Introduction

I started learning Japanese on March 22 2023. At the time of writing, It has been about 70-80 days since. Currently I would place myself at N4 level (now studying N3). I became very inspired to study Japanese after (a) visiting Niseko (Hokkaido) and (b) reading a post on Reddit about someone who claims to pass N1 from zero in 8.5 months.
The purpose of this post is to offer (a) alternative perspectives to learning Japanese, (b) prove that it is possible to learn quickly, (c) challenge some of the existing recommendations. This post is part one out of eight articles detailing my journey to N1 from zero in 8 months. Disclaimer, this post will be very long and ranty!
This post will cover some of the study techniques and experiments I’ve conducted for the first month, as well as the results of my experimentation and insights. As for the elephant in the room, I’m currently studying N3 after 60+ days into my Japanese learning journey. I’m sure many are skeptical or might presume that I have bad mastery of N5 and N4 content, but by the end of the post, I’m confident that I would have responded to them. This post is not created to discouarge anyone >< I just wanted to see if my studying tips can inspire or resonate with other people.
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Prior Knowledge

I started watching anime since Naruto. I think that was 15 years ago. I’m not particularly obsessed with Japanese culture but I do follow the mainstream anime like Bleach, Tokyo Ghoul, My Hero Academia, Attack on Titan, and most recently Demon Slayer. So I do possess 15 years of acclimatising to the sound of Japanese anime speech. However my Vocab is very limited. I know how to count from 1-99, konnichiwa and itadakemasu, and a couple more words that I might remember if I was prompted. I also know the hand signs from Naruto. Apart from that, I consider myself truly zero in Japanese knowledge.

While your brain can only hold 7-9 items in the short term memory at once, it does not mean you cannot study more than 9 items in a day.

I see most people on Reddit recommending 15-20 new cards on Anki. Personally I think this pace is way too slow, especially for the beginner. Most typical N5 vocab deck would have about 600-700 cards. 15cards/day means that it would take 40-50 days just to see all the cards. I also came across a study that says our short term brain cannot store more than 9 items at a time. This would seem to support support the recommendation of 15-20 vocabulary cards a day. While reading Moonwalking with Einstein, a book on the capabilities of the human memory, I read about a story of a guy who could draw the landscape of New York with shocking precision after flying pass the city on a helicopter once. The book also hinted at the idea that we possess some form of photographic memory.
And so, i tried to do about 50-100 new cards a day. Within 10 days, I’ve seen all the N5 Vocab. Around day 15 or so, i became concerned that cramming so many words in a day would mean that the retention rate will be low. So I tested myself on those 700 words and I think I got about 85% correct.
Personally i was very happy with that score. I thought I could do a lot worse. So clearly, trying to learn 100 new cards a day wasn’t detrimental to retention rate (I will address my thoughts on burnout on a later point). What is happening?
My hypothesis is that while we can’t store more 6-9 items in our short term memory, it doesn’t mean that when we study our 10th,11th, 20th or 100th item, our brain would completely reject the input. You are still imprinting something onto the brain. What this means is that while you should not expect to see a word once and remember it forever, it says nothing about the upper limit of how many words you can simultaneously start on the first stage of the SRS system. We all know that SRS takes time to turn short term memory into long term memory. It could take weeks or a few months. But if we can start 100 words on the SRS system vs 15-20 words, and there is no significant cost to doing more words, then starting 100 new cards a day will bring us to our destination much faster.

Self-fulfilling prophecy

When you read about many people agreeing that 15-20 new Anki card a day is a good pace, or that it takes 300-500 hours to pass N5, then it sets the expectation of what is normal. The reason I was able to Master N5 in approximately 150-200 hours and learn all its vocab a couple of weeks is because I did not pay attention to what other people can achieve.

How I use Anki

https://preview.redd.it/wdwqgc0ok04b1.png?width=3840&format=png&auto=webp&s=89548a0e0972cfd2cde0c48a58515bfb9fef829b
From my survey on Reddit, it seems that people get overwhelm by the amount of reviews on Anki. And I think this reveals that the are doing reviews differently from how I do it.
When I do my Anki reviews, I only entertain two state of minds when marking the flash cards. The first is I know the answer (the answer pops into my brain instantaneously) and the second is I don’t know the answer (mind is blank). I do not try to recall the answer. Recalling takes time. If I try to recall the answer, it might take me upwards of a minute or two to remember it (and even then, I might still be wrong). Instead i like my Anki reviews to be snappy. It feels like I take about a fraction of a second to answer my Anki cards, although the Anki statistics tells me that I take 4second per card. Still fast either way. At 4s/card I can do 900 reviews in one hour.
Next is how I use Easy, Good, Again and Hard. The rule of thumb is to be more liberal than strict. I try to use Easy, instead of Good as much as I can because I don’t want my reviews to pile up. I almost never use Hard even if I get the card completely wrong. Speaking of reviews pilling up, we need to define what marking an Anki item as Good or Easy means to me.
For a lot of people it means aiming for perfection. That means that the person only click Easy or Good if his answer exactly matches the back side of the card. For myself I set an extremely low bar, as long the vague feeling of what I think the answer is somewhat matches the answer on the back side, I’m happy to give it a Good at least. Why? Because it’s the nature of Anki or SRS system to return cards you previously click Easy and Good. I don’t have to worry about being too forgiving on myself and being ignorant about the fact because I can always count on the card to return eventually. And if I a card I previously marked as Good, came back, and feels difficult, I would then make a mental note to study it in greater detail. Secondly, a lot of the 700 words in a typical N5 vocab deck are so common that you will encounter them all the time in the wild. This is called organic or natural SRS. If you are strict on your Anki at this stage, it can be quite an overkill in hindsight. Of course it may not feel like an overkill in the beginning because you are still gettting cards wrong.

Burnt out

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https://preview.redd.it/yo4br6nyk04b1.png?width=3840&format=png&auto=webp&s=c15be37671fe334cb577a8e9ac33974933f00689
https://preview.redd.it/vnsx0umzk04b1.png?width=3840&format=png&auto=webp&s=c69555aa237a3e6bcf538db3014ef410aee3f34b
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Okay what about burnout. Surely I might be overdoing it, and wouldn’t burnout eventually catch up to me. Yes and no. I think the phenomenon of burnout is highly exaggerated. I don’t like to use the word burnt out whenever I’m feeling “burnt out” because it has a lot of negative connotations and because negative connotations can lead to self-fulfilling prophecies. Instead, I prefer to use the phrase, “I’m tired now”. I kind of compare myself to Shonen protagonists where there’s this big villain coming up and then some special training to level up. The special training is usually quite intense, and sometimes dangerous, and they will eventually be quite tired by the end of the training. But these protagonists always reemerge stronger with new abilities and can now overcome stronger foes.
Similarly, whenever I study too much, I would just acknowledge that I’m tired, watch some anime and something different. I’m usually okay by the next morning. I attribute my ability to resist burn out my thoughts and attitude.

Consistency, multimodality learning, and resourcefulness

Okay the N1 tango book is really too difficult for me. I bought it thinking i could get a headstart on N1 while concurrently studying N3. Its just too much at this point.
I only believe in one kind of consistency, and that is that you have to show up almost every day. But I don’t believe in the kind of consistency that requires me to be on a 365-day Anki/wanikani/immersion streak. This is also one factor that helps to protect burn out. When I feel like doing textbook learning, that’s what I’m going to do. If want to do pure Bunpro and Anki for the next 3 days without reading any textbook, that’s what I’ll do.
I also believe in the idea of multimodality learning. I use everything at my disposal:
All the textbooks (Genki, Minna no nihongo, Tae Kim)
YouTube videos (Misa ammo, game gengo, tokiniandy)
Podcast
Songs
Doing active immersion with anime
Changing my phone language to Japanese (this one unfortunately is a bad advice. I recommend to stay away from this if you are still at N5)
Posters
Instagram and TikTok accounts of Japanese tutors
Websites (tofugu, human Japanese, Japanese tutors’ blogs)
Apps (wanikani, language reactor, bunpro)
Japanese grammar dictionaries
Assessment books
Discord or Reddit or forums
Japanese classes
There’s often this debate on which is better, Genki vs Minna vs Tae kim. If cost or ability to procure them is not an issue, why not use all of them? It’s okay to have one source as your primary source. Mine was Genki 1. But when I wanted to understand a nuance that Genki does not explain well enough, I’ll usually consult my other sources. And if I’m bored of Genki, I can easily switch to Tae Kim, for a change of scenery. If I don’t feel like reading, Misa or Tokiniandy is there for me.
My observation is that many people are usually only using one modality to acquire a new skill. This is causing their journey to be unnecessarily monotonous.

