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Why Evidence-Based Medicine is Not Going Away, Despite Alleged Ban of the Term

December 20, 2017
Pain practitioners share their views in light of the President's reported call for certain phrases to no longer be used by the CDC.

The scientific community has been incensed—as well as confused—by the past week’s alleged ban/unban of certain words by the Trump administration in connection with the US Centers for Disease Control and Prevention’s 2019 budget proposals. Among other terms, “evidence-based” and “science-based” were called into question.1

The use of “evidence-based medicine” has been around since the 1990s, and calls for merging available research, clinical expertise, and patient values/preference when making a decision about a treatment plan.2 Some practitioners have scoffed at the terminology, especially after the 2016 CDC guidelines3 on prescribing opioids emerged, noting that the most effective way to treat a patient is through a case-by-case, personalized approach. Individualized medicine may be especially pertinent when long-term, large population studies are lacking for certain complex, comorbid, lifelong, or rare diseases and conditions (ie, most cases presented by patients with chronic, intractable pain). Regardless, evidence-based medicine remains the standard of care even as patient-centered medicine is gaining traction.

While writers on The Hill and within CDC’s Atlanta headquarters work to figure out which phrases may—or may not be—referred to in federal documents that discuss science and medicine, Practical Pain Management collected feedback from its editorial advisory board members. This group of clinical, pharmacological, research, and academic professionals work day in and out in to assess, diagnose, and treat patients living with chronic pain conditions.

The following comments contribute to the conversation at stake.

“In general, I believe that evidence-based medicine (EBM) can serve an important role in improving the quality of medical care. Sackett et al defined EBM as ‘the conscientious, explicit, and judicious use of current best evidence in making medical decisions about the care of individual patients.’ Who would argue against that? The problem is that the process is badly misunderstood. Administrators and politicians think it means physicians using diagnostic and management algorithms developed externally for the purpose of standardizing medicine and lowering its cost. In fact, that misconception would logically lead to more medical services being offered by non-physicians, however caring [‘Barefoot Doctors’ is an international model that many will recall and would not wish to emulate].

“The truth is that EBM ‘may [actually] raise, rather than lower, the cost of ...care’ (Sackett et al). It is expensive for good research to develop evidence of value and it takes much expensive physician time to become well informed about that evidence. It is then expensive for physicians to inform their patients of the evidence, so they [the patients] will have confidence in the medical care provided.

"Before I would be willing to develop a response to any attempt—political or otherwise – to sideline EBM, I would require a better understanding of the argument against EBM and the logic behind the attempt. I would also wish the opponent to better understand EBM.”
Source: Sackett D et al. Evidence-based medicine: what it is and what it isn’t. Brit Med J 1996: 312:71-72.
-I. Jon Russell, MD, PhD, ACR Master, Fibromyalgia Research and Consulting, Texas

“These expressions come and go. The National Science Foundation has to find homonymous expressions that relay the same meaning. For someone like me who spent his childhood behind the Iron Curtain, this was a favorite task that people actually enjoyed doing to fight the communists. Examples could be found in the novels Brave New World and 1984. The advent of the curtailing of freedoms in our country may give some room for thought to the people who looked down at those living under the Iron Curtain.”
-Gabe Sella, MD, MPH MSc, PhD, Ohio Valley Medical Center, Wyoming

“The absurdity and wrongfulness of dictating what words can be used is an insult to science and our nation. If we don’t champion evidence-based or science-based medicine, we might as well return to the age of witchcraft, blood-letting, and snake-oil salesmen.”
-Don L. Goldenberg, MD, Oregon Health Services University, Oregon

“The lack of the use of evidence-based medicine is one of the many reasons for the travesty that is the CDC Guidelines.3 Failure to use evidence-based or scientifically based data to create guidelines or use them to write certain medical and scientifically based literature would, many times, reduce the work to anecdotal information, or even bobe-mayse (fairy tales) for those who care.”
-Gary W. Jay, MD, Neurology, University of North Carolina

“There must be some way to document that a treatment is supported by tried and true scientific studies. Otherwise, how can we report that a treatment is proven effective and safe? Would ‘scientifically confirmed’ or some other similar term be acceptable?”
-Edwin Dunteman, MD, MS, A&A Pain Institute, Missouri

“Interestingly, the ‘PharmacoMafia’ has to find evidence of only 5% above average placebo of 35% to claim a drug is ‘effective.’ No drug is 100% effective and virtually all produce complications called side effects. The bottom line is: What does effective mean? And what does evidence- or science-based mean?”

-Norman Shealy, MD, PhD, International Institute of Holistic Medicine, Missouri

“Asking the CDC to avoid using the words ‘evidence-based’ and ‘science-based’ within their budget documents is a form of censorship that breaks down safety barriers. I do believe that clinicians must use common sense and not always rely exclusively on evidence-based medicine in an effort to treat the individuality of each patient. But, where evidence is lacking, we must rely on science. To eliminate both in discussions and official documents propagates lawlessness to government and the clinicians that care for patients. A case in point is the recent publication ‘Safety Concerns with the Centers for Disease Control Opioid Calculator’ (Fudin et al) which explains the Wild-Wild-West mentality that was allowed in the development of the controversial 2016 CDC guidelines on opioid prescribing, and the risk to patients from their non-evidence/non-science based online opioid conversion calculator.”
Source: Fudin J, Raouf M, Wegrzyn EL, Schatman ME. Safety concerns with the Centers for Disease Control opioid calculator. J Pain Res. 2017:10. In press. Early release at https://www.dovepress.com/articles.php?article_id=36042
-Jeffrey Fudin, PharmD, DAIPM, FCCP, FASHP, Remitigate, New York; Western New England University College of Pharmacy; Albany College of Pharmacy and Health Sciences

“As a scientist, of course I am evidence- and scientifically based, but as a working clinician, I am much more open to the concept of new uses for older medications. In my IV clinic, I have utilized everything from propofol, ketamine, baclofen, tramadol, lidocaine, ziprasidone, and other proprietary substances in order to help those that are suffering. This includes laser techniques with high-end dual lasers for chronic pain.

"So I do not cotton well to the usual platitudes of ‘Let’s see if it works, and then we’ll use it.’ If we do consider ourselves as the pioneers of pain management, then we ought certainly do no harm, but we also owe our patients the best efforts, within our specialties and interests. And our strong desire is to help the ones in need.”
-John Claude Krusz, MD, PhD
Anodyne Headache, PainCare & Well-Being, Texas


As scientists and policymakers pave their way through the terminology of today, the most swaying impact comes down to the patient level and what treatment will provide them with the most safe, effective, long-term outcome. Fortunately, CDC Director Brenda Fitzgerald, MD, stated in a release that the “CDC has a long-standing history of making public health and budget decisions that are based on the best available science and data and for the benefit of all people – and we will continue to do so.”4

The views of the editorial advisory board members expressed herein do not necessarily represent the views of their organizations, centers, or affiliations.

Last updated on: December 20, 2017
Continue Reading:
Editorial: Moving Forward from Trump's Opioid Declaration

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1 comment.

By vetbird on 12/23/2017
The use of opioids to treat chronic pain has never been documented to be effective in the eyes of "evidence based science" because no long term double blinded study has ever been done. Nor, for obvious reasons, is one ever likely to be done. But its a tragic mistake to conclude they shouldn't be used in the face of an overwhelming number of patients who have been successfully treated this way. Its become as much of a political problem as a medical one.
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