Revising the Opioid Guidelines

Nuance – if there is a single word that could describe the essence of the National Center for Injury Prevention and Control (NCIPC) meeting last week which discussed revising the 2016 Centers for Disease Control and Prevention (CDC) opioid prescribing guidelines – this would be it.

So if nuance is the word that defines the meeting, then we should inquire into the meaning of nuance. Since how people speak reflects how people think.

Nuance is defined as a subtle distinction or variation, but the manner in which it was applied during the meeting suggests a different definition – complex. So after nearly five years of debating the validity of the CDC guidelines, we arrive at where we began – the diagnosis and treatment of pain using opioids is complex, ‘requiring nuance’.

A phrase repeated ad nauseam during the meeting. But in referring to pain management as a fundamentally complex concept, one that requires nuance, were the committee members defining it appropriately, or simply side-stepping any definition at all?

This is the problem with nuance, just as it is the problem with complexity. Often the conversation devolves into meaningless generalities rather than addressing the core issue at hand. To say something is complex often relies upon a broad definition, more conceptual than anything else.

And when it comes time to apply that definition within a specific context – or a specific application – the nuances give way to the concrete.

What is complex becomes simple.

This is a well known tendency. Largely responsible for why we landed here in the first place, needing to revise the guidelines at all. They were a poor approximation of all the complexity that goes into opioid prescribing.

The decision-making is complex, so we simplified it with guidelines. But in simplifying something complex, we find errors of approximation – manifesting as unintended consequences.

We knew this 2016 when we codified the guidelines. But from the manner in which committee members spoke, it appears as though we just now realized opioid prescribing is complex – or requiring nuance.

The circular logic was on full display throughout the meeting, and the logical fallacy might portend similar failings in the revised guidelines. Since how people think reflects how people act.

The tendency for people to speak complexly yet act with certain simplicity is the singular conceptual problem perpetuating the opioid epidemic. And explains why no guideline, no matter how well constructed, how well intentioned, can address the systemic root of the opioid epidemic.

The systemic root is epistemological, rooted in how we think, the thoughts we form. The guidelines should not try to codify decisions by their most apparent outcome, nor by the most obvious point of decision-making.

Rather the guidelines should emphasize particular patterns of thought, focusing on critical junctures of decision-making in which the balance of proper legal oversight balances alongside the protection of patient’s healthcare rights.

A balance not necessarily the same for every person, but one that should be pursued for every patient.

Maybe this is not quite a guideline. Maybe I too am side-stepping the issue, in favor of nuance.

Maybe that is what is ultimately needed.

Forgo the desire for revised guidelines in favor of a conceptual shift in how we think about opioid prescribing.

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