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Patient advocate Richard A. Lawhern discusses the article “U.S. opioid policy history: How politics replaced science in pain care.” Richard argues that for decades, public policy on pain treatment has been driven by sociopolitical factors rather than medical science. He traces the history from the “business corruption” phase of pill mills to the current “political phase” launched by the 2016 CDC guidelines. The conversation highlights how anti-opioid zealotry and legal fears have forced physicians to abandon effective pain care, leaving patients to suffer or turn to illicit markets. Richard also critiques the rising reliance on buprenorphine, suggesting it is popular not because of superior efficacy for pain, but because it offers a legal “safe harbor” for clinicians. Discover why Richard believes the confusion between physical dependence and addiction is driving a public health failure.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Richard A. Lawhern. He is a patient advocate, and the KevinMD article we are talking about today that he co-authored is “U.S. opioid policy history: how politics replaced science in pain care.” Richard, welcome back to the show.
Richard A. Lawhern: Thank you very much. It is a pleasure to be with you.
Kevin Pho: All right, so tell us what led you and your co-author, I believe it is Stephen Nadeau, to write this article and share it on KevinMD.
Richard A. Lawhern: Well, Dr. Nadeau and I have been longtime colleagues and co-advocates in a process of basically challenging what we believe is outright health care fraud on the part of major U.S. health care public policy agencies. From his clinical experience in behavioral neurology, he is presently a behavioral neurologist with the University of Florida Medical Center, and my experience as an advocate, we have carefully probed the literature on multiple subjects.
If I might add a note of introduction for your readers, I personally have been active in this field for almost three decades. I am not a clinician myself. I am, however, a data analyst and health care educator with over 300 articles published, a good number of them with KevinMD, in this field. I focus particularly on the field of public policy with regard to the prescription of opioids. Dr. Nadeau has added to, helped to shape, and basically mentored me in the process of understanding how science and politics have influenced the development of health care policy concerning the treatment of pain and addiction.
One thing that we are aware of is that public health policy has been controversial with regard to the prescription of opioids for something over 50 years. Dating all the way back to the Controlled Substances Act and the creation of the Drug Enforcement Agency, what we have seen is a steady erosion of clinician latitude or discretionary power in the practice of medicine that addresses pain management or addiction management. Dr. Nadeau and I are both convinced that current health care policy is clearly wrong on both scientific fact and ethics. It is wrong in ways that we believe the authors and reviewing officials of several of the opioid prescribing guidelines have known well before publication of their guidelines were simply not true. That is the basis for our accusations of fraud.
In the current article, what we are witnessing is that drugs prescribed for addiction management are coming to be used widely on the basis of CDC and VA guidelines for the treatment of pain. However, the literature behind those treatments and behind that use reveals that these drugs are commonly understood to be basically very weak pain relief drugs. Their primary purpose is indeed in suppressing cravings or providing an alternative. Methadone, of course, also provides an alternative to people who are experiencing deep cravings for opioid drugs for a variety of reasons.
In that regard, what patients tell doctors these days is that the drugs that are now being seen as sort of a safe haven for clinicians, where they anticipate that if they prescribe those drugs they are not going to be challenged by the DEA or by their state boards, really have very little useful application in pain management. Patients tell us that they might take the edge off, and that is a phrase I have heard often, but they don’t really deal with it.
In many cases, patients tell us that if one was to measure their pain on a scale of one to ten, a lot of their days are spent with pain at level twelve. For pain that is less than level ten, it is a little unusual for these drugs to reduce pain. For instance, buprenorphine reduces pain by no more than one or two levels on a scale of ten. Yet we are seeing those drugs, and the drugs commonly used to treat neuropathy, which is a very narrowly defined disorder, being proposed as substitutions for opioids. That is simply scientifically unsupported.
So going back and looking at this history, and this is what we did for the article you mentioned, which is “U.S. opioid policy history: how politics replaced science in pain care,” from our combined experience of over 40 years in patient advocacy, pain management, and behavioral neurology, we are convinced that U.S. public perception and public policy on the treatment of pain have been driven almost entirely for close to 50 years by politics, not by science. They have very seldom in recent years been driven by science or even significantly influenced by it.
For instance, in the late 1990s through about 2008, the U.S. enjoyed a very brief period of scientifically enlightened policy. A large number of patients almost certainly benefited from that policy. However, tragically, patients who were treated with opioids were very soon to become legacy patients. They were made prime targets for involuntary opioid tapering. Although university medical centers might have provided some scientifically based countervailing force to the various non-scientific influences, most of the time they simply flat out failed to do so.
