Why doctors aren’t to blame for the U.S. opioid crisis [PODCAST]

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Join us for an eye-opening episode as we discuss the truth behind the U.S. opioid crisis with our guest, patient advocate Richard A. Lawhern. Contrary to popular belief, doctors did not cause this crisis by over-prescribing opioid pain relievers to their patients. Instead, illegal street drugs primarily drive this crisis, which is fueled by socio-economic determinants of health. We’ll delve into the profound misdirections and fraudulent nonsense of current public policy on addiction, overdose deaths, and harm reduction, and explore the multi-dimensional redirections of health care policy needed to address the crisis. Tune in for an informative discussion on the need for new laws and policy redirections to ensure better access to opioid medications under medical supervision, and ultimately, to provide solutions to the millions of U.S. citizens living in a nation in pain.

Richard A. Lawhern is a patient advocate.

He shares his story and discusses his KevinMD article, “The real cause of America’s opioid crisis: Doctors are not to blame.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at kevinmd.com/podcast. Get CME for this episode by clicking on the CME link in the show notes. Today we welcome Red Lawhern. He’s a patient advocate, and his KevinMD article is titled “The real cause of America’s opioid crisis: Doctors are not to blame.” Red, welcome to the show.

Richard A. Lawhern: Thank you very much. I’m glad to join you.

Kevin Pho: We’ll get into your article in a little bit, but first off, briefly share your story and journey to where you are today.

Richard A. Lawhern: Well, as noted, I am a patient advocate. I got here by becoming involved in trying to understand a very rare facial neuralgia disorder that my wife came down with some, I guess, 26 years ago now. It took us a year and six different doctors to figure out what was going on with her face, which turned out to be something called trigeminal neuralgia. It’s a relatively rare facial neuropathy. And in the process, I got quite a dose of exposure to patient support groups and to other patients who were experiencing a lot of difficulty getting authoritative information.

So flash forward by two years, and the question that I asked in one of the face-to-face support group meetings that I engaged in with my wife in 1996 and ’97 resulted in my being invited to sign on with the U.S. Trigeminal Neuralgia Association, now rebranded as the Facial Pain Association, as their webmaster and principal researcher and writer for a lot of the material that we were putting up to assist facial pain patients in understanding what they were experiencing.

I got into a broader context over a period of time, probably around 2010, after doing quite a lot of social media work, because I was hearing from patients who were having increasing difficulty getting treatment for chronic pain of all kinds. Obviously, I’m a nonphysician. My background, by the way, is engineering and engineering systems. But as somebody who was self-studied, I was not about to go out and try to do a lot of diagnosis with people online. That’s just not something that’s wise to do or in their best interest.

But I kept getting inquiries from people who were saying, “My doctor is feeling really, really persecuted at this point. And he is basically telling me I’m either going to have to find another doctor or be tapered down from a dose of one or more opioids that has been serving my needs very well for the last 5 or 10 or 15 or 20 years.” And I was talking to patients who had that breadth of experience.

I then began investigating the nature of what we have called the “opioid crisis,” quote, unquote, and what is sometimes mislabeled as the “prescription opioid crisis,” which I grew increasingly convinced it is not. And I broadened my social media presence and started writing for publication. So in that, I’ve had probably about 200 papers published in this field by various platforms, and certainly KevinMD is one of the absolute best, exposed to many, many clinical professionals and patients, and I’m grateful for the opportunity to speak there.

But I guess out of those 200 publications, what has basically emerged, sort of one piece at a time, is that I’ve become a very sharp critic of the U.S. Centers for Disease Control and Prevention for what I regard as very misguided and very misdirected public policy that is denying patients treatment. And that was very much the motivation behind my article and behind many other efforts that I’m making in other publications.

Kevin Pho: Now, before we talk about your article specifically, when you talk to other patients in these patient support groups and they say they’re having increasing difficulty obtaining opioids, or their prescriber is finding it more difficult to prescribe opioids, tell us one of those stories. What are some of the reasons they say that’s happening?

Richard A. Lawhern: Well, I’d say this is the dominant theme that I’m hearing from patients. Patients believe that the CDC guidelines have exercised a very strong overshadowing influence. But likewise, doctors are leaving the field right, left, and backwards, if you will, in very large numbers, because they’re basically being actively persecuted by a DEA that has run completely amok.

