How CDC Duped the Nation
How CDC Duped the Nation: With Artificially Inflated Data — Part I
When the Centers for Disease Control & Prevention (CDC) began discussing development of the Guideline for Prescribing Opioids for Chronic Pain [1] back in 2012, the “opioid crisis” was not even a blip on the radar but the crisis has been covered rather rigorously in the media since the development of the guideline as well as other initiatives. Much of the coverage that has followed has conflated patients in pain with having a use disorder i.e. addiction, while many other articles are simply based on false information. Why do I say that? Well, we will talk more about that but this guideline was the impetus for many patients being force tapered off of medications which were keeping them stable and productive, and in many cases, alive.
Even though the guideline is not “prescriptive”, and is ostensibly “voluntary” for physicians, and any changes in care or treatment were supposed to be decided by physicians and their patients, patients have continued to be force tapered off of their medications even when it’s medically unsafe to do so. The guideline was also supposed to exempt palliative and hospice care patients but even these patients have been left to deal with the aftermath of forced taper in some cases.
The guideline was supposedly really only meant for voluntary use and application by primary care physicians, so it makes even less sense why so many pain management specialists have been force tapering their patients off of medications that were keeping them stable and functional, there is a very logical reason for that which I will detail later but it may not be for the reason you think.
The CDC Guideline was the result of an initiative called for by the Institute of Medicine (IOM) now known as the National Academy of Medicine (NAM) back in 2011 with the report “Living Well with Chronic Illness: A Call for Public Health Action” [2] The report was released in 2012 and the recommendations contained in this report were the genesis of the CDC guideline. The guideline is loosely part of the Healthy People initiative driven by the Office of Disease Prevention & Health Promotion (ODPHP). Healthy People is a sweeping national health initiative with many other initiatives hierarchically structured beneath it which I will discuss at length in the future. It’s of import to note that other guidelines may be underway for other common conditions by the CDC based on recommendations proposed by the IOM committee:
“The committee recommends that the federal health and related agencies that create and promulgate guidelines for general and community and clinical preventive services evaluate the effectiveness of these services for persons with chronic illness and specifically catalog and disseminate these guidelines to the public health and health care organizations that implement them.” [2]
The purpose of the guideline was ostensibly to help combat the “opioid crisis” and the CDC is also a stakeholder in other important and meddlesome federal initiatives however, if you look a little deeper into the statistics that the CDC makes available for overdoses and which the media cites as gospel, it’s clear that many of these overdose deaths were the result of polypharmacy and illicit fentanyl among other illicit or illicitly obtained substances. Polypharmacy is “the simultaneous use of multiple drugs to treat a single ailment or condition” and also applies to recreational users.
Does Exposure Cause Addiction?
We have all seen the provocative headlines that repeatedly claim that the “opioid crisis” is a “prescription opioid crisis” and an “addiction crisis”, however; this claim has not been backed up with adequate evidence. It’s important to note that co-occurring addiction in the chronic pain patient demographic is incredibly low, “less than 1% of chronic pain patients without a history of substance abuse problems became addicted to opioids during treatment.” [3] It’s important to realize that most patients in severe debilitating pain are not likely to divert their legally obtained medications because they need them to perform simple daily tasks that most Americans take for granted, it’s that simple.
It absolutely amazes me how much we talk about opioid prescriptions as if they were some terrible blight with almost no benefit whatsoever in the public discourse without ever mentioning the explosion in disease that got us to a point where painful chronic disease has become commonplace. The potential for serious injury has also increased over the last century, and with it, the potential to develop chronic or intractable pain.
It’s often claimed that opioids were being handed out like candy by physicians before the “opioid crisis” hit in earnest but this is not true aside from a few pill mills that were shut down long before the overdose rates began to climb so high. Most patients would not receive an opioid for pain unless in the case of trauma or surgery. Those with chronic pain had to try a long list of conservative treatments before an opioid would even be considered and this was before the idea of the “opioid crisis” was plastered in the news media every day and before the guideline was created. Further, as Dr. Thomas Kline points out, the incidence rate for what he calls type 2 addiction has not changed since we began tracking the statistic in the 1920’s [4] despite increased “exposure” to opioids in the general population due to both an increase in population and as a result of the campaign to treat pain more aggressively (e.g. pain as the fifth vital sign). It’s possible that genes play a role in the development of what Dr. Kline calls “type 2 addiction”:
“The Theory of “substance exposure” rests on the assumption that if you spread enough substance around the addiction rates will increase, and people will die as a result. This is correct for what we call the Type 1 addiction group: cocaine, marijuana, amphetamines and most overuse of alcohol. This is not correct for Type 2 addiction, the opiate or heroin addiction which is multiple genetic errors in gene A118G which controls the mu receptor in the brain, peripheral nerves, and in inflammatory tissue.” [4]
It’s important to realize that addiction happens independent of substances that have potential to be abused, someone either has it or doesn’t and considering that exposure rates had increased between the 20th and 21st centuries, if the exposure premise was true, we would have been more likely to see an absolute explosion in incidence rates, but we haven’t, instead, around the year 2001 when illicit fentanyl began flooding over our borders, we began to see a slow but steady increase in overdoses which appears to have hit a crescendo around 2015. Problem is, without proper data, we have no idea how many people have actually died from overdose, nor what substance(s) were the main catalyst to death. We do know that polypharmacy is a big problem among both recreational and addicted users who have died, but what appears to be pretty clear on the surface is that prescription opioids which are obtained and used legally by patients with severe pain are not the driver of the overdose crisis. If they were, after all of the extra controls that have been put in place from forced tapering, to supply chain disruptions by DEA, to prison terms for physicians, it’s likely there would not be an expected increase in overdoses into 2025 [5]; but with CDC’s conception of how it should compile data, maybe it’s no wonder it’s expected to rise.