Sloppy learning and conjugations

One very integral component of the Japanese language is conjugation. It’s especially important for the N5. Conjugations can allow you to express many meaning in Japanese. Learning how to conjugate accurately is going to be a struggle for any beginner(think godan and ichidan verbs and conjugating to masu, te, negative forms, etc).
A lot of Japanese textbook and assessment will make you do drills. I skipped all of them. Rather than trying to brute force your way to memorizing conjugations I employ a technique called sloppy learning(this phrase is borrowed from “Japan Like A Breeze” on patreon). I define sloppy learning as learning just enough to acquire the essence of the concept.
For example, ,whether the verbs is in its polite form, short form, negative form or past tense form etc, can be easily recognised by looking at the last few syllabus of a word. If a words end on a “ta”, it must be past tense form. If it ends on a “masu” it must be the polite/long form. This concept can literally be understood in 5 mins.
Thus for me. When conjugating oyogu (泳ぐ）into past tense form, I just conjugate it as oyogu-ta (oyogu +ta) Or sometimes oyota. Now oyota is wrong of course. But that’s all I need at this stage. I desire to understand Japanese, not to get full marks on conjugation drill table. You must always try to look at the big picture. Trying to do well on conjugation drills is an opportunity cost. Ultimately one needs to judge what is worth spending effort on. Hence the idea of sloppy learning is to be deliberate about what to focus on.
Once I can consistently remember that masu means polite and ta meant past, this is where I try to conjugate them correctly. Conjugations is difficult because they all don’t behave like ru verbs. You cannot simply drop the ru at the end of a word and append ta or masu to them. Oyogu for example doesn’t even have a ru ending.
The path I chose was to hope that I can organically (I like this word a lot, but it also sometimes means magically) , know how to conjugate correctly one day. And to a certain extent I acquired some intuition on conjugations without any active involvement from my part. I soon became aware that if a word ends in a gu or a ku, then instead of a ta, it might be ita or ida.
The break through came on day 35. When I couldn’t endure the fact that I wasn’t able to magically acquire conjugation intuition for free. So i goggled “why are godan verbs conjugate the way they are”. And Tofugu came to the rescue.
Essentially they introduced three concepts (a) double consanent with small tsu, (b) assimilation with n, and (c)consonant removal. After that article, conjugating became a breeze. In hindsight, my ability to conjugate only costed me the time to read one tofugu article (and one month of passively intuiting the conjugation patterns) Because I did not spend time on conjugation drills, i was able to progress to the other grammatical points in Genki 1. I didn’t remain stuck in one place for too long.And this is another aspect of sloppy learning. You learn just enough to move on to the next level, you don’t aim for perfection.
Your brain can’t do everything at once. Your brain cannot remember that masu means polite form, and all the rules for conjugating verbs to masu in one sitting. If you try to do that, you can remain stuck, despite already understanding the general idea of conjugation. Better to move on and let the intuition develop. If you judge that the intuition is not going to progress or progress quickly enough, you can always intervene later by supplementing with new knowledge.

Mnemonics when I get something wrong too often

Often there will be a vocab or grammar point that I always can’t seem to latch on. No vague feelings, no guesses, just an empty mind. When this happens, it can be a scary feeling. It may feel like you are not good enough.
Really the solution is very simple. Just add one more inferential step. When I first encountered the word bengoshi（弁護士） , my mind does not produce any intuition or pictures or feelings. What I did was to create a mnemonic, a story. How to relate a lawyer to the sound ben go shi? I managed to came up with “when the judge announces his judgement, the bench(jury) goes “shhhh””Sorry, I know it’s really bad. But when I created that story, bengoshi never stumped me again.I’ve seen a lot of criticism of mnemonics that I don’t agree with

1. ‘they are not for me”>>I’ve seen people said that Anki is not for me. Srs is not for me. While I believe in individual differences and effectiveness in different methodologies, I feel that sometimes people decide too quickly what is or isn’t for them. What is optimal may first have a learning curve in the beginning. And instead of saying that something is not for me and moving on to the next thing, we need to consider if it isn’t we ourselves that should change to make it fit for us.
2. “If I’m trying to memorize something, how does adding more things to remember help. Now I not only have to remember the word, but I need to remember the story to remember the word.”>> Between a story and a random string of number “89779012879” , the brain can remember the short story more easily than the string of number despite the story consisting of more words. It’s just how our brain works.

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On active immersion

Active immersion means trying to pick up words or trying to understand what is being said in Japanese media like anime or novels. Passive immersion means enjoying the content without really worrying about improving your Japanese.
On day 21 I tried active immersion with Weathering with You. I came to the conclusion that active immersion is not efficient for the new learner. I can imagine myself doing a lot of sentence mining and active immersion in the future (spoiler, I’m now on day 70-80 and I’m immersing a lot more now). But definitely a hard no for me to recommend new comers as the only and primary form of learning Japanese.

Why textbook learning and structural learning is important for fast gains.

Textbook learning is great for fast gains because it prioritises for you. Textbooks are not prepared by a random person. They are usually prepared while respecting certain pedagogical principles in mind by a team of qualified academics. While appealing to authority doesn’t make it correct, we should at least be cognisant that the textbooks might be doing a few things right.
One of those pedagogical principles is incremental or progressive learning. Building knowledge upon what was previously learnt.
Another principle is foundational concepts. A textbook will usually introduce foundational concepts that act as a scaffold for everything else as early as possible. And because textbook learning is progressive, it means that the difficulty is always going to feel just about right. In active immersion the difficulty can be wild because it does not respect your level of Japanese proficiency.
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Completing N5 in 30 days.

In this 30 days, I was not only learning Japanese, but also learning how to learn. They call it building a plane while flying it hahahah. The principles outlined here helped me to finish N5 content at an insane rate. I was spending about 6-8 hours a day on Japanese (in chunks). So one point not stated here is time. There's no way around time investment.
On the 30th day I did a lot of mock tests and I performed quite well (80-90% correct).When I started on N4 on day 31, I was really surprised by the bump in difficulty. I gave myself 30 days to clear N4. That was the hardest 30 days in my Japanese learning journey. I’m fact I had a better time when I was studying for N3 on day 65 onwards. In my next post I’ll share why N4 was harder than N5 and N3 for me and share some more insights. Hope this has been helpful in offering new perspectives. Thank you for reading this long rant of mine.

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Grandmaster Emblem & Calling Card.

Welcome, future Grandmasters!

Whether you're on the Grandmaster / Ultra-Mastery Grind for the coveted Calling Card, Emblem, and Charm, a Shipment 24/7 aficionado, or just looking for some high-powered ultra-mobility setups, I hope you find the builds presented in this post helpful! They are crafted to my personal specifications to be the pound-for-pound, stat-for-stat, mathematically best possible builds for Shipment 24/7 to assist those on the Ultra-Mastery grind.

For the uninformed - What is Ultra-Mastery?

The Weapon Grandmaster or Ultra-Mastery grind is a reward for scoring 1000 kills with 51 weapons. This is not a very widely-earned achievement, but from what I have been able to hear, it is any 51 weapons (just like Polyatomic & Orion) - not the base 51 weapons (which would force you to include the dreaded Riot Shield and Launchers). Obviously, Shipment 24/7 is the path of least resistance, so it makes sense to optimize excellent builds to assist with 1000 kills each.

Attachment & Stat Priority Overview

A very basic TL;DR of the stat priority for Shipment is ADS > Strafe > everything else. Maximize ADS and movement speed (and thus, strafe), with as large of a magazine as possible, and by cleverly utilizing newly buffed big mags and mobility barrels, craft snappy, high-mobility, high-capacity powerhouses that move fast without excessive recoil.
The first thing you might notice about these optimized builds is that I don't actually use the No Stock attachment on any AR build; this is because despite the mobility boon, the recoil and first-shot kick penalties are far too extreme, even for Shipment. In short, in their current state, No Stock attachments are effectively useless (certain exceptions apply). If you're ever trying to knock someone off from headglitching a crate, the first-shot kick and visual recoil is going to obfuscate your own aim, no matter how much you humanly compensate for recoil.
To properly counter the No Stock penalties and get the weapon into a controllable state, you have to essentially stack recoil attachments, and by the time you do, you have no room for that extended magazine and your mobility numbers end up being worse with No Stock than the possible mobility combinations without it. At least, if you want something firing smoothly and clearly enough to knock people off mounted crate headies in Shipment.
The builds I present pervasively use mobility barrels, strafe stocks (carefully selected between Strafe/Sprint and full mobility options that harm recoil), Corio Laz Lasers (same ADS as FSS OLE-V, without the S2F bonus), Recoil Control Rear Grips, and extended magazines. While I outfitted every build with the intermediate option, 40/45-round extended magazines, all of these builds maintain strong mobility with maximum 60-round capacity magazines. The idea is to extract as much ADS and movement/strafe speed as humanly possible while countering the recoil with as little hand-holding as possible, placing the onus of recoil control in your hands. However, these builds have more than manageable recoil - I think you'll be quite surprised how quickly they can handle with how little recoil they have!
A particular ace attachment is the generic +Recoil Control Rear Grip. It has many names across many guns, but it provides an impressive amount of recoil reduction with absolutely no penalty to ADS. Aiming Idle Stability, despite being one of the most important stats in the game, is almost wholly unimportant on Shipment, considering that the sway (which is active while firing, contradicting 'idle') has little chance to knock you off target in your frequent short-range encounters. In the same vein, Recoil Stabilization takes a backseat as stable plots aren't necessarily needed when targets are so close.