Beginning around the year 2000, corrupt physicians collaborated with corrupt pharmacies to create pill mills. In these organizations, a five-minute visit with a so-called clinician who was basically just a drug provider could net someone a prescription for a thousand pharmaceutical-grade oxycodone or OxyContin 30-milligram tablets, which would then be very promptly filled. The so-called patient would then disappear, often across state lines. Worse, the national drug distributors such as McKesson, AmerisourceBergen, and Cardinal Health strongly supported the pill mills. The pharmaceutical companies, particularly Mallinckrodt, provided volume discounts to the distributors.
As a result, a tsunami of opioid goods flooded the country, and vulnerable populations began to evolve to become the heart of the modern phase of what we are now calling the opioid crisis. The decade from 2000 to 2010 was dominated by business corruption. In response, the DEA began prosecuting pill mills. The reason for that prosecution wasn’t particularly transparent, and most pharmacists have since become fearful that dispensing opioids in any quantity would put them at risk.
From 2008 to the present, there is a pharmacy shuffle that has emerged. By that we mean patients who had an opioid prescription issued by a clinician, even a clinician with excellent credentials, could not find a pharmacist who would fill that prescription. If the pharmacist was prescribing for any large number of patients, they might be absolutely put out of business by state attorneys general working with the DEA. We are now facing a panic phase of the opioid crisis, and well-intentioned pharmacists have revealed that they are after all human beings. They are afraid for their own livelihoods and they are refusing to fill legitimate prescriptions.
Kevin Pho: So what I am hearing is that because of the DEA crackdown on opioid medications, a lot of these physicians, like you said earlier, are prescribing medications like buprenorphine and some of the medicines that are aimed for neuropathy like gabapentin, and they don’t have the same efficacy as opioids. Under that setting where the DEA is cracking down on these pill mills and cracking down on opioid overprescribers, what is a path forward for physicians who do want to legitimately treat chronic pain?
Richard A. Lawhern: This path forward is not going to be easy. Physicians are going to have to stand up and be counted, and they are going to have to do it in public forums, and they are going to have to do it in Congress. Basically, our congressional representatives do not really understand medicine and aren’t really interested in medicine because any subject that threatens their political contributions from hospital associations and from anti-opioid zealots simply doesn’t get a hearing.
A phrasing on this that I have used in some of my publications and in my podcasts has been that we are going to have to convince legislators at all levels and state boards of pharmacy and medicine at all levels that they must either reconsider their unjustified restrictions on opioid prescriptions or they are going to find themselves confronted with the need to avoid being prosecuted for negligent homicide.
Now, this is not a conspiracy as such, and it is not a trivial consideration. But the reality is, and Congress must be convinced in both houses that it is, that present opioid policy that is promulgated by the CDC, the FDA, the Veterans Administration, and the DEA is profoundly destructive. It is overpoliticized and it is killing patients by the thousands by denying them pain care.
What we are trying to do is to bring this subject to a head by repeatedly publishing the real science, which largely has not been acknowledged by the DEA, and by assisting doctors to defend themselves in adversarial proceedings. Those adversarial proceedings have literally thrown at least hundreds of clinicians into prison and they have forced thousands of clinicians out of pain management. That is not acceptable. The public realizes it is not acceptable. That is basically the purpose that Stephen Nadeau and I have undertaken along with a rather large network of other physicians who are also writing in this field.
Kevin Pho: So let me ask, in terms of the current narrative of the opioid crisis where you have the addictive potential of opioids taking the forefront, how do you square that narrative of opioid addiction with appropriate chronic pain treatment sometimes needing opioids?
Richard A. Lawhern: Squaring a circle in a sense is what we have done by analysis of the literature. We have demonstrated very conclusively and from multiple sources over the last 16 years that the addictive potential of opioids is far lower than has ever been acknowledged by the public health agencies. In fact, I will be giving a presentation in Virginia this coming March to a harm reduction conference called SYNC 2026, where I have been invited by the DC Department of Health and a harm reduction outfit called HealthHIV to present an indictment of the public health policies of our major agencies based on published data. That published data shows us, and this is really essential, that the so-called addictive potential of opioids affects fewer than one patient in 1,000 who are treated.
We have multiple sources for that, and I can quote them for you. As a matter of fact, I have quoted several of them in the work that we have done together on KevinMD. The science simply does not support the position that is being taken by the agencies, and Congress has to fix that because the DEA and those agencies are never voluntarily going to let go of their distorted positions on this.
The CDC has demonstrated this conclusively because they have published two guidelines, one in 2016 and the other in 2022. They flat out ignored the science and not only ignored it, they misrepresented the science. That is proven just by reading these documents. Anyone with an appropriate understanding of the medical science that surrounds this issue will tell you, and any doctor will tell you, that opioids are among the least toxic medications used in medical science.