Redundancies in National Overdose Data & Other Concerns
It’s of import to note that the CDC does appear to count overdose deaths repeatedly [6] based on the number of substances that are found in decedents at autopsy via toxicology reports: “Deaths involving more than one drug (e.g., a death involving both heroin and cocaine) were counted in all relevant drug categories (e.g., the same death was included in counts of heroin deaths and in counts of cocaine deaths).” The CDC also says “Drug overdose deaths may involve multiple drugs; therefore, a single death might be included in more than one category when describing the number of drug overdose deaths involving specific drugs.” [7]
The average number of substances found in a decedent’s system at autopsy is six substances [8] for overdose victims which means that one decedent is counted as a death on average, six times (or as many times as there are substances present). It’s also possible that the CDC is counting illicit fentanyl and heroin as a “prescription opioid” even though heroin and illicit fentanyl and its analogues are never prescribed by a physician. How else might the statistics be inflated? Since one of the metabolites of heroin is morphine, some of these deaths may be counted as morphine overdoses instead of counting the actual substance that was most likely the catalyst to death: “because heroin and morphine are metabolized similarly, some heroin deaths might have been misclassified as morphine deaths”. Another example they cite: “a death that involved both heroin and fentanyl would be included in both the number of drug overdose deaths involving heroin and the number of drug overdose deaths involving synthetic opioids other than methadone.” [7]
Another concern is that CDC researchers came forward recently and claimed that overdose statistics were significantly inflated:
“In an article in the April 2018 issue of the American Journal of Public Health, four researchers at the Centers for Disease Control and Prevention’s Division of Unintentional Injury Prevention report that the CDC’s methods for tracking opioid overdose deaths have over-estimated the number of those deaths due to prescription opioids, as opposed to heroin, illicitly manufactured fentanyl, and other illicit variants of fentanyl. They called the prescription opioid overdose rate “significantly inflated.” [9]
The CDC appears to require some remedial steps in relation to gathering and compiling their data and has begun work on “improving the quality and timeliness of data on drug overdose deaths” which is a project underway at the CDC that was undertaken in August 2017, after the guideline’s implementation and before these researchers admitted that the data may be “significantly inflated”. This project is part of their State Unintentional Overdose Reporting System or SUDORS database. The purpose of this database, at least since 2017, is “to collect information on all substances that contributed to death as well as “all substances for which the decedent tested positive”. [10]
You would think that the CDC would have already been engaging in collecting data on all substances that contributed to death as well as all substances for which the decedent tested positive, especially considering that they are counting one decedent more than once in many cases, and you’d also think that they would have parsed those substances appropriately and made it clear in any statistical graphs that decedents were counted more than once, but it’s difficult to say what the status quo was before this effort without more visibility, it could be even worse than the above; if that is even possible. The federal government appears to want to track “social determinants of health”, but what about simply providing some accurate statistics on overdose rates and mastering that first? We are approaching this problem in a completely illogical way for more reasons than the above.
Why does any of this matter?
Considering that many public health policies, laws, initiatives, strategies and media coverage which affect patient lives are based on this data, it would have made sense to make sure the statistics were sound before possibly millions of very sick and injured patients were forced to suffer needlessly due to forced taper via implementation of the guideline as well as development of many other initiatives and interventions. It also seems logical to assume that maybe these remedial steps should have been taken long before a fear campaign in the national media was initiated in regard to the involvement of opioids in overdose deaths and before a guideline for prescribing was published and then forced onto physicians via attrition by the Drug Enforcement Agency (DEA) and the Department of Justice (DOJ) among others. It also seems logical that maybe some external, competent stakeholder(s) should be called in to ensure accuracy.
The CDC claims the guideline was “misapplied” yet their communique on its “misapplication” did not come until years after the guideline’s implementation and many patients have died, many more suffer needlessly and more will continue to die and physicians continue to force taper patients against their better judgement because they are facing “corrective” action by the federal government if they continue prescribing based on arbitrary dosing caps that have no basis in reality or any current scientific understanding. I will detail more on that later but there are also many other initiatives which have been developed and implemented over the last decade that I will dig into in detail in future articles as well.
Summation
Based on the above information, the Centers for Disease Control and Prevention have demonstrated that they are less than competent in regard to both data collection and compilation and we will discuss other very important shortcomings on the part of CDC and other federal agencies in future installments.
It seems like common sense to begin asking some difficult questions at this point in the history of the crisis as a new crisis has emerged. A crisis where patients, both acute and chronic/intractable pain patients are being left to suffer needlessly, and some have even committed suicide while others have died from complications of intractable pain disease; ostensibly based on others’ illicit use of mostly illicit substances. The “opioid crisis” is being “fought” with billions in tax payer dollars and it may be time to start scrutinizing where this money is going as overdose rates are expected to rise despite the extremely heavy-handed approach we’ve seen in the United States since the CDC Guideline was published, and despite all of the feel good interventions that are being forced on patients that sound good on paper but which anecdotal evidence suggest are catastrophic for human health.