Let me give you an example, and I think that’s what you’re asking for. There was a lady by the name of Rhonda Fevero, who has given me permission to share her story, and I have in other published sources. Her husband had brain cancer. It became clear that it was going to be terminal. He was in the hospital, the tumor was progressing, and he was in very, very severe pain. And none of his doctors would prescribe anything beyond Tylenol.

And she asked these people, “What in the world are you thinking? My husband is crying with pain every day.” And the clinician who responded to her said, “Well, I can’t prescribe for him, or the DEA will come after me and I will lose my livelihood, regardless of whether my practice is actually well grounded and within the general guidelines that we consider to be applicable in this field. The DEA, and by the way, also state medical boards, are going after any clinician who prescribes opioids for any reason, in any context. And as a result, we’re being forced to force-taper our patients, either to lower doses that are often ineffective or to no doses, sometimes very rapidly, because we don’t want to lose our livelihoods. We don’t want to wind up spending all of our time in court. And so patients like your husband, as much as we hate to admit it, are being deserted.”

And it’s happening on a very wide scale, a very large scale. This is separate from the input that Rhonda got, but there are literally thousands of documented cases of suicide among patients who’ve been deserted by their doctors and can’t find another, or who have been force-tapered to levels of treatment that are not effective for them. And that’s documented in a very excellent editorial that was published by Maia Szalavitz in The New York Times. She references the work of Anne Fuqua, who has actually talked with over 1,000 families that are in this situation.

So by way of example, that’s one. Another is that, of course, I’m present in social media, not every day, and I hear repeated stories that have many common elements in them. There’s another example that is truly horrifying. A group of patients found themselves deserted involuntarily by a doctor by the name of Bockoff in Southern California, because the DEA, with no notice, basically revoked his privilege to prescribe controlled substances. And he was told, “You can no longer support your patients. Stop.” Just cold, period. No notice, no previous investigation, no nothing.

And when those patients tried to find care in major Southern California pain treatment centers, they were uniformly refused. They could not get a doctor to take them because of their previous history of opioid use, regardless of the fact that they were stable and had received good results from opioid prescription. They were by no means diverting opioids anywhere else, and there was no evidence that they ever were. And one patient and her caregiver died by suicide from sheer hopelessness.

And that group of patients is now involved in a lawsuit against the DEA, seeking to become parties to the DEA’s action against the clinician who had been serving their needs. He, by the way, had his assets seized by the DEA several months ago without any trial proceeding whatever, under the assumption that he would in some way use those assets to escape prosecution. I would personally regard that not as prosecution, but persecution. So, due to the generosity of two of his patients, he is continuing, and the DEA is essentially dragging its feet and refusing to recognize the merits of either his case or the desire of patients who have been affected by his case to participate in the proceedings.

Kevin Pho: Now, you talk more about this issue in your KevinMD article, “The real cause of America’s opioid crisis: Doctors are not to blame.” One of the things that you mentioned earlier was that public policy from the CDC and whatnot is influencing these prescribers’ practices. So tell us more about this policy that you feel is misguided.

Richard A. Lawhern: OK. Both the 2016 guidelines and the revised 2022 guidelines for prescription of opioids to patients with chronic pain, and more recently both chronic and acute pain, basically give lip service, and I’m using that term realizing that it is pejorative, because it just infuriates me. They are using words at the top level, up there in their document, which say, “We know these are not hard-and-fast standards.” But when you look at the details, you realize that the CDC has advocated that there is a point of diminishing returns in opioid dose at around 50 morphine milligram equivalents per day, which is not a very high dose. And they’ve asserted that on the basis of research which, when you analyze it, frankly doesn’t say what they say it says. They’ve likewise advocated for non-opioid, and in fact non-pharmaceutical, interventions as preferable to opioids, and there is no science literature in trials to support that position whatever.

And finally, as far as what’s basically going on here, it’s kind of like a wink-wink situation. The CDC has basically said, and I might add that this is also the Veterans Administration, because they’ve separately published, but both organizations have said, “We know that opioids must be tailored to the individual patient.” But they repeat over and over and over again the recipe that says, “We think that there are diminishing returns above 50 MME.” When a clinician or the lawyer of a hospital reads that repetitious story, the message is absolutely clear. And the message is that if you do prescribe above that level, we will find a way to put you out of practice, and the DEA is actively doing exactly that.

