__________________________________ Prescription Opioids: Risk Management and Strategies for Safe Use on value judgments, organizational preferences, or opinion. Guidance is frequently misinterpreted as mandate, when individualized treatment is the best practice [214]. Clinical practice guideline authority and influence usually comes from the sponsoring organization and status of the publishing journal. Once issued, the organization may become the promoter and defender of the guidelines, and panel members the stakeholders in the acceptance of their recommendations [115; 215].
Cum Hoc, Ergo Propter Hoc Fallacy A prototypical example of this type of fallacy comes from the 2011 CDC reporting of the same data in three publications related to a stated epidemic in opioid analgesic deaths and addiction and their direct relation to increasing opioid prescribing as reflected by sales data. Evidence to support this argu- ment came from simultaneously increased trends in opioid analgesic sales, opioid analgesic overdose deaths, and addiction treatment admissions for opioid analgesics [212; 213; 219]. Many profession- als found this persuasive evidence of a cause-effect relationship, and this conclusion was also reported by the news media and widely referenced in aca- demic papers. With causation inferred from correlational data, the fallacy in this reporting was that few alternate expla- nations for the correlations were presented. One credible explanation would have been exaggeration in the true rates of unintended overdose fatalities directly caused by opioid analgesics, a fact conceded by the CDC. Omitted entirely was discussion of the escalating population of patients with chronic pain. Sicker patients may also have been increas- ingly prescribed multiple medications with overdose potential for their disorders, including opioids. Another reason that causal inference from corre- lational data is erroneous is that when causation is based on simultaneously occurring events, it is not possible to determine which event came first. The true direction of causation may actually be the reverse of that reported by researchers. For instance, studies finding a significant correlation between fibromyalgia and obesity in women concluded these female patients developed fibromyalgia because they were overweight. The order of events, such as whether obesity or fibromyalgia came first, was never examined, and it is just as likely the pain and disability associated with fibromyalgia promoted activity avoidance and weight gain or that medica- tions used to treat fibromyalgia promoted weight gain or that medications used to treat fibromyalgia promoted weight gain.
Bias can also negatively affect the validity of system- atic reviews and meta-analyses that can form the basis of clinical practice guidelines. For example, several practice guidelines on long-term opioid therapy for chronic pain were published between 2008 and 2011. Although each guideline was based on analysis of essentially the same body of pub- lished research, the guideline conclusions differed markedly. The educated reader may look deeper for possible explanations for these discrepancies, including bias. Areas to explore would include the source of funding or sponsorship for development and financial and other material ties of the authors to industry, organization, or agency (e.g., slanted reporting of findings, conclusions consistent with industry of agency interests or agenda); the quality of evidence used to support a recommendation (by either endorsing or discouraging use of a drug, dose level, or therapy duration) and, in particular, weak evidence used inappropriately as definitive proof; whether the authors solely used published studies; and whether the studies used were industry funded [216]. FALLACIES OF ARGUMENT Fallacies of evidence or argument are used in pain medicine research to support or defend a false con- clusion ( Table 12 ). Many are intended to convince the reader of a cause-effect relationship when the actual evidence is weak or absent. Considerable evidence is required to establish a true cause-effect relationship, and the evidence purported to show causation may actually reflect association instead. It is important to maintain a degree of critical thinking to avoid being persuaded into accepting a falsehood or rejecting a truth.
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MDMS1526
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