If “social determinants” are so important to health, then why are we not looking at the guideline as a determinant of adverse outcomes? Maybe it’s time we begin taking a look at the mountain of anecdotal evidence, as “weak” as this form of evidence may be. At what point does it become a responsibility to investigate patient and physician claims? How many have to die or suffer needlessly before this happens?
There are other reasons why we should be asking questions which I will detail in depth in future articles but one thing is clear to physicians, patients and their families, the overdose crisis has been mismanaged since the start and continues to be with impunity and no one is better off for it.
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Special Thanks
Special thanks to Dr. Thomas Kline, Dr. Jeffrey Singer, Dr. Michael Schatman and Jeffrey Fudin for all of their hard work and support for patients, the patient community, as well as others who wish to remain anonymous; (you know who you are!) thank you all for your contributions, support and guidance.
References:
[1] CDC Guideline for Prescribing Opioids for Chronic Pain: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
[2] Living Well with Chronic Illness: A Call for Public Health Action: https://www.nap.edu/catalog/13272/living-well-with-chronic-illness-a-call-for-public-health
[3] Cochrane Opioids for long-term treatment of noncancer pain: https://www.cochrane.org/CD006605/SYMPT_opioids-long-term-treatment-noncancer-pain
[4} Opioid Addiction, is it rare? https://medium.com/@ThomasKlineMD/opioid-addiction-is-it-rare-or-not-abaa3722714 Thomas Kline MD, PhD
[5] Prevention of Prescription Opioid Misuse and Projected Overdose Deaths in the United States: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2723405Qiushi Chen, PhD; Marc R. Larochelle, MD, MPH; Davis T. Weaver, BS, et al
[6] National Vital Statistics Reports Volume 67, Number 9: https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf
[7] Provisional Drug Overdose Death Counts: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
[8] Pain management, prescription opioid mortality, and the CDC: is the devil in the data? https://www.dovepress.com/pain-management-prescription-opioid-mortality-and-the-cdc-is-the-devil-peer-reviewed-article-JPR Michael E Schatman, PhD, CPE; Stephen J Ziegler, PhD, JD
[9] CDC Researchers State Overdose Death Rates From Prescription Opioids Are Inaccurately High: https://www.cato.org/blog/cdc-researchers-state-overdose-death-rates-prescription-opioids-are-inaccurately-high Jeffrey A. Singer, MD
[10] Separating Prescription From Illicit Fentanyl: https://www.pharmacytimes.com/contributor/jeffrey-fudin/2018/10/separating-prescription-from-illicit-fentanyl Jeffrey Fudin, PharmD, DAIPM, FCCP, FASHP
Dez is a human rights and disability advocate, Founder of the National Advocacy Access Clinic (NAAC), and Owner & Editor of The Compendia Project. You can follow Dez on Twitter here or you can visit NAAC here.
© National Advocacy Access Clinic (2016- 2020) All rights reserved. Content does not constitute a medical consultation or legal advice. Please see a certified medical professional for medical advice or consult an attorney for legal advice.
How CDC Duped the Nation: by Exploiting Known System Failures — Part II
In my last piece, we discussed the artificial inflation of CDC data in regard to overdose deaths, deaths which are the basis of CDC’s and the federal government’s argument for why a guideline for prescribing opioids was required, however; there are other points of confusion when it comes to data compilation that I didn’t touch on in that piece for brevity. We are going to go into some of that now and the focus of this article will be more about local data collection and the process of death investigation.
Before, we discussed more of an overview or “macrocosm” in regard to overdose death data at the federal level and how it’s compiled, but now we are going to discuss an overview of the “microcosm”, all of the smaller moving pieces, agencies and individuals involved in recording these deaths at the local level and how differences in jurisdictions can affect data compilation and statistics at both the state and federal levels.
Overview: How Information is Collected at the Local Level
There is a specific term for death investigation called medicolegal death investigation or MDI. MDI is employed to ascertain and certify the manner and cause of death, specifically in cases where death is sudden, unexplained, or appears to be unnatural. While death certificates are based on the US Standard Certificate of Death [1], death certificates vary by jurisdiction as far as how they are completed (including other important steps in the death investigation process), so the data that is captured also varies by jurisdiction making it nearly impossible to track the same variables over time at the state or national levels.
Recommendations have been made by multiple stakeholders in regard to how we might improve the process of death investigation for overdoses in particular, I will list only a few here while also focusing on the systemic issues that exist within the local processes currently. “Recommendations for certifying opioid-related deaths are set out in three important papers, as described below. The first of these, a position paper from the National Association of Medical Examiners (NAME), presented evidence-based recommendations for the investigation, diagnosis, and certification of deaths related to opioid drugs. The recommendations called for a complete death scene investigation, with a comprehensive toxicology panel and interpretation of toxicology results in the context of circumstances of death, listing all responsible substances by generic names on death certificates, and classification of deaths due to misuse or abuse of opioids without any apparent intent of self-harm as “accidents”. [2]
Essentially what this paper is saying here and what it goes on to say later is there is no national standard for the investigation, diagnosis, and certification of deaths related to opioid drugs, documenting cause of death on death certificates, distinguishing between “drug-caused” and “drug-detected” deaths, toxicology screening or a standardized approach for increased death surveillance, specifically relating to overdose surveillance. The authors of these papers are not alone in their interpretation of the way local death investigations are carried out. We will discuss this in detail as I dig deeper into how this process is carried out.