It's a Good Time to Mention: the Best Ways to Control Recoil

If you missed it, I included a pretty detailed writeup on the best ways to control recoil - all in a clever series of settings that make an absolute world of difference. Section 3 of my Polyatomic & Orion guide - if you don't have these settings enabled, you'll be playing a different (and better) game soon.

Fully Optimized Assault Rifles for Shipment

If you're using Old Reddit, you may not see these pictures embedded. You should be able to click the links. All builds feature advanced stats, optimized directly from Symthic, including ADS, S2F, TTK, Range, Strafe, and TacSprint Speed!

M4A1

[Image] M4A1 optimized build for Shipment with advanced stats.
The classic M4A1. Good all around. Excellent mobility and best-in-class strafe speed.

Taq-56

[Image] Taq-56 optimized build for Shipment with advanced stats.
My personal favorite. The expected Taq mobility and pinpoint accuracy mixed with a mobility blend. Flash Hider added for minimal recoil control incurring a tiny ADS penalty to clear up the firing conditions. Just .08ms shy of the fastest fully-automatic TTK - a testament to its lethality.

Kastov 762

[Image] Kastov 762 optimized build for Shipment with advanced stats.
The Kastov 762 is difficult to save considering its bulky profile, but the barrel helps it come a long way. It almost starts to feel like an SMG, surprisingly enough. This will have one of the more intense recoil models.

Lachmann-556

[Image] Lachmann-556 optimized build for Shipment with advanced stats.
The newly buffed Lachmann-556 can now shred the entirety of Shipment in its native damage range while maintaining the signature easy, smooth recoil. Fastest movement speed in class, but low damage.

STB 556

[Image] STB 556 optimized build for Shipment with advanced stats.
A classic powerhouse with plenty of DPS and slaying power despite the unimpressive TTK, with unfortunately limited options in the mobility department; Strafe speed is below average and lowest in the class, but thankfully, the STB is a naturally fast-handling weapon.

M16

[Image] M16 optimized build for Shipment with advanced stats.
The obvious weakling and the only build to not feature an extended magazine. Everything is focused into tightening the consistency of the one-burst, and mobility is an afterthought.

Kastov-74u

[Image] Kastov-74u optimized build for Shipment with advanced stats.
The fan-favorite ASMG that will live up to your every expectation. Be as aggressive as you want, this 74u packs the speed and damage to keep up. Second-fastest ADS, and tied for fastest fully-automatic TTK with the Kastov 545. Third-fastest movement speed.

Kastov 545

[Image] Kastov 545 optimized build for Shipment with advanced stats.
An ultra-smooth recoil pattern complemented by extremely fast strafe. Unexpectedly amazing, especially with 60 rounds. Tied for fastest fully-automatic TTK with the Kastov-74u.

M13B

[Image] M13B optimized build for Shipment with advanced stats.
The M13 you remember from MW19. Lower damage, but fast mobility - and this one goes very fast. Randomly pleasing 1-2-3 cascade of timings with ADS/S2F/TTK. Intense recoil, but it's worth the mobility gains. Fastest ADS, second-fastest movement speed, and just .02m/s shy of fastest strafe speed.

Chimera

[Image] Chimera optimized build for Shipment with advanced stats.
Despite looking like a cookie-cutter build, this build took me a long time to find, and it still sucks! Unfortunately, the Chimera simply isn't good at anything, and I think this is about as good as you can get.

ISO Hemlock

[Image] ISO Hemlock optimized build for Shipment with advanced stats.
If only the Ironsights were better, I'd love to include the classic Recoil Control Rear Grip. Nonetheless, recoil is extremely manageable and movement is swift.

And there we have it!

I really hope you enjoy some of these builds. Despite following a similar formula, I paid very close attention to the stat weights of each individual attachment, considering the impact of diminishing returns and adjusting Tuning as such. You should find that they go much faster than advertised thanks to Tuning, so make sure to turn those dials to 11.

Let me know which build is your favorite, or which build(s) you liked! Yes, more fully optimized Shipment 24/7 loadouts are coming soon - SMGs next.

Did this guide help you?

You should consider joining XVI to find all of my guides in one place without having to look far - a one-stop shop for all of my guides. All of my guides are posted here to ModernWarfareII, but categorized and organized in XVI so you can find them easily. The mention of this subreddit is not intended to divert or "steal" traffic from this subreddit. There are no user posts in my subreddit and it is purely an informational resource for people to find my guides.
Thanks for reading. See you next guide :)

