Observational report neglects to consider confounding naloxone campaigns in lethal overdose reductions, attributes gains to treatment effects while OD deaths soar the more treatment provided

by Clark Miller

Published March 1, 2024

We’ve seen this before, and we know how it goes. 

From the popularizing media accounts – 

Clearly “linked”!

In the JAMA published study using data from Medicare claims over a 6-month period beginning with COVID onset and isolation measures (March of 2020), individuals with a diagnosis of opioid use disorder (OUD) whose health providers billed for some OUD-related services, at least some via telehealth, and who did and may have received other OUD-related services including medications used for OUD (MOUD) and other supports, also were found to experience statistically lower risk of lethal overdose than other Medicare recipients diagnosed with OUD and not receiving treatments involving MOUD or elements of treatment via telehealth. 

Those things happened together, over the same time frame. 

So . . .  definitely linked. 

So it goes without saying that these results support what we already know – that the more of American Medicine’s gold standard opioid replacement cures – buprenorphine and methadone – can be dispensed to affected brains, and with fewer restrictions like requiring in-person clinical visits, the more opioid overdose deaths will be prevented –

At the very end of the JAMA original research publication, after the authors reinforce for us what we already know, what goes without saying – that public health policies and clinical practices that result in less restrictive and more easily accessed provision of substitute opioids to diseased brains will result in curative moderation and decreased risk of harm due to the disease of OUD thereby reducing deaths – at that very end they dutifully note in the very last sentence of the section, “Limitations”,  that “Given the observational nature of the study, we cannot draw causal inferences.”

That’s one way of putting it. 

Let’s engage in the forbidden and frightening task of thinking about what is being said in this report, published in America’s top medical journal. First, the authors’ conclusions –

This cohort study found that receipt of OUD-related tele- health services was associated with a reduced risk for fatal drug overdose, as was receipt of MOUD from OTPs and receipt of buprenorphine in office-based settings, demonstrating the potential benefits of continuing these services.

demonstrating the potential benefits of continuing these services

Yeah! . . .  but no, actually, NO. 

Only if that association is something distinctly different from an association, instead a casual relationship, grounded in the study results, in the broad context of related evidence, on critical examination point to the treatment factors, and not some other factors, cause the observed outcomes. And that those outcomes and confident inferences, with potentially confounding factors considered, are replicated across various settings, investigators, and populations. 

Certainly not, NO, if that broad context of related evidence over decades of research and worsening lethal public health crisis failed to support, disconfirmed in general ways any significant reductions in mortality or health benefits from use of substitute opioids in MAT (MOUD). 

Certainly not if instead, all lines of meaningful, related evidence established that MOUD (MAT) has in fact been contributing to lethality and worsening of the opioid crisis. 

The fatal flaw – more accurately described as the confounding effect precluding any meaningful conclusions and which had to be ignored – in this study is the failure to observe and account for the obvious and certain effects in reducing overdose deaths attributable directly to the intentional, concerted, and effective campaigns over the study period to increase distribution and use of the OD lethality-reversing drug naloxone (Narcan) by a variety of state legislative, policy, clinical, and other measures. 

Most of these measures, as described in detail in previous posts like this, and here, and here, were intended to and would have had differential focus of provision and effects, naturally, to focus efforts on increasing naloxone provision to individuals at higher risk of fatal overdose – individuals not only with a diagnosis of OUD, but with histories of abuse or over-prescription of opioids, and especially if enrolled in services for MOUD or that are OUD-related due to identified need, compulsion, social pressure, and/or mandate. Samples of those individuals, in fact, constituted the study “factors” or “treatment groups” for statistical comparisons of lethal overdose incidence, compared to samples of others also with a diagnosis of OUD, but not in such services.

Look at those linked posts, and do some research on the pronounced expansion of naloxone provision, training, and re-supply to those individuals involved in services, naturally  enhanced by their regular contact with the healthcare providers, case managers, pharmacies where they must pick up their MOUD, other contacts. 

Data are clear and pervasive that the Narcan campaigns have been successful by increasingly averting potentially lethal opioid overdoses by reversals, to survival. It is not only an invalidating confounder, instead a near certainty that the results in this study, quite distinct from being suggestive that telehealth and MOUD constructed as types of “treatment” for OUD in fact provided such benefit, instead point to what is clear in the much broader context of evidence – that any moderation of incidence of lethal opioid overdose is attributable to the compensatory effects of naloxone campaigns against steadily mounting rates of potentially lethal  high-risk opioid use, mounting as American Medicine’s gold standard and “miracle molecule” MOUD opioids are increasingly administered to diseased brains


As described in multiple posts over past years here and here, there are, in contrast to the measure of fatal opioid overdoses, other measures not confounded by the continuously increasing use of naloxone to reduce OD deaths (a confounding factor from the beginning of MAT/MOUD, for decades). One of those is nonlethal overdoses, increasingly problematic as naloxone reversing saves are made in the community by peers, passersby, family, others in settings and situations that do not lead to recording of the potentially lethal high-risk use of opioids, predicting significant underestimates. 

A more reliable and direct measure is the persistently increasing incidence of opioid injection related infectious disease, each incidence representing multiple incidences of or chronic high-risk opioid use, prevention of such use the only mechanism by which benefit can occur from the use of America’s gold standard, medically supplied MOUD opioids, most commonly buprenorphine, its provision increasing steadily over past years and decades. 

Line graph in trends of buprenorphine provision

I wonder what the trends have been looking like for that – for incidence of opioid-involved injection-related infectious disease. 

Here‘s a place to start. 

There are no surprises here – not in the banal, normalized mendacity of America’s esteemed scientific and medical institutions entrusted with protecting health and lives, not in the lethal incompetence, not in the pretense of authority and accountability. 

There are only the predictable expert self-protective lies and a professional class of useful idiots to provide them to you. 

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.”

– Pierre Bourdieu  Outline of a Theory of Practice (1972)

In Bourdieu’s Theory of Practice, heterodoxy is dissent, challenge to what “goes without saying” – the accepted, constructed doxa, “knowledge”, reality, that goes without saying precisely because it “comes without saying”, without real scrutiny, untested, unquestioned. The function of doxa is not knowledge or truth or promotion of the collective good, but to protect and serve the interests of those with the power, the cultural capital, to create it.

Why A Critical Discourse?

Because an uncontrolled epidemic of desperate and deadly use of pain-numbing opioid drugs is just the most visible of America’s lethal crises of drug misuse, suicide, depression, of obesity and sickness, of social illness. Because the matrix of health experts and institutions constructed and identified by mass media as trusted authorities – publicly funded and entrusted to protect public health – instead collude to fabricate false assurances like those that created an opioid crisis, while promising medical cures that never come and can never come, while epidemics worsen. Because the “journalists” responsible for protecting public well-being have failed to fight for truth, traded that duty away for their careers, their abdication and cowardice rewarded daily in corporate news offices, attempts to expose that failure and their fabrications punished.

Open, critical examination, exposure, and deconstruction of their lethal matrix of fabrications is a matter of survival, is cure for mass illness and crisis, demands of us a critical discourse.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.

Latest Stories

Sign Up For A Critical Discourse Newsletter

You'll receive email alerts of new or upcoming posts.

A Critical Discourse

Fog Image