It’s also of import to note that the coding system that is used (ICD-10) does not always make it easy to identify specific drugs as they are often included in broad groups or categories which can make it difficult to elucidate the specific drug(s) or even the class of drug most likely to have been the catalyst to death. “Of special interest is T50.9 (other and unspecified drugs). When a drug overdose death record includes T50.9 as the only contributing drug code in the range T36–T50, it typically means that no drug name or drug class was listed on the death certificate.” [2]
This is consistent with research that I have done which makes it clear that some decedents may have “overdose” listed as the cause of death without anything other than that on the death certificate, despite toxicology not being performed in many cases among other important nuances that I will detail later. No one agency has quality control over the entire death investigation process which is probably a good thing, however these agencies should work more closely to ensure accuracy.
Myriad Agencies & Individuals Responsible for Death Investigation
Drug overdose surveillance data is generated by multiple actors, most of which are completely separate entities with their own policies and procedures and this may not be an exhaustive list of those processes or actors, but it will give you an overview of the local processes that take place when an “overdose death” occurs.
“Notably, the data used in drug overdose mortality surveillance is generated by multiple agencies and actors, with no single agency having quality control oversight of the entire process (Fig. 1).”
“Drug overdose mortality surveillance relies on the ability of the medicolegal death investigation (MDI) system to generate death certificates with complete and specific information on drugs that are responsible for or contributed to overdose deaths. However, lack of routinely performed comprehensive toxicology testing, analytical challenges to detection and quantification of novel synthetic opioids, and errors in death certificate completion can introduce bias in quantifying the involvement of specific drugs in drug overdose mortality.” [2]
The above paper is making it clear that there are serious issues to be considered when looking at the overdose statistics, both in how the raw data is collected and how data are then compiled and this is just at the local level. The local collection of information at a death scene or at the morgue is not as glitzy as cable TV has led multiple generations to believe, in fact, some offices that process decedents do not even have computers or x-ray machines, contrary to what you may have seen on CSI or the like with the instant 3D images of the human body and internal damage.
Distorted Conceptions of the Death Investigation Process & Varying Technological Capabilities by Region
“Death investigations in the U.S. are often carried out in settings that bear little resemblance to the glitzy, high-tech morgues shown on television. When a death occurs under suspicious circumstances, the investigation into its cause is overseen by a coroner, often an elected official with no medical background, or a medical examiner, usually a doctor who specializes in forensic pathology.” [3]
As CBS News reports: “long delays in receiving death certificates and autopsy reports…can not only compound grief, but also can create financial hardships by holding up life insurance payouts and other benefits. The delays are driven largely by underfunding, a severe shortage of medical examiners and relatively low pay when compared with other medical specialties.” [4]
Except, it’s not only families that are adversely impacted by the lack of resources, there are also widely varying technological capabilities and other problems which can adversely impact public health response to certain threats, as well as adverse impacts to those who are the target of public health interventions. At a recent Association of State and Territorial Health Officials (ASTHO) stakeholder meeting, “a few participants noted the importance of considering states’ varying capacities with technology in general… For example, one state represented at the meeting doesn’t have computers in all coroners’ offices” [5] and some jurisdictions do not have in-house toxicology labs or even x-ray machines making it difficult to complete death certificates in an efficient, accurate and timely manner.
While “some death investigation units do a commendable job” … “New Mexico has a new facility equipped with a full-body CT scanner to help detect hidden injuries. Virginia has an efficient, thorough system, staffed by more than a dozen highly trained doctors. The autopsy suite in its Richmond headquarters is as sophisticated and sanitary as a top hospital.” [6] Still, a “National Academy of Sciences’ study found far-reaching and acute problems. Across the country, the academy said, coroners and medical examiner offices are struggling with inadequate resources, poor scientific training and substandard facilities and technology. Their limitations can have devastating consequences.” [6] To find out what some of those consequences are aside from my interpretations, I encourage you to read this PBS report in full, it’s an exceptional exposé.