I would add one more thing that is more on the science of this. Ask any clinician who’s bothered to study or who is board-certified: There is a very wide range in the minimum effective dose of opioids, and of many other medications, I might add, in treating pain of any type. And that wide variation is grounded in variations in individual genetics. It turns out that with the enzymes that affect opioid metabolism, the breakdown of opioids in the bloodstream, specifically in the liver, there is a wide range of expressions of those enzymes in the liver.

And that wide range produces at least a 15-to-1 variation in morphine milligram equivalent dose, which is nowhere mentioned in the CDC or VA guidelines at all. There’s only one mention of genetics at all in those documents, and it is strictly peripheral. The implication of those documents, however, is that the trials which have been interpreted as suggesting that there’s no real major usefulness to opioids, those trials have not acknowledged the wide range of morphine milligram equivalent dose, nor have they accounted for that wide range in trial design. So what we have is a literature that is literally blind, deaf, and dumb to the variation between individual patients that the CDC was supposedly saying had to be taken into account.

Kevin Pho: So I am certainly understanding and hearing your viewpoint about how some patients are not getting the appropriate pain management treatment, but I also hear from other podcast guests about how habit-forming these opiates potentially are, even in small doses, for patients who are naive to them. Now tell me, for these public policy entities like the CDC, what’s your path forward? How should they balance both of those issues in terms of their guidance?

Richard A. Lawhern: Part of what you are hearing represents the caution of clinicians who don’t want to be targeted. Part of it also reflects the fact that many practitioners in general practice are not particularly well trained in the assessment of addiction. There are landmark papers now available that inform us that the assumption of the CDC, and their public representations to the effect that even small doses of opioids may be habituating, are deeply unbalanced, and they’re not reflected in the statistics that the CDC itself publishes.

There’s a very excellent paper that I think should be required reading, and it’s getting a lot of citations now. It’s by B. Thomas Carr and Larry Aubry. And it basically reanalyzes the data that the CDC claims they analyzed to determine that there was a relationship between rates of prescribing versus rates of opioid hospitalizations or of opioid-related or opioid-involved overdose mortalities. When they’re reanalyzed, what we discover is that the trends that the CDC relied on have not, in fact, been represented in any of the data since 2012. They were working on dated information, and information that had numerous unexplored or unacknowledged confounds in it.

What we do note is this. Even though prescribing was increasing at the same time as opioid-related deaths prior to 2010 and the DEA crackdown on pill mills in that era of 2011, and the two trends were parallel during that period, the period before 2010, when the pill mills were being put out of business and prescribing was dropping by at least 55 percent over the next eight years, the rate of opioid-related mortalities tripled. And it tripled not only on a national level, but on a state-by-state level. In most U.S. states, the rate of overdose deaths was not in any way affected by the rate of prescription. You can’t get that result from any medical model of cause and effect. It can’t happen. The CDC is still pushing the same story.

So what I’m suggesting is that what we’re dealing with is a political agenda that has significantly distorted and misrepresented science. And that is not a small issue. It’s one that probably will have to be settled by legislation, removing the CDC from policymaking roles in the practice of pain medicine. That’s going to be a major leap, and it’s going to be opposed by people who have a financial or emotional self-interest in the narrative that I believe you have heard from some clinicians.

Kevin Pho: So if you were creating your own, say, pain management guidelines that were in contrast to those of the CDC, what would you do differently?

Richard A. Lawhern: As a matter of fact, I’ve published multiple times in this field, and there are a good number of others who have as well. We know that opioids can be habit-forming. It’s called tolerance and/or dependence. We know that they may create symptoms of withdrawal if they’re tapered too rapidly. But we also know that they are both safe and effective in millions of patients.

What is required in new guidelines will be an acknowledgment that there has to be a relationship of trust, with full disclosure, between clinicians and their patients. There has to be care in tapering up any opioid to a level where either it is effective or the side effects that come along with it are considered to be sufficiently disabling that it really shouldn’t be used. And if you do see those side effects, then you taper the patient down on that opioid and look for a different class or combination of classes of opioids that will be effective in pain management.