AMA RESOLUTION 235 November 2018 INAPPROPRIATE USE OF CDC Guidelines FOR PRESCRIBING OPIOIDS (Entire Document)
“Resolution 235 asks that our AMA applaud the CDC for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths; and be it further, that no entity should use MME thresholds as anything more than guidance and that MME thresholds should not be used to completely prohibit the prescribing of, or the filling of prescriptions for, medications used in oncology care, palliative medicine care, and addiction medicine care: and be it further, that our AMA communicate with the nation’s largest pharmacy chains and pharmacy benefit managers to recommend that they cease and desist with writing threatening letters to physicians and cease and desist with presenting policies, procedures and directives to retail pharmacists that include a blanket proscription against filling prescriptions for opioids that exceed certain numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care; and be it further, that AMA Policy opposing the legislating of numerical limits on medication dosage, duration of therapy, numbers of pills/tablets, etc., be reaffirmed; and be it further, that physicians should not be subject to professional discipline or loss of board certification or loss of clinical privileges simply for prescribing opioids at a quantitative level that exceeds the MME thresholds found in the CDC Guidelines; and be it further, that our AMA encourage the Federation of State Medical Boards and its member boards, medical specialty societies, and other entities to develop improved guidance on management of pain and management of potential withdrawal syndromes and other aspects of patient care for “legacy patients” who may have been treated for extended periods of time with high-dose opioid therapy for chronic non-malignant pain.
RESOLVED, that our American Medical Association (AMA) applaud the Centers for Disease Control and Prevention (CDC) for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths
RESOLVED, that our AMA actively continue to communicate and engage with the nation’s largest pharmacy chains, pharmacy benefit managers, National Association of Insurance Commissioners, Federation of State Medical Boards, and National Association of Boards of Pharmacy in opposition to communications being sent to physicians that include a blanket proscription against filing prescriptions for opioids that exceed numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care.
RESOLVED, that our AMA affirms that some patients with acute or chronic pain can benefit from taking opioid pain medications at doses greater than generally recommended in the CDC Guideline for Prescribing Opioids for Chronic Pain and that such care may be medically necessary and appropriate, and be it further
RESOLVED, that our AMA advocate against misapplication of the CDC Guideline for Prescribing Opioids by pharmacists, health insurers, pharmacy benefit managers, legislatures, and governmental and private regulatory bodies in ways that prevent or limit patients’ medical access to opioid analgesia, and be it further
RESOLVED, that our AMA advocate that no entity should use MME (morphine milligram equivalents) thresholds as anything more than guidance, and physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the MME thresholds found in the CDC Guideline for Prescribing Opioids.””
Pain Management Best Practices Inter-Agency Task Force - Draft Report on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations Official Health and Human Services Department Released December 2018
“The Comprehensive Addiction and Recovery Act (CARA) of 2016 led to the creation of the Pain Management Best Practices Inter-Agency Task Force (Task Force), whose mission is to determine whether gaps in or inconsistencies between best practices for acute and chronic pain management exist and to propose updates and recommendations to those best practices. The Task Force consists of 29 experts who have significant experience across the disciplines of pain management, patient advocacy, substance use disorders, mental health, and minority health.”
In addition to identifying approximately 60 gaps in clinical best practices and the current treatment of pain in the United States, HHS PMTF provided recommendations for each of these major areas of concern. In alignment with their original charter, the PMTF will submit these recommendations to Congress to become our ‘National Pain Policy’. The 60+ gaps and inconsistencies with their recommendations will serve to fill gaps in pain treatment at both the state and federal level; and the overwhelming consensus was that the treatment of pain should be multimodal and completely individualized based on the individual patient. The heart of each recommendation in each section was a resounding call for individualization for each patient, in regards to both non-pharmacological and pharmacological modalities; including individualizations in both opioid and non-opioid pharmacological treatments.
While each of the gap+recommendation sections of what is poised to become our national pain policy is extremely important, one that stands out the most (in regards to opioid prescribing) is the Stigma section. Contained in this section is one of the core statements that shows our Health and Human Services agency - the one that should have always been looked to and followed - knew the true depth of the relationship (or lack of) between the overdose crisis and compassionate prescribing to patients with painful conditions:
“The national crisis of illicit drug use, with overdose deaths, is confused with appropriate therapy for patients who are being treated for pain. This confusion has created a stigma that contributes to raise barriers to proper access to care.”
The recommendation that follows - “Identify strategies to reduce stigma in opioid use so that it is never a barrier to patients receiving appropriate treatment, with all cautions and considerations for the management of their chronic pain conditions” - illustrates an acknowledgment by the top health agency of the federal government that the current national narrative conflating and confusing compassionate treatment of pain with illicit drug use, addiction, and overdose death is incorrect and only serving to harm patients.
Since March of 2016 when the CDC Guidelines were released, advocates, patients, clinicians, stakeholders, and others, have began pointing out limitations and unintended consequences as they emerged. In order to address the unintended consequences emerging from the CDC Guidelines, this task force was also charged with review of these guidelines; from expert selection, evidence selection, creation, and continuing to current misapplication in order to provide recommendations to begin to remedy these issues.
“A commentary by Busse et al. identified several limitations to the CDC guideline related to expert selection, evidence inclusion criteria, method of evidence quality grading, support of recommendations with low-quality evidence, and instances of vague recommendations. In addition, the CDC used the criterion of a lack of clinical trials with a duration of one year or longer as lack of evidence for the clinical effectiveness of opioids, whereas Tayeb et al. found that that was true for all common medication and behavioral therapy studies.
Interpretation of the guideline, in addition to some gaps in the guideline, have led to unintended consequences, some of which are the result of misapplication or misinterpretation of the CDC guideline.
However, at least 28 states have enacted legislation related to opioid prescription limits, and many states and organizations have implemented the guideline without recognizing that the intended audience was PCPs; have used legislation for what should be medical decision making by healthcare professionals; and have applied them to all physicians, dentists, NPs, and PAs, including pain specialists.441–444 Some stakeholders have interpreted the guideline as intended to broadly reduce the amount of opioids prescribed for treating pain; some experts have noted that the guideline emphasizes the risk of opioids while minimizing the benefit of this medication class when properly managed.”
“The CDC guideline was not intended to be model legislation for state legislators to enact”
“In essence, clinicians should be able to use their clinical judgment to determine opioid duration for their patients”
https://www.hhs.gov/ash/advisory-committees/pain/reports/2018-12-draft-report-on-updates-gaps-inconsistencies-recommendations/index.html
HHS Review of 2016 CDC Guidelines for responsible opioid prescribing
The Pain Management Task Force addressed 8 areas that are in need of update or expansion with recommendations to begin remediation for each problem area:
Lack of high-quality data exists for duration of effectiveness of opioids for chronic pain; this has been interpreted as a lack of benefit Conduct studies Focus on patient variability and response for effectiveness of opioids; use real-world applicable trials
Absence of criteria for identifying patients for whom opioids make up significant part of their pain treatment Conduct clinical trials and/or reviews to identify sub-populations of patients where long-term opioid treatment is appropriate
Wide variation in factors that affect optimal dose of opioids Consider patient variables for opioid therapy: Respiratory compromise Patient metabolic variables Differences in opioid medications/plasma concentrations Preform comprehensive initial assessment it’s understanding of need for comprehensive reevaluations to adjust dose Give careful considerations to patients on opioid pain regimen with additional risk factors for OUD
Specific guidelines for opioid tapering and escalation need to be further clarified A thorough assessment of risk-benefit ratio should occur whenever tapering or escalation of dose This should include collaboration with patient whenever possible Develop taper or dose escalation guidelines for sub-populations that include consideration of their comorbidities When benefit outweighs the risk, consider maintaining therapy for stable patients on long term opioid therapy
Causes of worsening pain are not often recognized or considered. Non-tolerance related factors: surgery, flares, increased physical demands, or emotional distress Avoid increase in dose for stable patient (2+ month stable dose) until patient is re-evaluated for underlying cause of elevated pain or possible OUD risk Considerations to avoid dose escalation include: Opioid rotation Non-opioid medication Interventional strategies Cognitive behavior strategies Complementary and integrative health approaches Physical therapy
In patients with chronic pain AND anxiety or spasticity, benzodiazepine co-prescribed with opioids still have clinical value; although the risk of overdose is well established When clinically indicated, co-prescription should be managed by specialist who have knowledge, training, and experience with co-prescribing. When co-prescribed for anxiety or SUD collaboration with mental health should be considered Develop clinical practice guidelines focused on tapering for co-prescription of benzodiazepines and opioids
The risk-benefit balance varies for individual patients. Doses >90MME may be favorable for some where doses <90MME may be for other patients due to individual patient factors. Variability in effectiveness and safety between high and low doses of opioids are not clearly defined. Clinicians should use caution with higher doses in general Using carefully monitored trial with frequent monitoring with each dose adjustment and regular risk reassessment, physicians should individualize doses, using lowest effective opioid dose that balances benefit, risk, and adverse reactions Many factors influence benefits and risk, therefore, guidance of dose should not be applied as strict limits. Use established and measurable goals: Functionality ADL Quality of Life
Duration of pain following acute and severely painful event is widely variable Appropriate duration is best considered within guidelines, but is ultimately determined by treating clinician. CDC recommendation for duration should be emphasized as guidance only with individualized patient care as the goal Develop acute pain management guidelines for common surgical procedures and traumas To address variability and provide easy solution, consideration should be given to partial refill system
Human Rights Watch December 2018 (Excerpt from 109 page report)
“If harms to chronic pain patients are an unintended consequence of policies to reduce inappropriate prescribing, the government should seek to immediately minimize and measure the negative impacts of these policies. Any response should avoid further stigmatizing chronic pain patients, who are increasingly associated with — and sometimes blamed for — the overdose crisis and characterized as “drug seekers,” rather than people with serious health problems that require treatment.
Top government officials, including the President, have said the country should aim for drastic cutbacks in prescribing. State legislatures encourage restrictions on prescribing through new legislation or regulations. The Drug Enforcement Administration (DEA) has investigated medical practitioners accused of overprescribing or fraudulent practice. State health agencies and insurance companies routinely warn physicians who prescribe more opioids than their peers and encourage them to reduce prescribing. Private insurance companies have imposed additional requirements for covering opioids, some state Medicaid programs have mandated tapering to lower doses for patients, and pharmacy chains are actively trying to reduce the volumes of opioids they dispense.
The medical community at large recognized that certain key steps were necessary to tackle the overdose crisis: identifying and cracking down on “pill mills” and reducing the use of opioids for less severe pain, particularly for children and adolescents. However, the urgency to tackle the overdose crisis has put pressure on physicians in other potentially negative ways: our interviews with dozens of physicians found that the atmosphere around prescribing for chronic pain had become so fraught that physicians felt they must avoid opioid analgesics even in cases when it contradicted their view of what would provide the best care for their patients. In some cases, this desire to cut back on opioid prescribing translated to doctors tapering patients off their medications without patient consent, while in others it meant that physicians would no longer accept patients who had a history of needing high-dose opioids.
The consequences to patients, according to Human Rights Watch research, have been catastrophic.”
[https://www.hrw.org/report/2018/12/18/not-allowed-be-compassionate/chronic-pain-overdose-crisis-and-unintended-harms-us](
Opioid Prescribing Workgroup December 2018
This is material from the Board of Scientific Counselors in regards to their December 12, 2018 meeting that culminated the works of a project titled the “Opioid Prescribing Estimates Project.” This project is a descriptive study that is examining opioid prescribing patterns at a population level. Pain management is a very individualized process that belongs with the patient and provider. The Workgroup reviewed work done by CDC and provided additional recommendations.
SUMMARY There were several recurrent themes throughout the sessions.
Repeated concern was voiced from many Workgroup members that the CDC may not be able to prevent conclusions from this research (i.e. the benchmarks, developed from limited data) from being used by states or payors or clinical care systems to constrain clinical care or as pay-for- performance standards – i.e. interpreted as “guidelines”. This issue was raised by several members on each of the four calls, raising the possibility that providers or clinical systems could thus be incentivized against caring for patients requiring above average amounts of opioid medication.
Risk for misuse of the analysis. Several members expressed concerns that this analysis could be interpreted as guidance by regulators, health plans, or clinical care systems. Even though the CDC does not plan to issue this as a guideline, but instead as research, payors and clinical care systems searching for ways to reign in opioid prescribing may utilize CDC “benchmarks” to establish pay-for-performance or other means to limit opioid prescribing. Such uses of this work could have the unintended effect of incentivizing providers against caring for patients reliant upon opioids.
…It was also noted that, in order to obtain sufficient granularity to establish the need for, dosage, and duration of opioid therapy, it would be necessary to have much more extensive electronic medical record data. In addition, pain and functional outcomes are absent from the dataset, but were felt to be important when considering risk and benefit of opioids.
...Tapering: Concerns about benchmarks and the implications for tapering were voiced. If tapering occurs, guidance was felt to be needed regarding how, when, in whom tapering should occur. This issue was felt to be particularly challenging for patients on chronic opioids (i.e. “legacy” patients). In addition, the importance of measuring risk and benefit of tapering was noted. Not all high-dose patient populations benefit from tapering.