Errors in Death Data & Reporting
It’s important to recognize that “counts and rates of overdose deaths involving specific drugs are only as accurate as the drugs listed on death certificates. If drugs are not listed because of a certifier’s systematic approach or jurisdictional office policy, rate quantifications could be severely biased. Warner et al. showed that states with centralized medical examiner systems had on average higher percentage completeness on listed drugs (92%), compared with states with decentralized systems (medical examiner (71%), hybrid ME/C (73%), or coroner (62%)).” Another thing to keep in mind that I touched on is that “multiple studies have reported that common ME/C errors in death certification can affect the accuracy of death certificate data for public health action. Hanzlick provides an excellent review on the important role of ME/Cs in generating MDI data for epidemiological research and the public health impact of MDIs in the USA.“ [2]
Conversely, there are ways in which abrupt changes in drug specificity could inadvertently skew the statistics: “A cautionary example illustrating the effects of an abrupt change in degree of drug specification comes from South Carolina (SC). The reported age-adjusted prescription opioid-related poisoning (T40.2–T40.4) mortality rate in SC was 4.7/100,000 in 2013, rising to 9.3/100,000 in 2014. The twofold increase could be interpreted mistakenly as a sudden worsening in opioid overdose deaths in SC. However, in reality, it primarily reflected an impressive increase in the percentage of drug poisoning death certificates that listed specific contributing drugs (57.7% in 2013; 94.4% in 2014), attributable to the January 2014 implementation of a SC Office of Vital Statistics process to collect specific drug names for all deaths.“ [2]
What the above referenced paper didn’t mention was that most in the United States live and or die in an area where only a coroner is available and with a 62% accurate disposition rate in regard to drug specificity on death certificates, it’s easy to see how biased the data truly is when you consider all of the nuances of how data collection varies regionally, as well as education level and other variables that contribute to regional differences and go on to influence state and national statistics. To see an application with statistics of what areas have coroners rather than medical examiners, take a look at this ProPublica Forensics API. The entry regarding drug specificity is particularly alarming considering that many stakeholders have recommended changes in how this data is collected by states. It doesn’t appear that government actors are sophisticated enough to recognize the ways in which their process changes are affecting patients via the federal response which is based on deliberately skewed data at the federal level. We won’t discuss some of the other variables that are contributing to distorting the data until I release Part 3 of this series but there is more to consider that I don’t believe most Americans have thought about because of how this process is portrayed in popular culture. The way the overdose crisis is framed to the public via mass media is simply hysterical while glamorizing a process that has myriad serious system failures.
Summation
Already in our overview of how overdose data is collected at the local level, some very troublesome information is coming to light, information that federal agencies are well aware of, and yet they do not make an attempt to explain that the data may be “severely biased” because of systemic failures which are occurring at the local level and federal levels. This in turn creates a zeitgeist around opioids in the public consciousness and wider culture that is simply not accurate, but that doesn’t stop federal agencies from selecting interventions into people’s lives that the data does not even support. What do I mean by that? We will discuss that much more in Part 3 but the premise since the beginning of the overdose crisis has been that patients and their physicians are a main driver of the crisis and its resulting deaths, however; when we dig even deeper into this issue, it will become even more apparent that there is simply not enough evidence to justify the response we have and are witnessing.
Based on just the overview, it’s clear that not only is the CDC lacking a common sense approach to the overdose data and or their interventions, but local jurisdictions also have badly ingrained system failures which don’t appear to have a quick or financially sustainable fix. The local data are what the CDC statistics are based on and we see nothing but problems everywhere we look as it relates to death investigation. In the next piece, we will discuss who actually gets an autopsy or toxicology screening and you may be very surprised to learn what the statistics are on collecting information for those two practices. Typically, we assume that toxicology screening and autopsies are standard in any case where a death does not immediately appear to be due to natural causes, but this simply is not the case and the statistics will frighten you.
There are serious systemic issues when it comes to government sourced data, whether it’s compiled at the local or national level and that is simply unacceptable when that data is being used as an excuse to force taper patients off of medications that were keeping them stable and, in many cases, alive, while that same data is responsible for other interventions into patient lives which I will detail in a different series in the future. It’s time to begin asking some very uncomfortable questions, and it’s time that the American public began challenging some of the ideas that are ingrained in us by those with power. It’s not clear how many of each state’s officials actually know about these problems, they may just not know how the data is compiled and just take the word of federal agencies that drastic measures must be taken in each state to “combat the opioid crisis” and “protect our children”. With that, it’s of import to note that children and other extremely vulnerable groups are far more vulnerable now than they’ve been in many years as it relates to the medical machine, this experiment in public health intervention, and how they are and will be treated in the future due to the hysteria and subterfuge that dominate this topic, and nobody with addiction nor recreational drug users have been “saved” because of it.
Want to support independent journalism and help me to continue this important work? Please consider joining my Patreon Community.
Special Thanks
Special thanks to the administrator of truth0rdare.com, the patient community, as well as others who wish to remain anonymous; (you know who you are!) thank you all for your contributions, support and guidance.
References:
[1] CDC, U.S. STANDARD CERTIFICATE OF DEATH — REV. 11/2003 https://www.cdc.gov/nchs/data/dvs/death11-03final-acc.pdf
[2] Methodological Complexities in Quantifying Rates of Fatal Opioid-Related Overdose: Svetla Slavova, Chris DelcherJeannine M. Buchanich, Terry L. Bunn, Bruce A. Goldberger, Julia F. Costich https://link.springer.com/article/10.1007/s40471-019-00201-9
[3] Autopsies in the U.S.A. Krista Kjellman Schmidt, Al Shaw and Jennifer LaFleur, ProPublica, Jan. 31, 2011 https://projects.propublica.org/forensics/
[4] Families suffer due to medical examiner shortage: AP https://www.cbsnews.com/news/families-suffer-due-to-medical-examiner-shortage/
[5] Association of State and Territorial Health Officials 2018 http://www.astho.org/Rx/Improving-Drug-Spec-and-Comp-on-Death-Certs-for-Overdose-Deaths-Meeting-Report/
[6] The Real CSI: How America’s Patchwork System of Death Investigations Puts The Living At Risk https://www.pbs.org/wgbh/pages/frontline/post-mortem/real-csi/
Dez is a human rights and disability advocate, Founder of the National Advocacy Access Clinic (NAAC), and Owner & Editor of The Compendia Project. You can follow Dez on Twitter here or you can visit NAAC here.
© National Advocacy Access Clinic (2016- 2020) All rights reserved. Content does not constitute a medical consultation or legal advice. Please see a certified medical professional for medical advice or consult an attorney for legal advice.
