THE MYTH OF IMMUTABLE METRICS AND RISE OF THE PROSECUTORIAL PSYCHOPATH: “CAUSING REAL WORLD HARM IN THE SEDUCTIVE POWER OF A SIMPLE SOLUTION,” THE DR. NABARUN DASGUPTA’S “WORKING DISCUSSION NOTES” (SERIES-5a Extension)

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The Myth of Immutable Metrics: Reforming Mme Calculations in Care

INTRODUCTION

Dr. Nabarun Dasgupta of the Opioid Data Lab at UNC presented research demonstrating that at least four different methods are used to calculate the “day” component of the MME/day metric. These methods were reverse-engineered from the 18 key studies cited in the original CDC guideline to justify the 90 MME/day threshold.

Critically, none of those papers explicitly defined their calculation methods, and in some cases, the same authors used different definitions across different studies without comment.

Background

Dr. Nabarun Dasgupta received a 2025 MacArthur Fellowship, known as the “genius grant.” The honor, announced on Oct. 8 by the John D. and Catherine T. MacArthur Foundation, recognizes Dasgupta’s work as an epidemiologist and harm reduction advocate who combines scientific research with community involvement to decrease deaths and other harms from drug use and overdose. Dasgupta and his team have played a key role in the national response to the opioid epidemic.

This lack of standardization has been entirely overlooked in scientific literature and clinical practice, despite MME/day being enshrined in law in at least 14 states.

The fundamental problem is that clinicians, researchers, payers, and regulators have been “unwittingly calculating daily MME in different ways, but never realized it.”

This document synthesizes a critical analysis of the Morphine Milligram Equivalent per day (MME/day) metric, revealing that it is not a standardized clinical measure.

FINDINGS

The core finding is that variations in MME/day calculations stem not from debated pharmacological conversion factors, but from at least four distinct, silently used definitions for the denominator—the word “day.” This definitional ambiguity has profound and previously overlooked consequences.

Stanford Pain Relief Innovations Lab Speaker Series, Webinar.

The fundamental thing that you need to understand here, from what I’m saying, is that these two assumptions conflate distinct causal pathways that are separated in time, and by this I’m talking about four possible causal pathways, and I’m generalizing here. But this is kind of where we think you know the paths, we think, where uh medical opioid exposure may subsequently be associated with overdose uh overdose deaths, and this is again not a high um. It’s not a high-frequency event in our studies.

DASGUPTA:

“..In North Carolina we found the rate the one year of of overdose among paying patients to be like zero point zero. Sorry zero point zero two. So this is a very, These are very rare events. But This is a important question that a lot of people are trying to study. So we’re trying to make this make the assumptions more clear, so that we can have better data…

So I think there are and feel free to disagree with this. But there are four generally general causal pathways, and the reason we break these out is because the kind of statistical methods you need as an Ep….The study designs you would use to measure each of these causal pathways are different…But this is something we don’t really take into account, where the published studies have really not taken into account, so there could be patient behavior taking more than prescribed…

…uh, and a subset of that could be a people who had a previous history of substance, use disorders, or pace placed on opioid analogy at therapy with limited guard rails and end up having trouble with those medications there’s, also prescriber behavior medication errors, two high-starting doses for opioid naive patients medication interactions, and those are a lot of the things that are controllable within a medical system…”

DASGUPTA:

Three:

“..There’s also this popular concept of Irogenic exposure. Whether this is real or not. Um, that that patients get predisposed to opioid disuse disorders from getting prescribed a medication, and then eventually overdose, either from leftover diverted or illicitly manufactured opioids, and then the fourth possible causal pathways, abrupt disc discontinuation, where patients on long term opioid therapy have their doses abruptly reduced or terminated resulting in either suicide, because their pain is in adequately managed, or ah having to supplement from getting opioids on the street..”

THE PROSECUTOR’S PLAYBOOK: USE ALL TOOLS

RISE OF THE PROSECUTORIAL PSYCHOPATH

DISCUSSION

‘THE DASUPTA MORPHINE FLAWED FACTORS’

So when we combine these all these causal pathways and try to create like a omnibus um on the bus. You know, the association between prescribed dose and overdose death. We’re actually seeing a lot of heterogeneity in what we’re measuring and in the research question.

Um. So again, we will come back. I will hopefully, in a future seminar, be able to give you the results from this. But the short of it is that these are things that we should be considering.

So, going back to the definitions. What do doctors and patients think so first of all. So here’s an example of where policy matters when it comes to how you define MME. Um.

And so Arkansas Medicaid required beneficiaries with greater than two hundred and fifty MME. Per day, to be paper tapirts, ninety milligrams per day. During an eighteen-month period. Period. But we saw how…four is not ideal for patients already on opioid therapy, but when using the CDC mobile app, this could easily be the definition that gets applied clinically, while another prescriber may choose on therapy days, because that definition, two which makes a lot more clinical sense.