Post-Surgical Pain
General comments. Workgroup members noted that most patients prescribed opioids do not experience adverse events, including use disorder. Many suggested that further discussion of opioids with patients prior to surgery was important, with an emphasis on expectations and duration of treatment. A member suggested that take-back programs would be more effective than prescribing restrictions.
Procedure-related care. Members noted that patient factors may drive opioid need more than characteristics of a procedure.
Patient-level factors. Members noted that opioid-experienced patients should be considered differently from opioid-inexperienced patients, due to tolerance.
Chronic Pain
It was noted that anything coming out of the CDC might be considered as guidelines and that this misinterpretation can be difficult to counter. There was extensive discussion of the 50 and 90 MME levels included in the CDC Guidelines. It was recommended that the CDC look into the adverse effects of opioid tapering and discontinuation, such as illicit opioid use, acute care utilization, dropping out of care, and suicide. It was also noted that there are major gaps in guidelines for legacy patients, patients with multiple diagnoses, pediatric and geriatric patients, and patients transitioning to lower doses.
There were concerns that insufficient clinical data will be available from the dataset to appropriately consider the individual-level factors that weigh into determination of opioid therapy. The data would also fail to account for the shared decision-making process involved in opioid prescribing for chronic pain conditions, which may be dependent on primary care providers as well as ancillary care providers (e.g. physical therapists, psychologists, etc).
Patient-level factors. Members repeatedly noted that opioid-experienced patients should be considered differently from opioid-experienced patients, due to tolerance.
Members noted that the current CDC guidelines have been used by states, insurance companies, and some clinical care systems in ways that were not intended by the CDC, resulting in cases of and the perception of patient abandonment. One option raised in this context was to exclude patients on high doses of opioids, as those individuals would be qualitatively different from others. A variant of this concern was about management of “legacy” patients who are inherited on high doses of opioids. Members voiced concerns that results of this work has caused harm to patients currently reliant upon opioids prescribed by their providers.
Acute Non-Surgical Pain
Patient-level factors. Members felt that opioid naïve versus experienced patients might again be considered separately, as opioid requirements among those experienced could vary widely.
...Guidelines were also noted to be often based on consensus, which may be incorrect.
Cancer-Related and Palliative Care Pain
It was noted that the CDC guidelines have been misinterpreted to create a limit to the dose of opioids that can be provided to people at all stages of cancer and its treatment. It was also noted that the cancer field is rapidly evolving, with immunotherapy, CAR-T, and other novel treatments that affect response rates and limit our ability to rely upon historical data in establishing opioid prescribing benchmarks.
Concern that data would not be able to identify all of the conditions responsible for pain in a patient with a history of cancer (e.g. people who survive cancer but with severe residual pain). Further, it was noted that certain complications of cancer and cancer treatment may require the least restrictive long-term therapy with opioids.
The definition of palliative care was also complicated and it was suggested that this include patients with life-limiting conditions.
Overall, it was felt that in patients who may not have long to live, and/or for whom returning to work is not a possibility, higher doses of opioids may be warranted.
https://www.cdc.gov/injury/pdfs/bsc/NCIPC_BSC_OpioidPrescribingEstimatesWorkgroupReport_December-12_2018-508.pdf
CDC Scientists Anonymous ‘Spider Letter’ to CDC
Carmen S. Villar, MSW Chief of Staff Office of the Director MS D­14 Centers for Disease Control and Prevention (CDC) 1600 Clifton Road Atlanta, Georgia 30329­-4027
August 29, 2016
Dear Ms. Villar:
We are a group of scientists at CDC that are very concerned about the current state of ethics at our agency. It appears that our mission is being influenced and shaped by outside parties and rogue interests. It seems that our mission and Congressional intent for our agency is being circumvented by some of our leaders. What concerns us most, is that it is becoming the norm and not the rare exception. Some senior management officials at CDC are clearly aware and even condone these behaviors. Others see it and turn the other way. Some staff are intimidated and pressed to do things they know are not right. We have representatives from across the agency that witness this unacceptable behavior. It occurs at all levels and in all of our respective units. These questionable and unethical practices threaten to undermine our credibility and reputation as a trusted leader in public health. We would like to see high ethical standards and thoughtful, responsible management restored at CDC. We are asking that you do your part to help clean up this house!
It is puzzling to read about transgressions in national media outlets like USA Today, The Huffington Post and The Hill. It is equally puzzling that nothing has changed here at CDC as a result. It’s business as usual. The litany of issues detailed over the summer are of particular concern:
Recently, the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) has been implicated in a “cover up” of inaccurate screening data for the Wise Woman (WW) Program. There was a coordinated effort by that Center to “bury” the fact that screening numbers for the WW program were misrepresented in documents sent to Congress; screening numbers for 2014 and 2015 did not meet expectations despite a multi­million dollar investment; and definitions were changed and data “cooked” to make the results look better than they were. Data were clearly manipulated in irregular ways. An “internal review” that involved staff across CDC occurred and its findings were essentially suppressed so media and/or Congressional staff would not become aware of the problems. Now that both the media and Congresswoman DeLauro are aware of these issues, CDC staff have gone out of their way to delay FOIAs and obstruct any inquiry. Shouldn’t NCCDPHP come clean and stop playing games? Would the ethical thing be to answer the questions fully and honestly. The public should know the true results of what they paid for, shouldn’t they?
Another troubling issue at the NCCDPHP are the adventures of Drs. Barbara Bowman and Michael Pratt (also detailed in national media outlets). Both seemed to have irregular (if not questionable) relationships with Coca­Cola and ILSI representatives. Neither of these relationships were necessary (or appropriate) to uphold our mission. Neither organization added any value to the good work and science already underway at CDC. In fact, these ties have now called into question and undermined CDC’s work. A cloud has been cast over the ethical and excellent work of scientists due to this wanton behavior. Was cultivating these relationships worth dragging CDC through the mud? Did Drs. Bowman and Pratt have permission to pursue these relationships from their supervisor Dr. Ursula Bauer? Did they seek and receive approval of these outside activities? CDC has a process by which such things should be vetted and reported in an ethics review, tracking and approval system (EPATS). Furthermore, did they disclose these conflicts of interest on their yearly OGE 450 filing. Is there an approved HHS 520, HHS 521 or “Request for Official Duty Activities Involving an Outside Organization” approved by Dr. Bauer or her Deputy Director Ms. Dana Shelton? An August 28, 2016 item in The Hill details these issues and others related to Dr. Pratt.
It appears to us that something very strange is going on with Dr. Pratt. He is an active duty Commissioned Corps Officer in the USPHS, yet he was “assigned to” Emory University for a quite some time. How and under what authority was this done? Did Emory University pay his salary under the terms of an IPA? Did he seek and receive an outside activity approval through EPATS and work at Emory on Annual Leave? Formal supervisor endorsement and approval (from Dr. Bauer or Ms. Shelton) is required whether done as an official duty or outside activity.
If deemed official, did he file a “Request for Official Duty Activities Involving an Outside Organization” in EPATS? Apparently Dr. Pratt’s position at Emory University has ended and he has accepted another position at the University of California ­ San Diego? Again, how is this possible while he is still an active duty USPHS Officer. Did he retire and leave government service? Is UCSD paying for his time via an IPA? Does he have an outside activity approval to do this? Will this be done during duty hours? It is rumored that Dr. Pratt will occupy this position while on Annual Leave? Really? Will Dr. Pratt be spending time in Atlanta when not on Annual Leave? Will he make an appearance at NCCDPHP (where he hasn’t been seen for months). Most staff do not enjoy such unique positions supported and approved by a Center Director (Dr. Bauer). Dr. Pratt has scored a sweet deal (not available to most other scientists at CDC). Concerns about these two positions and others were recently described in The Huffington Post and The Hill. His behavior and that of management surrounding this is very troubling.
Finally, most of the scientists at CDC operate with the utmost integrity and ethics. However, this “climate of disregard” puts many of us in difficult positions. We are often directed to do things we know are not right. For example, Congress has made it very clear that domestic funding for NCCDPHP (and other CIOs) should be used for domestic work and that the bulk of NCCDPHP funding should be allocated to program (not research). If this is the case, why then is NCCDPHP taking domestic staff resources away from domestic priorities to work on global health issues? Why in FY17 is NCCDPHP diverting money away from program priorities that directly benefit the public to support an expensive research FOA that may not yield anything that benefits the public? These actions do not serve the public well. Why is nothing being done to address these problems? Why has the CDC OD turned a blind eye to these things. The lack of respect for science and scientists that support CDC’s legacy is astonishing.
Please do the right thing. Please be an agent of change.
Respectfully,
CDC Spider (CDC Scientists Preserving Integrity, Diligence and Ethics in Research)
https://usrtk.org/wp-content/uploads/2016/10/CDC_SPIDER_Letter-1.pdf
January 13, 2016
Thomas Frieden, MD, MPH Director Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30329-4027
Re: Docket No. CDC-2015-0112; Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain
Dear Dr. Frieden:
There is no question that there is an opioid misuse epidemic and that efforts need to be made to control it. The Centers for Disease Control and Prevention (CDC) is applauded for its steps to undertake this lofty effort. However, based on the American Academy of Family Physicians’ (AAFP’s) review of the guideline, it is apparent that the presented recommendations are not graded at a level consistent with currently available evidence. The AAFP certainly wants to promote safe and appropriate prescribing of opioids; however, we recommend that the CDC still adhere to the rigorous standards for reliable and trustworthy guidelines set forth by the Institute of Medicine (IOM). The AAFP believes that giving a strong recommendation derived from generalizations based on consensus expert opinion does not adhere to evidence-based standards for developing clinical guideline recommendations.
The AAFP’s specific concerns with the CDC’s methodology, evidence base, and recommendations are outlined below.
Methodology and Evidence Base
All of the recommendations are based on low or very low quality evidence, yet all but one are Category A (or strong) recommendations. The guideline states that in the GRADE methodology "a particular quality of evidence does not necessarily imply a particular strength of recommendation." While this is true, it applies when benefits significantly outweigh harms (or vice versa). When there is insufficient evidence to determine the benefits and harms of a recommendation, that determination should not be made.
When evaluating the benefits of opioids, the evidence review only included studies with outcomes of at least one year. However, studies with shorter intervals were allowed for analysis of the benefits of nonopioid treatments. The guideline states that no evidence shows long-term benefit of opioid use (because there are few studies), yet the guideline reports "extensive evidence" of potential harms, even though these studies were of low quality. The accompanying text also states "extensive evidence" of the benefits of non-opioid treatments, yet this evidence was from shorter term studies, was part of the contextual review rather than the clinical systematic review, and did not compare non- opioid treatments to opioids.
The patient voice and preferences were not explicitly included in the guideline. This raises concerns about the patient-centeredness of the guideline.
https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/risk/LT-CDC-OpioidGuideline011516.pdf The Myth of Morphine Equivalent Daily Dosage Medscape Neuro Perspective
For far too many years, pain researchers and clinicians have relied on the concept of the morphine equivalent daily dosage (MEDD), or some variant of it, as a means of comparing the "relative corresponding quantity" of the numerous opioid molecules that are important tools in the treatment of chronic pain.
...And, most unfortunately, opioid prescribing guideline committees have relied on this concept as a means of placing (usually arbitrary) limits on the levels of opioids that a physician or other clinician should be allowed to prescribe. Although these guidelines typically bill themselves as "voluntary," their chilling effect on prescribers and adaptation into state laws[2] makes calling them "voluntary" disingenuous.
Although some scientists and clinicians have been questioning the conceptual validity of MEDD for several years, a recent study[3] has indicated that the concept is unequivocally flawed—thereby invalidating its use empirically and as a tool in prescribing guideline development.
The authors used survey data from pharmacists, physicians, nurse practitioners, and physician assistants to estimate daily morphine equivalents and found great inconsistency in their conversions of hydrocodone, fentanyl transdermal patches, methadone, oxycodone, and hydromorphone—illustrating the potential for dramatic underdosing or, in other cases, fatal overdosing.
Patients with chronic pain (particularly that of noncancer origin) who are reliant on opioid analgesia are already sufficiently stigmatized and marginalized[7] to allow this type of practice to continue to be the norm.
Although the use of MEDD in research and, to a greater extent, in practice, is probably due to unawareness of its inaccuracy, we posit that the use of MEDD by recent opioid guideline committees (eg, the Washington State Opioid Guideline Committee[8] and the Centers for Disease Control and Prevention Guideline Committee[9]) in the drafting of their guidelines is based more heavily on disregarding available evidence rather than ignorance. Furthermore, their misconduct in doing so has been more pernicious than the use of MEDD by researchers and individual clinicians, because these guidelines widely affect society as a whole as well as individual patients with persistent pain syndromes. We opine that these committees are strongly dominated by the antiopioid community, whose agenda is to essentially restrict opioid access—irrespective of the lack of data indicating that opioids cannot be a useful tool in the comprehensive treatment of carefully selected and closely monitored patients with chronic pain.
Above 100% extracted from: Medscape Journal Brief https://www.medscape.com/viewarticle/863477_2
Actual Study https://www.dovepress.com/the-medd-myth-the-impact-of-pseudoscience-on-pain-research-and-prescri-peer-reviewed-article-JPR
Are Non-Opioid Medications Superior in Treatment of Pain than Opioid Pain Medicine? Ice Cream Flavor Analogy...
In the Oxford University Press, a November 2018 scientific white paper[5] was released that examined the quality of one of the primary studies that have been used to justify the urgent call to drastically reduce opioid pain medication prescribing while claiming that patients are not being harmed in the process.
The study is commonly referred to as ‘the Krebs study’. “The authors concluded that treatment with opioids was not superior to treatment with non opioid medications for improving pain-related function over 12 months.”
Here is an excerpt from the first paragraph of the design section (usually behind a paywall) from the Krebs study that gives the first hint of the bias that led to them to ‘prove’ that opioids were not effective for chronic pain:

“The study was intended to assess long-term outcomes of opioids compared with non opioid medications for chronic pain. The patient selection, though, specifically excluded patients on long-term opioid therapy.” 

Here is an analogy given in the Oxford Journal white paper to illustrate how the study design was compromised:
If I want to do a randomized control study about ice cream flavor preferences (choices being: vanilla, chocolate, or no preference), the results could be manipulated as follows based on these scenarios:
Scenario A: If a study was done that included only current ice-cream consumers, the outcome would certainly be vanilla or chocolate, because of course they have tried it and know which they like.
Scenario B: If a study was done that included all consumers of all food, then it can change the outcome. If the majority of study participants do not even eat ice-cream, than the result would certainly be ‘no preference’. If the majority do eat ice-cream it would likely be ‘chocolate’. Although this study is wider based, it still does not reflect real world findings.
Scenario C: In an even more extreme example, if this same study is conducted excluding anyone who has ever ate ice-cream at all, then the conclusion will again be ‘no preference’ and the entire study/original question becomes so ludicrous that there is no useful information to be extracted from this study and one would logically question why this type of study would even be conducted (although we know the answer to that)
Scenario C above is how the study that has been used to shift the attitudes towards the treatment of pain in our nation's medical community was designed. “One has to look deep into the study to find that they began with 9403 possible patients and excluded 3836 of them just because they had opioids in their EMR. In the JAMA article, they do not state these obvious biases and instead begin the explanation of participants stating they started with 4485 patients and excluded 224 who were opioid or benzo users.” That is the tip of the iceberg to how it is extremely misleading. The Oxford white paper goes into further detail of the studies “many flaws and biases (including the narrow focus on conditions that are historically known to respond poorly to opioid medication management of pain)”, but the study design and participant selection criteria is enough to discredit this entire body of work. Based on study design alone, regardless of what happened next, the result would be that opioids are no more effective than NSAIDs and other non-opioid alternatives.
The DEA Is Fostering a Bounty Hunter Culture in its Drug Diversion Investigators[8]
A Good Man Speaks Truth to Power January 2019
Because I write and speak widely on public health issues and the so-called “opioid crisis”, people frequently send me references to others’ work. One of the more startling articles I’ve seen lately was published November 20, 2018 in Pharmacy Times. It is titled “Should We Believe Patients With Pain?”[9]. The unlikely author is Commander John Burke, “a 40-year veteran of law enforcement, the past president of the National Association of Drug Diversion Investigators, and the president and cofounder of the International Health Facility Diversion Association.”
The last paragraph of Commander Burke’s article is worth repeating here.
“Let’s get back to dealing with each person claiming to be in legitimate pain and believe them until we have solid evidence that they are scamming the system. If they are, then let’s pursue them through vigorous prosecution, but let’s not punish the majority of people receiving opioids who are legitimate patients with pain.”
This seems a remarkable insight from anyone in law enforcement — especially from one who has expressed this view in both Pain News Network, and Dr Lynn Webster’s video “The Painful Truth”. Recognizing Commander Burke’s unique perspective, I followed up by phone to ask several related questions. He has granted permission to publish my paraphrases of his answers here.
“Are there any available source documents which establish widely accepted standards for what comprises “over-prescription?” as viewed by diversion investigators?” Burke’s answer was a resounding “NO”. Each State and Federal Agency that investigates doctors for potentially illegal or inappropriate opioid prescribing is pretty much making up their own standards as they go. Some make reference to the 2016 CDC Guidelines, but others do not.