Let me give you an example if I may, and please interrupt me if you feel you need to. We know, for instance, that many people who are imprisoned with a history of drug use have acclimated to a dose level of opioids that you would measure not in milligrams of morphine, but in grams of morphine every day. That is like a 2,000 to 3,000 morphine milligram equivalent daily dose. It is only when they are weaned off of those opioids while in prison and then are discharged later that they overdose because they come back to the original dose levels that they experienced and were taken off of too rapidly.
We can ask a question about this, and it is a serious question. This is not a trivial issue or a distortion. What other medications do we know that can be tapered to a level 50 times the recommended maximum dose without killing the patient? Opioids are one of those medications.
The consequence of that is simply what we are recommending and what we have demonstrated in many of our published papers. One of the best that Stephen Nadeau and I were active in is called “The two opioid crises.” It is in Frontiers in Pain Medicine from about three years ago, and it is being very widely cited right now in the literature. One of the things that we have recognized is that the guidance that is being provided by the agencies flat out and fraudulently ignores the reality that there is an enormous range of tolerable dosages among people who are treated for pain using opioids. That range is at least 15 to one, and we know why it is 15 to one. The why is never once mentioned in CDC or FDA or DEA proceedings. It is never mentioned.
Kevin Pho: Now, what is the motivation? What is their motivation for overstating, according to your data, the addictive potential of opioids? Money?
Richard A. Lawhern: There is enormous money and it is traveling in very hard to trace circles. But basically money, professional dominance, and a certain degree of emotional denial are all operating in the policies of these agencies and in the activism of anti-opioid zealots. People who have lost a kid to opioid addiction or overdose want somebody to blame. Doctors who have staked their professional reputations on anti-opioid positions are quite willing to distort the science to defend themselves from basically being forced to retract what they have said up to now.
Politicians don’t give a rip one way or the other unless it generates campaign contributions. We all know that Congress certainly does not act on behalf of constituents until they are bludgeoned half to death. I realize I am being a little confrontational on that, but that is the way the system works. So the motivation here is that there is a lot of personal prestige and there is a lot of money from health care insurance companies. This is basically invested in the proposition that the more chronic pain patients we can kill off, the higher our profits will be.
I know this is not an extreme position, and at least I encourage those who are seeing our podcast to realize this is not an extreme position. This is a position that is taken by tens of thousands of people on social media who are patients who have seen how this operates, and who are doctors and have been personally persecuted by a state board or by the DEA. One of the members of my speakers bureau in the national campaign to protect people in pain is a doctor who was successfully persecuted and imprisoned for seven years by the DEA and by its pet anti-opioid expert witnesses. If you basically review the proceedings, you realize that what really occurred was a kangaroo court.
The judge himself was absolutely convinced that nothing that the defense had to say would make any difference at all, and he actively denied the defense any opportunity to challenge the qualifications of those who testified on behalf of the government. This is not unusual. I have seen it repeatedly and other doctors have seen it. Doctors more qualified than I have seen it in the court proceedings that have occurred against clinicians. To answer your question or reprise your question, money is the answer to this. The more patients the insurance companies can kill, the higher their profits.
You know, we had an incident a year ago in New York when a health care insurance company executive was killed and the court proceedings have now been delayed for over a year. An effort is being made to move them out of the city of New York for a basic reason. The prosecutors are not convinced that they can get a conviction with any jury that has on it someone who has been mistreated by an insurance company. That is appalling. But runaway juries basically realize what is going on here. They realize that the corporate executives deliberately deny them care because the company doesn’t want to pay. It is no more complicated than that.
Kevin Pho: We are talking to Richard A. Lawhern, patient advocate. Today’s KevinMD article is “U.S. opioid policy history: how politics replaced science in pain care.” Richard, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Richard A. Lawhern: OK, basic messages. One, I personally can be contacted at Lawhern. That is L-A-W-H-E-R-N at hotmail.com. I head up a national organization of over 1,500 patients and doctors. It is called the National Campaign to Protect People in Pain. We have an excellent website fresh out that you can come to, to amplify on these themes. Read the literature and understand where the factors are that you need to account for. It is called NCP3-advocates.org. We are here for you. We invite you to join as either patients or clinicians. We intend to force the retraction of all CDC and FDA guidelines on this subject in favor of doctors functioning with evidence-based practical medicine without the interference of state agencies. Our mission is a large one. Come join us and help us do it.
Kevin Pho: Richard, thank you so much for sharing your insight. Thanks again for coming back on the show.
Richard A. Lawhern: Thank you very much.