How CDC Duped the Nation Using Distorted Conceptions — Part III
In Part II of this exposé, we discussed an overview of how medicolegal death investigations (MDI) are carried out, the agencies and individuals involved, the data that is captured, errors in data and or interpretation, the lack of a standardized approach to death investigation, and other problems related to how these investigations are carried out.
We’re going to start this piece by delving into more shocking information in regard to process failures in local death investigation and expound on some of the issues we discussed previously, and we’re going to discuss how these issues destroy the credibility of the alarmist data being proffered up as justification for denying a particular type of care to millions of people. This information also discredits the federal agencies responsible for the narrative surrounding the overdose crisis, not only for exploiting the known system failures that exist at the local level, but also for their own intentional manipulation of the statistics at the national level among other things.
Extreme Variations in Education & Training of Death Investigators
The Association of State and Territorial Health Officials (ASTHO) mentions that education is an important issue that needs to be addressed when it comes to drug specificity on death certificates for both medical examiners and coroners, however, the problems don’t stop there. [1]
According to ProPublica, PBS FRONTLINE and NPR:
“The qualifications of those who oversee death investigations vary widely from state to state — and, in some areas, from county to county. But the main divide is between medical examiner systems, run by doctors specially trained in forensic pathology, and coroner systems, run by elected or appointed officials who often do not have to be doctors.”
“In many places, the person tasked with making the official ruling on how people die isn’t a doctor at all. In nearly 1,600 counties across the country, elected or appointed coroners who may have no qualifications beyond a high-school degree have the final say on whether fatalities are homicides, suicides, accidents or the result of natural or undetermined causes.” [2]
While I’m not anti-coroner (rather, pro-training), it seems absolutely absurd to me that we are relying on data collected by people who often have absolutely no medical training, and this data goes on to inform public policy. There’s no doubt that the profession requires reform but that will prove to be difficult at best without better incentives for those already working in the field as well as appropriate resources among other things.
While the truth is often stranger than fiction, the truth gets even more bizarre when you realize that many of the physicians who carry out death investigations are not even certified to carry out such a task:
“Many of the nation’s busiest coroner and medical examiner offices employ physicians who are not certified. A survey of more than 60 of the nation’s largest medical examiner and coroner offices by ProPublica, PBS “FRONTLINE” and NPR found 105 doctors who have not passed the exam — or more than 1 in 5 doctors on their full-time and part-time staffs.” [2]
It’s important to note that “by most estimates the United States has only 400 to 500 full-time forensic pathologists. It’s a tiny cadre of professionals for a country where roughly 2.5 million people die every year.” [2]
Keep in mind that most people live in an area where only a coroner is available and that PBS FRONTLINE and NPR surveyed some of the nation’s busiest coroner and medical examiner offices that employ actual physicians. Investigating the smaller ones that don’t process as many decedents may yield even more interesting information. Many of these doctors who aren’t certified failed their exams repeatedly and these are the folks along with coroners who often have no training at all that are sending data up the line that make it to CDC via state vital statistics. Another thing to consider is that these investigators have an incredibly high caseload which creates an environment where these offices become a breeding ground for oversights and mistakes which have also been studied in depth by PBS FRONTLINE and NPR in their eye-opening piece on the subject, and this piece does not stand alone, there have been many other articles and even studies carried out by others that have communicated similar issues.
The endemic problems and failures in the field have even made it into popular culture in recent weeks via HBO:
Few Actually Receive an Autopsy
It’s important to recognize that not every decedent that dies under suspicious circumstances goes through the entire death investigation process, at least not in the way it’s been depicted on popular TV shows. The fact of the matter is, few receive an autopsy. A little over 8% of US decedents are autopsied annually and this percentage is not likely to improve any time in the near future due to funding and other constraints.
The CDC says that: “From 1972 through 2007 autopsy rates declined for deaths from disease conditions from 16.9 percent to 4.3 percent and generally increased from 43.6 percent to 55.4 percent for deaths from external causes.” [3]
With these statistics, it’s even more curious to consider the official narrative as it relates to the overdose crisis. If many chronic disease patients with painful conditions were on opioid therapy at the time of death which were certainly at least nominal contributors to the overdose crisis if the CDC’s narrative and data are correct, the fact that only 4.3 percent of these types of patients are autopsied within the whole 8% of autopsies conducted annually means that true causes of death may have been missed in a large percentage of these patients which would make the statistics wrong, again.
The remaining 95.7% of these patients did not receive an autopsy which would have either confirmed or altered the cause of death, whether circumstantial or not if the disposition was “overdose”. What do I mean by that? Well, when death investigators log a cause of death on a death certificate for “overdose”, oftentimes they will use circumstantial evidence to support their disposition such as pill bottles, prescription history, the presence of illicit drugs or drug paraphernalia at the scene. In many cases, this is how the disposition is reached without ever conducting an autopsy.
For very sick chronic disease patients who have “overdose” listed on the death certificate (who may have actually died due to complications of disease), it seems absurd not to conduct an autopsy in these cases and instead rely on circumstantial evidence found at the death scene or via prescription history. In some cases, when toxicology screening is actually carried out, the simple words “opioids” or “overdose” may be logged on the death certificate if this class of drugs is found during the screening process, but it doesn’t necessarily mean that the drugs, prescription or otherwise, were the catalyst to death; it simply means that the drugs were present. Still, in many cases, the cause of death is listed as an “overdose”, even if that hasn’t been definitively proven.