1. “Thousands of individual doctors have left pain management practice in recent years due to fears they may be investigated, sanctioned, and lose their licenses if they continue to treat patients with opioid pain relievers.. Are DEA and State authorities really pursuing the worst “bad actors”, or is something else going on?

Burke’s answer: “Regulatory policy varies greatly between jurisdictions. But a hidden factor may be contributing significantly to the aggressiveness of Federal investigators. Federal Agencies may grant financial bonuses to their in-house diversion investigators, based on the volume of fines collected from doctors, nurse practitioners, PAs and others whom they investigate.

"No law enforcement agency at any level should be rewarded with monetary gain and/or promotion due to their work efforts or successes. This practice has always worried me with Federal investigators and is unheard of at the local or state levels of enforcement.”

Commander Burke’s revelation hit me like a thunder-clap. It would explain many of the complaints I have heard from doctors who have been “investigated” or prosecuted. It’s a well known principle that when we subsidize a behavior, we get more of it. Financial rewards to investigators must inevitably foster a “bounty hunter” mentality in some. It seems at least plausible that such bonuses might lead DEA regulators to focus on “low hanging fruit” among doctors who may not be able to defend themselves without being ruined financially. The practice is at the very least unethical. Arguably it can be corrupting.
I also inquired concerning a third issue:

1. I read complaints from doctors that they have been pursued on trumped-up grounds, coerced and denied appropriate legal defense by confiscation of their assets – which are then added to Agency funds for further actions against other doctors. Investigations are also commonly announced prominently, even before indictments are obtained – a step that seems calculated to destroy the doctor’s practice, regardless of legal outcomes. Some reports indicate that DEA or State authorities have threatened employees with prosecution if they do not confirm improper practices by the doctor. Do you believe such practices are common?”

Burke’s answer: “I hear the same reports you do – and the irony is that such tactics are unnecessary. Lacking an accepted standard for over-prescribing, the gross volume of a doctor’s prescriptions or the dose levels prescribed to their patients can be poor indicators of professional misbehavior. Investigators should instead be looking into the totality of the case, which can include patient reports of poor doctor oversight, overdose-related hospital admissions, and patterns of overdose related deaths that may be linked to a “cocktail” of illicit prescribing. Especially important can be information gleaned from confidential informants – with independent verification – prior patients, and pharmacy information.”

No formal legal prosecution should ever proceed from the testimony of only one witness — even one as well informed as Commander John Burke. But it seems to me that it is high time for the US Senate Judiciary Committee to invite the testimony of others in open public hearings, concerning the practice of possible bounty hunting among Federal investigators.
C50 Patient, Civil Rights Attorney, Maine Department of Health, and Maine Legislature Collaborative Enacted Definition of Palliative Care
One suggestion that our organization would like to make is altering the definition of “palliative care” in such a manner that it can include high-impact or intractable patients; those who are not dying this year, but our lives have been shattered and/or shortened by our diseases and for whom Quality of Life should be the focus. Many of our conditions may not SIGNIFICANTLY shorten my life, therefore I could legitimately be facing 30-40 years of severe pain with little relief; that is no way to live and therefore the concern is a rapidly increasing suicide rate.
This is a definition that one of our coalition members with a civil rights attorney and the Maine Department of Health agreed upon and legislators enacted into statues in Maine. This was in response to a 100mme restriction. This attorney had prepared a lawsuit based on the Americans with Disability Act that the Department of Health in Maine agreed was valid; litigation was never the goal, it was always patient-centered care.
A. "Palliative care" means patient-centered and family-focused medical care that optimizes quality of life by anticipating, preventing and treating suffering caused by a medical illness or a physical injury or condition that substantially affects a patient's quality of life, including, but not limited to, addressing physical, emotional, social and spiritual needs; facilitating patient autonomy and choice of care; providing access to information; discussing the patient's goals for treatment and treatment options, including, when appropriate, hospice care; and managing pain and symptoms comprehensively. Palliative care does not always include a requirement for hospice care or attention to spiritual needs. B. "Serious illness" means a medical illness or physical injury or condition that substantially affects quality of life for more than a short period of time. "Serious illness" includes, but is not limited to, Alzheimer's disease and related dementias, lung disease, cancer, heart, renal or liver failure and chronic, unremitting or intractable pain such as neuropathic pain.
Here is the link to the most recent update, including these definitions within the entire statute: https://legislature.maine.gov/statutes/22/title22sec1726.html?fbclid=IwAR0dhlwEh56VgZI9HYczdjdyYoJGpMdA9TuuJLlQrO3AsSljIZZG0RICFZc
January 23, 2019
Dear Pharmacists,
The Board of Pharmacy has had an influx of communication concerning patients not able to get controlled substance prescriptions filled for various reasons, even when signs of forgery or fraudulence were not presented. As a result of the increased “refusals to fill,” the board is issuing the following guidance and reminders regarding the practice of pharmacy and dispensing of controlled substances:

1. Pharmacists must use reasonable knowledge, skill, and professional judgment when evaluating whether to fill a prescription. Extreme caution should be used when deciding not to fill a prescription. A patient who suddenly discontinues a chronic medication may experience negative health consequences;
   
2. Part of being a licensed healthcare professional is that you put the patient first. This means that if a pharmacist has any concern regarding a prescription, they should attempt to have a professional conversation with the practitioner to resolve those concerns and not simply refuse the prescription. Being a healthcare professional also means that you use your medication expertise during that dialogue in offering advice on potential alternatives, changes in the prescription strength, directions etc. Simply refusing to fill a prescription without trying to resolve the concern may call into question the knowledge, skill or judgment of the pharmacist and may be deemed unprofessional conduct;
   
3. Controlled substance prescriptions are not a “bartering” mechanism. In other words, a pharmacist should not tell a patient that they have refused to fill a prescription and then explain that if they go to a pain specialist to get the same prescription then they will reconsider filling it. Again, this may call into question the knowledge, skill or judgment of the pharmacist;
   
4. Yes, there is an opioid crisis. However, this should in no way alter our professional approach to treatment of patients in end-of-life or palliative care situations. Again, the fundamentals of using our professional judgment, skill and knowledge of treatments plays an integral role in who we are as professionals. Refusing to fill prescriptions for these patients without a solid medical reason may call into question whether the pharmacist is informed of current professional practice in the treatment of these medical cases.
   
5. If a prescription is refused, there should be sound professional reasons for doing so. Each patient is a unique medical case and should be treated independently as such. Making blanket decisions regarding dispensing of controlled substances may call into question the motivation of the pharmacist and how they are using their knowledge, skill or judgment to best serve the public.
   