The bottom line here is that MME. It cannot be considered a hard threshold because it’s not a standardized clinical metric. And uh, you know, interventions like this, and policy documents, clinical guidelines that Don’t define how Mme. Per day, especially the word day, is handled, are inherently problematic in my mind.

Uh Doctor uh, Dr. Tiji, who’s one of uh, one of the Uh Pain physicians and the head of pain. Medicine here at Unc. Um had this to say, while pairs insist they’re not dictating care because the patient can still pay out of pocket for the medication for most patients. This is not financially feasible, so the way the MME. Is calculated, and MME. Restrictions that are put on. Ah! Put on patients by insurance companies have a tangible effect on patient care and and the definitions that this, that the definitions we use are central to calculating those numbers.

We also have a quote here from a pain patient who we work with, Who’s also a sociologist on our team, and she says, far too often we are the victims of good intentions, of those wanting to do something about the opioid, overdose epidemic.

But that something that is done oversimplifies the problem, and pushes cookbook medicine upon those of us. With complicated medical situations. We wait and we suffer, and we hope it will all get sorted, so we can get the care that we need. And I think that’s the That’s the sentiment here that we need to remember of patients being affected by these arbitrary definitions.

Finally, Chris Delcher, Ah, who was who was part of the science, points out that this work is an example of how we can put PDMP data to work positively for patient care. And there are a lot of reasons why PDMPs are harmful to patients, and uh kind of have forced physicians into different in in, you know, box positions into corners in terms of how they handle patients, and we heard uh about that from one end during the last uh seminar series with Dr. Jennifer Olivia.

Um. So in this particular instance we were able to use the PDMP. Data for something useful. Um! And we were able to educate the PDMP at administrators on the importance of the Mme. Calculation. So that’s the um.

So that’s the That’s the so. The key message here that is, subtle. Choices have big consequences. What we’ve seen today, and reinforced by a lot of the presentations you’ve seen in this seminar series is that is proof that daily MME. Is not a standardized clinical metric, and so the question is like, Why has this not been detected sooner.

Here’s my take on it the computational ease and the evocative lure of molecular fundamentals collide in an optimal level of cognitive complexity to engender mmes with an unsubstantiated aura of immutability. They’re not immutable. These are not standardized clinical definitions.

Thank you,

Beth Darnall 46:58

Dr. Des Scoop, but thank you for a terrific lecture. I want to invite everyone um on the Webinar. You can chat in your questions. Um, so please chat, chat those in. We want you to be part of the discussion. Um, we have one here. Um! Would you comment on Gaba Penton? Combination concerns regarding overdose?

Dr. Nabarun Dasgupta 47:22

Yes, so Gaba Pens and Pre Gavelin are have been promoted as a way as an opioid sparing uh option uh, often given, like during surgery or right before surgery, and the hope that uh people will need less opioid analgesics uh post off.

Uh. What we have found is that that does not change. Uh, that is not actually change. How much uh pain really people get afterwards, and it’s probably more of a marketing thing. Um, in terms of overdose risk. It’s. I think it’s hard to say. I don’t see a lot of pharmacological mechanism that would lead to combined respiratory depression when it comes to uh to gab a pension plus opioids.

Um, but it does show up on toxicology. I don’t think it’s a major driver of overdose, even though it does show up

Beth Darnall48:17

“..terrific. Thank you. I You know I was so struck by how you were talking about how software vendors don’t need to disclose how they’re calculating. Um, me, I I just love to hear more your thoughts on that. You you described a Cdc mobile app. Is that true for the CDC mobile app as well.”

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Dr. Nabarun Dasgupta 48:39

“..the see? Yeah, the Cdc mobile app doesn’t like doesn’t break it out with enough detail, but we, we reverse engineered it. We figured it out. Um, there was like, there’s like using kind of other Cdc documents. Um, But Yeah, none of the clinical tools actually get down to this level. What you would think is a fundamental thing, but it’s just not something that has been..”

user avatarBeth Darnall49:04publicly disclosed in any of the clinical support tools that we looked at.

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Dr. Nabarun Dasgupta 49:21

Yeah, I agree. So like the you know, it’s like we’re We’re often talking to cedar right? Which is the drug division, And then Cdr. H. Which is the deviation. Yeah, I think it’s time for them to get it together and like, really understand. You know, I think that there’s a great like regulatory framework for mobile apps. I think these should. These definition issues with Mme. Calculators really need to be

Beth Darnall 49:44uh,

you know, really need to be looked at with a careful lens. Yeah, yeah, well stated um.