It’s important to note that “previous work has shown that about 25% of U.S. overdose deaths had no drugs specified on the death certificate.” [4] Authors of the paper I just quoted use this percentage to make the claim that drug overdose deaths are likely much higher but that is a dangerous assumption, especially considering how few actually receive an autopsy (or toxicology screening for that matter).
When you really dig into the infrastructure we have for “tracking” these things, it’s wrought with serious problems, much of which we discussed in Part II of this exposé. If autopsies are performed only 8% of the time, then it’s impossible to say in other cases whether drugs were actually the cause of death in many cases, especially if toxicology screening was also left out. It’s obvious that a complete system overhaul of our death investigation system is required if we are to source even half accurate statistics on the overdose (or any health) crisis and there are other serious problems when it comes to state vital statistics as well which I will detail another time. When it comes to intervening in American lives, we need facts, not extrapolations based on personal bias, lack of resources or other systemic issues and unfortunately, much of how this information is collected is based on opinion related to circumstantial evidence and formed by individuals that for the most part lack education, certification, resources or a standardized approach to collecting MDI information. These are problems that the CDC and other federal agencies are keenly aware of and appear to have exploited for their own purposes.
These kinds of issues in large part are why it was so easy for the CDC (and others) to dupe the nation using garbage data which was then communicated to you, the public, via hysterical news coverage which makes it seem as if your own grandma will get “addicted” to pain killers if they’re within several feet them. When you begin to look deeper into this information, it becomes clear that much of the official narrative surrounding overdose death rates is engineered and I will go into depth on all of the remaining issues we haven’t covered yet in the future.
It’s also of import to note that in some states, it’s admitted that if every overdose or suicide was investigated to the point where the disposition was beyond reproach, it would be “all consuming” and many offices simply don’t have the resources to keep up. They essentially won’t bother if it’s an “obvious” cause of death.
“Because of the grueling pace, the state has had to impose limits on the types of cases it investigates…If we did an autopsy on every suicide, it would be all consuming, as with drug overdoses.” [2]
The main takeaway is that we’re missing the mark if death investigation has this many systemic problems and we aren’t even done detailing them all yet.
Toxicology Screening is not Always Carried Out When Drug Overdose is Suspected
It’s not only autopsies that are often not completed for the reasons stated above, it’s also become routine not to complete toxicology screens: “medical examiner and coroner offices are overtaxed, so it has become routine to complete minimal toxicology and often no autopsy, even though this is against all standards. The offices are doing their best to keep up.” [1]
“Forensic toxicology testing is essential for the accurate identification of involved drugs, including the novel psychoactive substances (NPS). However, the USA has no nationally-accepted best practices, standards, or guidelines for postmortem toxicology testing. Further, it is noteworthy that many ME/C jurisdictions do not test all suspected drug overdose deaths for NPS drugs, including fentanyl and fentanyl analogs.” [5]
So essentially, many simply don’t even bother testing for NPS drugs like fentanyl or its analogs despite the fact that its presence on the streets has prompted a state of national emergency. Standard national criteria for toxicology testing just may be helpful in guiding different jurisdictions on what they should be testing for. Toxicology tests are also expensive and the staff needed to interpret the findings carry costs as well. Further, funding for toxicology is an endemic issue and often the reason why minimal toxicology testing has become routine, these issues should really be resolved before we craft policies that interrupt people’s lives. Maybe the federal government would be wise to upgrade the nation’s death investigation infrastructure so that we might have something other than garbage data to rely on for public health policy. Instead, they focus on arresting doctors and destroying people’s lives because a tiny percentage of people addict or overdose on street drugs (which they’d know if they were halfway competent).
CDC Duped the Nation
Many decedents who end up with “drug overdose” as their cause of death on the death certificate will also only have one drug or a class of drugs listed, even if it’s possible that multiple drugs or even diseases were involved in catalyzing death which doesn’t bode well for continuing faith in a system that is continually screaming that the sky is falling. Even so, the class of drug is simply too broad when you consider the amount of illicit drugs on the street. Drug specificity on death certificates is an absolute must if this information is going to continue to be used to justify interventions into people’s lives and medical care, most of which are based on a conflation of terms, shoddy data collection and or intentional manipulation of statistics.
It’s pretty clear based on the fact that prescription opioids are now essentially impossible for patients to obtain, that illicit substances are what drive the overdose crisis but you can see how this would be missed by CDC and others if many ME/Cs do not test all suspected drug overdose deaths for NPS drugs including fentanyl and its analogs. The types of fentanyl that are out on the streets are never prescribed by physicians, they’re illicitly manufactured street drugs that are currently killing with impunity. As I mentioned in Part I with a quote from CDC, “because heroin and morphine are metabolized similarly, some heroin deaths might have been misclassified as morphine deaths” which also skews the statistics on “prescription opioids”. The “prescription opioid crisis” is an artificial crisis and as such, it’s not difficult to see why overdoses are expected to rise despite heavy-handed federal interventions into patient care and people’s lives. Public health officials are focusing public health interventions in the wrong direction and I’m beginning to think it’s intentional. Why do I say that?