As a professional reminder, failing to practice pharmacy using reasonable knowledge, skill, competence, and safety for the public may result in disciplinary actions under Alaska statute and regulation. These laws are:
AS 08.80.261 DISCIPLINARY ACTIONS
(a)The board may deny a license to an applicant or, after a hearing, impose a disciplinary sanction authorized under AS 08.01.075 on a person licensed under this chapter when the board finds that the applicant or licensee, as applicable, …
(7) is incapable of engaging in the practice of pharmacy with reasonable skill, competence, and safety for the public because of
(A) professional incompetence; (B) failure to keep informed of or use current professional theories or practices; or (E) other factors determined by the board;
(14) engaged in unprofessional conduct, as defined in regulations of the board.
12 AAC 52.920 DISCIPLINARY GUIDELINES
(a) In addition to acts specified in AS 08.80 or elsewhere in this chapter, each of the following constitutes engaging in unprofessional conduct and is a basis for the imposition of disciplinary sanctions under AS 08.01.075; …
(15) failing to use reasonable knowledge, skills, or judgment in the practice of pharmacy;
(b) The board will, in its discretion, revoke a license if the licensee …
(4) intentionally or negligently engages in conduct that results in a significant risk to the health or safety of a patient or injury to a patient; (5) is professionally incompetent if the incompetence results in a significant risk of injury to a patient.
(c) The board will, in its discretion, suspend a license for up to two years followed by probation of not less than two years if the licensee ...
(2) is professionally incompetent if the incompetence results in the public health, safety, or welfare being placed at risk.
We all acknowledge that Alaska is in the midst of an opioid crisis. While there are published guidelines and literature to assist all healthcare professionals in up to date approaches and recommendations for medical treatments per diagnosis, do not confuse guidelines with law; they are not the same thing.
Pharmacists have an obligation and responsibility under Title 21 Code of Federal Regulations 1306.04(a), and a pharmacist may use professional judgment to refuse filling a prescription. However, how an individual pharmacist approaches that particular situation is unique and can be complex. The Board of Pharmacy does not recommend refusing prescriptions without first trying to resolve your concerns with the prescribing practitioner as the primary member of the healthcare team. Patients may also serve as a basic source of information to understand some aspects of their treatment; do not rule them out in your dialogue.
If in doubt, we always recommend partnering with the prescribing practitioner. We are all licensed healthcare professionals and have a duty to use our knowledge, skill, and judgment to improve patient outcomes and keep them safe.
Professionally,
Richard Holt, BS Pharm, PharmD, MBA Chair, Alaska Board of Pharmacy
https://www.commerce.alaska.gov/web/portals/5/pub/pha_ControlledSubstanceDispensing_2019.01.pdf
FDA in Brief: FDA finalizes new policy to encourage widespread innovation and development of new buprenorphine treatments for opioid use disorder
February 6, 2018
Media Inquiries Michael Felberbaum 240-402-9548
“The opioid crisis has had a tragic impact on individuals, families, and communities throughout the country. We’re in urgent need of new and better treatment options for opioid use disorder. The guidance we’re finalizing today is one of the many steps we’re taking to help advance the development of new treatments for opioid use disorder, and promote novel formulations or delivery mechanisms of existing drugs to better tailor available medicines to individuals’ needs,” said FDA Commissioner Scott Gottlieb, M.D. “Our goal is to advance the development of new and better ways of treating opioid use disorder to help more Americans access successful treatments. Unfortunately, far too few people who are addicted to opioids are offered an adequate chance for treatment that uses medications. In part, this is because private insurance coverage for treatment with medications is often inadequate. Even among those who can access some sort of treatment, it’s often prohibitively difficult to access FDA-approved addiction medications. While states are adopting better coverage owing to new legislation and resources, among public insurance plans there are still a number of states that are not covering all three FDA-approved addiction medications. To support more widespread adoption of medication-assisted treatment, the FDA will also continue to take steps to address the unfortunate stigma that’s sometimes associated with use of these products. It’s part of the FDA’s public health mandate to promote appropriate use of therapies.
Misunderstanding around these products, even among some in the medical and addiction fields, enables stigma to attach to their use. These views can serve to keep patients who are seeking treatment from reaching their goal. That stigma reflects a perspective some have that a patient is still suffering from addiction even when they’re in full recovery, just because they require medication to treat their illness. This owes to a key misunderstanding of the difference between a physical dependence and an addiction. Because of the biology of the human body, everyone who uses a meaningful dose of opioids for a modest length of time develops a physical dependence. This means that there are withdrawal symptoms after the use stops.
A physical dependence to an opioid drug is very different than being addicted to such a medication. Addiction requires the continued use of opioids despite harmful consequences on someone’s life. Addiction involves a psychological preoccupation to obtain and use opioids above and beyond a physical dependence.
But someone who is physically dependent on opioids as a result of the treatment of pain but who is not craving the drugs is not addicted.
The same principle applies to replacement therapy used to treat opioid addiction. Someone who requires long-term treatment for opioid addiction with medications, including those that are partial or complete opioid agonists and can create a physical dependence, isn’t addicted to those medications. With the right treatments coupled to psychosocial support, recovery from opioid addiction is possible. The FDA remains committed to using all of our tools and authorities to help those currently addicted to opioids, while taking steps to prevent new cases of addiction.”
Above is the full statement, find full statement with options for study requests: https://www.fda.gov/NewsEvents/Newsroom/FDAInBrief/ucm630847.htm
Maryland’s co-prescribing new laws/ amendments regarding benzos and opioids
Chapter 215 AN ACT concerning Health Care Providers – Opioid and Benzodiazepine Prescriptions – Discussion of Information Benefits and Risks
FOR the purpose of requiring that certain patients be advised of the benefits and risks associated with the prescription of certain opioids, and benzodiazepines under certain circumstances, providing that a violation of this Act is grounds for disciplinary action by a certain health occupations board; and generally relating to advice regarding benefits and risks associated with opioids and benzodiazepines that are controlled dangerous substances.
Section 1–223 Article – Health Occupations Section 4–315(a)(35), 8–316(a)(36), 14–404(a)(43), and 16–311(a)(8) SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, That the Laws of Maryland read as follows: Article – Health Occupations (a) In this section, “controlled dangerous substance” has the meaning stated in § 5–101 of the Criminal Law Article.
Ch. 215 2018 LAWS OF MARYLAND (B) On treatment for pain, a health care provider, based on the clinical judgment of the health care provider, shall prescribe: (1) The lowest effective dose of an opioid; and (2)A quantity that is no greater than the quantity needed for the expected duration of pain severe enough to require an opioid that is a controlled dangerous substance unless the opioid is prescribed to treat: (a.) A substance–related disorder; (b.) Pain associated with a cancer diagnosis; (c.) Pain experienced while the patient is receiving end–of–life, hospice, or palliative care services; or (d.) Chronic pain
(C.) The dosage, quantity, and duration of an opioid prescribed under [subsection (b)] of this [section] shall be based on an evidence–based clinical guideline for prescribing controlled dangerous substances that is appropriate for: (1.) The health care service delivery setting for the patient; (2.) The type of health care services required by the patient; (3.) and The age and health status of the patient.
(D) (1) WHEN A PATIENT IS PRESCRIBED AN OPIOID UNDER SUBSECTION (B) OF THIS SECTION, THE PATIENT SHALL BE ADVISED OF THE BENEFITS AND RISKS ASSOCIATED WITH THE OPIOID.

 (2) WHEN A PATIENT IS CO–PRESCRIBED A BENZODIAZEPINE WITH AN OPIOID THAT IS PRESCRIBED UNDER SUBSECTION (B) OF THIS SECTION, THE PATIENT SHALL BE ADVISED OF THE BENEFITS AND RISKS ASSOCIATED WITH THE BENZODIAZEPINE AND THE CO–PRESCRIPTION OF THE BENZODIAZEPINE. 

(E) A violation of [subsection (b) OR (D) of] this section is grounds for disciplinary action by the health occupations board that regulates the health care provider who commits the violation.
4-315 (a) Subject to the hearing provisions of § 4–318 of this subtitle, the Board may deny a general license to practice dentistry, a limited license to practice dentistry, or a teacher’s license to practice dentistry to any applicant, reprimand any licensed dentist, place any licensed dentist on probation, or suspend or revoke the license of any licensed dentist, if the applicant or licensee: (35) Fails to comply with § 1–223 of this article.
8–316. (a) Subject to the hearing provisions of § 8–317 of this subtitle, the Board may deny a license or grant a license, including a license subject to a reprimand, probation, or suspension, to any applicant, reprimand any licensee, place any licensee on probation, or suspend or revoke the license of a licensee if the applicant or licensee: (36) Fails to comply with § 1–223 of this article.
14–404. (a) Subject to the hearing provisions of § 14–405 of this subtitle, a disciplinary panel, on the affirmative vote of a majority of the quorum of the disciplinary panel, may reprimand any licensee, place any licensee on probation, or suspend or revoke a license if the licensee: (43) Fails to comply with § 1–223 of this article.
16–311. (a) Subject to the hearing provisions of § 16–313 of this subtitle, the Board, on the affirmative vote of a majority of its members then serving, may deny a license or a limited license to any applicant, reprimand any licensee or holder of a limited license, impose an administrative monetary penalty not exceeding $50,000 on any licensee or holder of a limited license, place any licensee or holder of a limited license on probation, or suspend or revoke a license or a limited license if the applicant, licensee, or holder:
(8) Prescribes or distributes a controlled dangerous substance to any other person in violation of the law, including in violation of § 1–223 of this article;
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect October 1, 2018.
Approved by the Governor, April 24, 2018.
https://legiscan.com/MD/text/HB653/id/1788719/Maryland-2018-HB653-Chaptered.pdf