media because they are brief in content and purpose, often reporting a specific point of view without evidence, making claims which appear reliable but offer little or no data nor peer review to substantiate the information reported.
My Media Review
A review I did last year on the popular media of more than 17,000 articles since 2010, less than 0.0026% referenced any original research from multiple sources when reporting on trends or phenomena about the opioid crisis. Less than 1/1,000th of the government agencies reporting on the opioid crisis included the data and methods they used when publishing their results and claims. For all practical purposes, from the public’s point of view, their results could be coming from a Magic 8 Ball and yet no one questions it, particularly the popular media.
Less than 1/10,000th of articles published online by the government, reference any original research or any clinical trials on the use of opioids in treating long term non-cancer pain and with good reason. The US government funding for research on the benefits or problems with the use of opioids in treating this type of pain has received less than $2 million annually, from the government’s $45 billion annual budget for medical research.
And the claims made with regards to prescription opioids as the leading cause for this crisis, have even fewer data to substantiate such claims. If you were to change Newton’s third law and the scientific process to support the standards which have been used since 2010 to make the case against prescription opioids, then planets would careen out of their orbits, every star and galaxy in the universe would fly apart and explode, and if we were still here, we’d be standing on a piece of rock and couldn’t see our hand in front of our face while we froze to death.
Without original research and clinical trials, any truths with regards to prescription opioids published by our government are only half-truths if they’re even that. Yet we’ve built a system based on the exclusion and denial of essential medicines for pain patients as a means to an end. Which claims, it will prevent opioid overdoses and addiction, yet the one piece of data which would shine the most light on such claims, Prescription Drug Monitoring Program Data (PDMP) cross-referenced against vital statistics on cause of death, remains a tight secret no state or federal agency is willing to share, even though it costs American taxpayers $2 billion per year per state to run these programs.
The Problem with Opioid Crisis
Remember, Newton’s third law says that a well-defined system of force, has a net value of zero when the cause equals the effects. When you add up all the causes of our system designed to stop drug abuse and overdoes, are those forces canceled out by the results? Not even close. Since 2010 we’ve applied the Vector Model of Disease and modeled it using mathematical principles for slowing down opioid overdose deaths which are the primary purposes of reducing access. But with no more than a 3% reduction in opioid prescribing nationwide and overdose deaths continue to climb, after 20 years it looks like this system has failed. So why do we hang on to it?
We have no measurement for the impact on illegal drug use from these measurements. The efforts aimed at reducing access to the best type of medical care for treating painful conditions just don’t add up to results reported. By any definition, one would have to say that those responsible for most of the opioid abuse have had little impact on their ability to access drugs on the street, while patients working within the system and compliant with medication use are having the most difficult time keeping access to these essential medications. Any rational person would conclude the model used for the last twenty years is broken and doesn’t work. Our government then, who prides itself on being evidence-based, is clearly not listening to the evidence. Yet try to get a government official to have an honest conversation about that.
Secondly, the measurements we’re using to gauge success or failure represent much less than half the problem. In 2018 the American Journal of Public Health reported that opioid overdose deaths from heroin and Fentanyl increased 426% between 2013 – 2014. States like New York have reported that overdoses caused by a single drug involving only heroin or Fentanyl as of 2018, represent more than 80% of all overdose deaths. If this is the case, why are we only measuring the percentage reduction in prescribed opioids?
What’s wrong with this picture, plenty!
Hiding PDMP evidence paid for by taxpayers that would once and for all tell us how much prescription opioids contribute to overdose deaths. Pressing for further reductions in the prescription opioid supply, even in the face of shortages for critical care facilities. Making no effort to ensure responsible individuals have access to essential medications, but more importantly, refusing to have an honest conversation with the chronic pain community about how efforts to date are harming innocent individuals. Yet the government agencies responsible for monitoring America’s drug problem continue to spend billions each year on limiting access to prescription opioids while not funding efforts to prove their effectiveness or support the claims made that opioids are no more effective than Tylenol.
Do your own math and leave a comment on how well you think things are adding up, how the efforts to reduce opioid overdoses by restricting access to legitimate patients is having a real and tangible impact on the real problem.
You can also do your part this fall by voting in the people who will sit down and have an honest conversation about such issues and how they can be improved.