The reference document for this entire philosophy would be the World Health Organization ladder of pain treatment. It’s been around since 1984, and it recognizes that you start with non-opioid prescriptions in disorders where that option seems to be effective for some people. If that’s not effective for a specific patient, then you look at weaker opioids like tramadol. Then, if that is not effective, you may combine the previous treatments that have been used with a stronger opioid and/or with what are called interventional pain techniques or ancillary methods. And you basically take the patient as far as they have to go, frequently monitoring their outcomes.

What you do not do is unilaterally discharge a patient on the basis of one urine test that you have misinterpreted. And I realize that’s also a red-flag alarm for a lot of clinicians, because a lot of clinicians aren’t very well trained in using urine tests. You use a prescription drug monitoring program to ensure that any patient who comes into your practice is not soliciting opioids from multiple providers or has not accidentally gotten multiple prescriptions that you weren’t aware of, because you clearly don’t want to overdose the patient.

You examine the utility of benzodiazepine-class drugs as controls for situational and circumstantial depression or anxiety, and you closely monitor, and you educate patients on the fact that they need to be pretty carefully monitored at home by someone in their family to be sure that they don’t have breathing suppression of any kind. Right now, there’s some evidence that the historical bias against co-prescription is not particularly well founded, and it needs to be reexamined. That’s research to be done.

The guidelines also basically should tell us that you don’t test for conditions that aren’t pertinent, which means that in states where cannabis is legal, you don’t test for THC, or for any other evidence that, for instance, CBD oil would produce, because it’s simply not pertinent to the patient’s care, unless in some way it is adding to a prescription process that is otherwise being monitored by the clinician.

If you’re going to use ancillary methods, so-called non-pharmaceutical techniques like cognitive behavioral therapy or massage or counseling, you start out with the understanding that these methods are temporary and they work only at the margins. They are not a replacement for opioid therapy or for pharmaceutical therapy of any kind. And there’s a monster study, an outcomes review published by the Agency for Healthcare Research and Quality, that establishes that reality. AHRQ surveyed a literature of over 5,000 trials of this class of techniques, and they found only 218 that met quality standards. Of those 218, the term “medical evidence weak” occurred in over 150 of them.

So we’ve got to realize that there’s some benefit to some patients some of the time in the ancillary techniques, but they are not a replacement for opioids, and they are not preferable to opioids by any stretch of a vivid imagination. That would be the outline, if you will. And I have published in this area several times.

There’s also excellent work by a doctor by the name of Jennifer Schneider, who is a member of the editorial board at the journal Practical Pain Management. She’s been working in the field, and she’s been training clinicians in this field since the early 2000s. And some of her papers in Practical Pain Management are truly excellent in perspective on this matter.

Kevin Pho: And my final question, Red, is briefly share your take-home messages that you want to leave with the KevinMD audience.

Richard A. Lawhern: The bottom-line take is that we now know beyond any contradiction, from data that the CDC has itself published, that doctors prescribing to their patients did not create and are not sustaining the opioid crisis. That crisis is a direct consequence of an evolved crisis, what we call the crisis of hopelessness. That crisis is the result of the socioeconomic determinants of health. That’s something that clinicians run into, and they’re trying.

Basically, what we’ve got going on here is that more than four decades, in fact probably more than seven decades, of inattention to workforce development and stagnating wages, and numerous other conditions, have basically created a population that is vulnerable, because of hopelessness, to the distractions, the temporary distractions, that opioids, illegal opioids, can offer. And if we’re going to deal with that problem, restricting patient pain care is not going to get us there from here. We have to take a different look at the problem and realize that we’re not doing what we could be doing to help people avoid opioid addiction. And as a consequence, basically, we need to refund the redevelopment of the workforce in America. That’s not going to be trivial.

But for darn sure, what is apparent in the takeaway on this is that we need to revise opioid policy to recognize that “first, do no harm” is the cardinal principle. And the CDC has done harm and must be removed from positions in which they can do more. And doctors need to stand up and be counted, regardless of whether someone may tell them, “Oh, but you’ll be targeted by the DEA.” It’s time they told the DEA to go stick its head in the sand, because that’s where it’s been for 40 years.

Kevin Pho: Thank you so much for sharing your time and insight. Thanks again for being on the show.

Richard A. Lawhern: And thank you for the opportunity.

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