Next question, Steve Arians,

“:.This all seems to ignore the elephant in the room. Pharmacogenomics, DNA testing..”

Dr. Nabarun Dasgupta 49:59

Sure, I think you know, genomics and metabolism, uh, of opioids and uh of different kinds of pain markers are really important for clinical decision-making. And uh, again, we’re not we weren’t. Looking at an outcome of pain or of overdose in this study. We were specifically looking at how we measure opioid Mme. A. Daily MME...

…Because that was that was our intent. So I agree that if you’re looking at something more nuanced with like more hard outcomes than pharmacogenomics, would be an important part of that..”

Beth Darnall50:35

“..terrific um. Dr. William Rose, given that standard of care is determined by the practice of the prudent physician, and that the Medical Board accusations against physicians are, in large part, based on the application of State-endorsed Pdmp data. How can one defend the standard? Recognizing the room for these errors?

Dr. Nabarun Dasgupta 50:59

“..I think this is a this. This is kind of like the part that I didn’t say out loud right and um! I think that some of the prosecutions against physicians need to be re-looked at in light of uh in in light of these findings. Right there is. There are legitimate reasons why you would use one definition versus another. And if the you know, if that definition, if what the standard of care definition is has not been specified. Um, I I don’t even know that it should be specified. But there is enough. There is enough variation here that I think. Um. You know defendants who are physicians being brought up in front of their medical boards, might want to look at some of this variation to push back against the you know, an arbitrary standard of care based on MME..”

The truth of opioid use disorder deception

Beth Darnall 51:52Terrific.

..You know. Um Dr. Desgupta, you made some really great concrete recommendations. Some of them I was live tweeting as you’re speaking. Um, but i’m curious. Do you have a single publication or resource hosted anywhere That would be a quick reference. Guide for your recommendations for how to minimize error in Mme. Calculations..”

Dr. Nabarun Dasgupta52:20

“..cool. I probably should do that. But I think, as I mean..”

Beth Darnall 52:26

…for clinicians, or some researchers, right, like maybe both. I was just like, because i’m thinking, Gosh! You know, if people just want to take away a summary, because I think from your talk, what we can appreciate is like. Look, there’s so much variability.

How do we minimize that?

And what do you recommend for clinicians? What do you recommend for researchers?

But I mean you’re the guy, so I I’d love to have those resources.

Dr. Nabarun Dasgupta 52:54

“.. I would say, go with the definition, too. I’ll make it very simple, you know. Make it face valid right like Don’t. Make the number of days longer than the number of days in a month, and don’t assume that patients are getting one script, you know, for an IR opioid and taking them over ninety days. I think that’s the bottom line. Um, I mean. There’s a lot of nuance and Epi studies that get swept under the rug, and there are a lot of, I will admit, there are a lot of epidemiologists in my profession who don’t pay attention to these details, either. But some of us are interested in the best types of outcomes for patients, and I think these are a part of being a conscientious and thoughtful scientist…”

Beth Darnall 53:43

Thank you. Um, Roger nags hopefully. I’m pronouncing your name right. Does the type of pain acute versus chronic pain make a difference?

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Dr. Nabarun Dasgupta 53:53

It does. And if you look back at the Meta analysis slide Um! That was where we broke it out By er and I are opioids. We were trying to get at that indirectly, because we couldn’t get a cute versus chronic in the data sets we had.

Um, but I think the more chronic pain patients you have in your, for example, especially if you’re in a practice setting where uh people are allowed to get uh I our opio is for breakthrough. More, there’s overlapping scripts. Or if you’re in a setting with where you’re using multimodal, you know different different opioid molecules. At the same time, when you’re over when you any time when you have overlapping scripts? What happens more in chronic pain than an acute pain,

Beth Darnall54:39

“..you will have the the the definition choices will get magnified so uh, definitely more of a concern with the chronic pain. Perfect? Thank you. Well, we’re just about it. Time. I want to thank you again. Dr. Nabaroon des scooped off for um a truly informative lecture giving uh clinicians, researchers, policymakers a lot to think about. Thank you so much for your important work in this space…

..Um, I want to thank Ashley Gomez for both organizing and carefully curating our lecture series and making it easy for people to register to um join the the lectures and have a good experience. Um. Ashley mentioned that after uh today, within a couple of hours, those of you who want Cme will receive an email with instructions for how to uh claim that Cme. And uh for the rest of you…

…Please join us in February for Dr. Mark McGovern and his uh his lecture on Implementation Science, and we will be having a speaker in January. That will be Tv. So please stay tuned, and we hope to see you on the next Stanford Pain Relief Innovations Lab Speaker Series, Webinar. Thank you. Everyone, and Happy Thanksgiving…”

The authors thank Bonny P. McClain MSc, of Data and Donuts for her graphical contributions.

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