In 2016, the CDC published a study detailing 59 deaths in Minnesota between 2006 and 2015 where decedents died of pneumonia and also had a prescription for opioids. The CDC made the case that such deaths should be recorded as “overdose deaths”, instead of pneumonia. [7]
Here’s a confused monkey…
It’s interesting that CDC was going out of its way to look for decedents with opioid prescriptions that died of pneumonia in the middle of the crisis. If they were so confident that this was a “prescription drug overdose crisis” and their data “proves it”, then it seems peculiar at best for them to go on a fishing expedition to find decedents who died of pneumonia who also had a prescription for opioids and then call for those deaths to be re-categorized as “overdose deaths”. [6] [7] I’m curious how many other times they may have engaged in this type of fishing expedition. It’s important to recognize that “opioid deaths are a bureaucratic category, not a scientific conclusion.” [6] The CDC report goes on to say that “we described UNEX-identified deaths with toxic opioid levels found at autopsy during 2006–2015” [7] only, there is no known reliable deadly dose for opioids because every person is different in regard to how their bodies process drugs. [6] [8]
Another thing to consider is that without knowing the time of death, it’s difficult to gauge how much of a drug a person may have taken. This is due to a process called postmortem drug redistribution. “Postmortem redistribution (PMR) refers to the changes that occur in drug concentrations after death. It involves the redistribution of drugs into blood from solid organs such as the lungs, liver, and myocardium.” [9] A “toxic dose” for you may be a perfectly therapeutic dosage for someone like me or vice versa so other variables do need to be considered for an accurate cause of death. The simple presence of opioids whether found via toxicology or circumstantial evidence (and no subsequent toxicology screen) should not automatically decide the disposition but CDC and other federal agencies have exploited these problems in MDI to suit their own agenda. Billions in taxpayer money are just waiting to be grabbed up after all and it would be a tragedy if researchers and others couldn’t have some of it.
Summation
Accurate analysis of overdose mortality data is complicated by varying technological capabilities between jurisdictions, including a lack of toxicology screening or autopsy in most cases, educational variation within the field, and a lack of resources and funding. The data itself is complicated by bias, uneducated opinions, intentional manipulation of data and shoddy investigative work that isn’t backed up by autopsy or toxicology in many cases.
These kinds of systemic issues are simply unacceptable and the way information is sourced in many of these cases should automatically exclude this type of data from influencing public health policy and interventions into people’s lives that have harmed far more people than they’ve helped.
We will discuss more about how these policies and interventions are harming people in future articles but one thing is clear, the systemic problems within government, both state and federal, are close to insurmountable and yet we’re expected to put our trust, lives, and healthcare in the hands of government while they experiment with what doesn’t work because their agenda is more important to them and that’s just not something the American people should stand for in an age where technology and knowledge are ubiquitous.
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Special Thanks
Special thanks to the administrator of truth0rdare.com for their incredible arguments which they allowed me to expound on in this piece, Josh Bloom, Ph.D. for his work explaining metabolism rates among other important nuances, and finally the patient community for their steadfast support. Thank you all for your contributions, support, and guidance.
References:
[1] Association of State and Territorial Health Officials 2018 http://www.astho.org/Rx/Improving-Drug-Spec-and-Comp-on-Death-Certs-for-Overdose-Deaths-Meeting-Report/
[2] The Real CSI: How America’s Patchwork System of Death Investigations Puts The Living At Risk https://www.pbs.org/wgbh/pages/frontline/post-mortem/real-csi/
[3] CDC — The Changing Profile of Autopsied Deaths in the United States, 1972–2007 https://www.cdc.gov/nchs/products/databriefs/db67.htm
[4] Drug Overdose Deaths: Let’s Get Specific https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547584/ Svetla Slavova, PhD
[5] Methodological Complexities in Quantifying Rates of Fatal Opioid-Related Overdose: Svetla Slavova, Chris DelcherJeannine M. Buchanich, Terry L. Bunn, Bruce A. Goldberger, Julia F. Costich https://link.springer.com/article/10.1007/s40471-019-00201-9
[6] Red Pill on Opiate Deaths http://truth0rdare.com/2018/03/17/red-pill-on-opiate-deaths/
[7] Deaths Associated with Opioid Use and Possible Infectious Disease Etiologies Among Persons in the Unexplained Death (UNEX) Surveillance System — Minnesota, 2006–2015 https://www.cdc.gov/media/dpk/cdc-24-7/eis-conference/pdf/Infectious-disease-complicates-opioid-overdose-deaths.pdf Victoria Hall, R. Lynfield, N. Wright, L. Hiber, J. Palm, J. Christensen, K. Smith, S. Holzbauer
[8] Opioid Policies Based On Morphine Milligram Equivalents Are Automatically Flawed https://www.acsh.org/news/2018/10/23/opioid-policies-based-morphine-milligram-equivalents-are-automatically-flawed-13529 Josh Bloom, Ph.D.
[9] Key concepts in postmortem drug redistribution https://www.ncbi.nlm.nih.gov/pubmed/16035199 Yarema MC, Becker CE
Dez is a human rights and disability advocate, Founder of the National Advocacy Access Clinic (NAAC), and Owner & Editor of The Compendia Project. You can follow Dez on Twitter here or you can visit NAAC here.
© National Advocacy Access Clinic (2016- 2020) All rights reserved. Content does not constitute a medical consultation or legal advice. Please see a certified medical professional for medical advice or consult an attorney for legal advice.
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