tag:blogger.com,1999:blog-6154923121857389373.post1949999208827420733..comments2023-07-07T05:11:26.707-05:00Comments on Substance Matters: Can We Trust Scientific Research?Mark Willenbring, MDhttp://www.blogger.com/profile/10556707753571367243noreply@blogger.comBlogger1125tag:blogger.com,1999:blog-6154923121857389373.post-23044982222530869582012-10-29T12:35:15.491-05:002012-10-29T12:35:15.491-05:00Excellent post and evidence based medicine is a go...Excellent post and evidence based medicine is a good starting point, but I do think that there are some qualifiers. As Feinstein pointed out 15 years ago, there is a lot of "soft" patient specific data that determines whether the EBM is particularly relevant or not. In that same article he expressed concerns about the abuse of EBM especially in the way it can be grossly applied by business interests or the government to their advantage. Arbitrary managed care or pharmacy benefit manager decisions are good examples of how EBM has been misapplied. <br /><br />There is also the question of political factors and EBM. They certainly factor significantly in addiction medicine. In the 1990's - opioid maintenance therapy for chronic non cancer pain (CNCP) was practically unheard of. In Minnesota, if you were a primary care physician and you wanted to prescribe this it usually called for consultation with a pain expert and getting a cover letter in case your prescribing was reviewed by the Board of Medical Practice. Then the Joint Commission (and others) looked at the evidence toward the end of the 20th century and concluded that pain was not being treated aggressively enough. The rest is history and we are now dealing with the fall out from that decision. Interestingly - at the time of the Joint Commission article in JAMA, the US had the highest per capita opioid consumption in the world.<br /><br />As far as the current evidence on opioids for CNCP guidelines vary from endorsing their use for people in recovery (SAMHSA) to referring all patients who might require opioids to a pain specialist (NICE). That is the difference between the 1990's and 2012. George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.com