The National Pain Council is pleased to host this resource page for our readers, from Richard A. “Red” Lawhern, PhD. Red is a well known subject matter expert on US and Canadian public health policy for treatment of chronic pain by means of opioid pain relievers. He has over 26 years of hands-on experience as a healthcare writer, medical research analyst and advocate for people in pain. He has published over 170 papers, articles and interviews in a mixture of medical journals and popular media. Red’s academic training is in systems engineering, operations research and advanced technology analysis. His wife became a chronic pain patient in the late 1990s, drawing him into research and advocacy for her and others. Some of his published work is co-authored with medical professionals. However he is not a licensed physician. Thus, anything of a medical nature that you take away from this page and the articles linked here should be discussed with your Primary Care Physician (PCP) before you make medical decisions.
To read the resources of Red’s Corner, click on links below. Each link is briefly
described or summarized.
The Problem: CDC Overreach and Anti-Opioid Bias
211 pages, hundreds of references
26,000 comments were received by the Federal Register from February to April 2022, of which about 5300 are available online. For reasons not explained to the public, names
of individuals have been “redacted” from these comments, even to the point of removing author names in literature references.
March 2022: 27 pages, 9300 words including ~40 References plus two attachments
March 9, 2022 -- A short article on Pain News Network summarizing major errors and
misdirection of the proposed revised CDC opioid guidelines.
The Science – Published Papers for Clinicians
Pain is the number one symptom that brings people to a medical doctor’s office. Many kinds of clinicians treat pain. These include general practitioners, pain management specialists, physician assistants, nurse practitioners, nurses, physical therapists, and even pain psychologists. Not all are licensed to prescribe opioid medications “scheduled” by the US Drug Enforcement Agency. However, all clinicians who treat pain should be interested in the status of research which illuminates principles and assesses public health policy as it applies to management of pain. Red’s Corner offers three papers that should be required reading for all clinicians and public health policy makers. These papers reflect a five-year collaboration between Red and Dr Stephen E Nadeau, a physician and working in the Veterans Administration healthcare system.
Co-authored with Dr. Stephen E Nadeau in 2018, this paper demonstrates that while so-
called “alternative” therapies may be helpful as additions to analgesic medication, they
cannot replace such medication as a primary therapy. However the CDC opioid guidelines have incorrectly recommended such therapies as “preferable” to opioids.
Fair disclosure: Red is an invited patient advocate on the editorial board of Practical
Pain Management, where this paper appears
Co-authored with Dr Stephen E Nadeau and Jeffry K Wu, this paper was published in Frontiers in Pain Research, August 2021 and earlier in March by The Journal of Medicine of the US College of Physicians. The paper has been viewed at Frontiers over 36,000 times - more than 98% of all other papers appearing in this journal. The paper offers ~120 references on a wide range of issues surrounding management of chronic pain by means of opioid pain relievers. The work is indexed on Pub Med, at the US National Library of Medicine.
An expanded abstract follows:
We conducted an analytic review of the clinical scientific literature bearing on the use of opioids for treatment of chronic non-cancer pain in the United States.
There is substantial, albeit not definitive, scientific evidence of the effectiveness of opioids in treating pain and of high variability in opioid dose requirements and side effects.
The estimated risk of death from opioid treatment involving doses above 100 MMED is ~0.25%/year. Multiple large studies refute the concept that short-term use of opioids to treat acute pain predisposes to development of opioid use disorder.
The prevalence of opioid use disorder associated with prescription opioids is likely <3%.
Morbidity, mortality, and financial costs of inadequate treatment of the 18 million Americans with moderate to severe chronic pain are high.
Because of the absence of comparative effectiveness studies, there are no scientific grounds for considering alternative non-pharmacologic treatments as an adequate substitute for opioid therapy but these treatments might serve to augment opioid therapy, thereby reducing dosage.
There are reasons to question the ostensible risks of co-prescription of opioids and benzodiazepines.
As the causes of the opioid crisis have come into focus, it has become clear that the crisis resides predominantly in the streets and that efforts to curtail it by constraining opioid treatment in the clinic are unlikely to succeed.
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Published June 1, 2022 and co-authored with Dr Stephen E Nadeau, this paper comprises 10,000 words supported by almost 200 references. The work is intended to suggest major needed revisions to public health policy implemented in the 2022 draft revised CDC practice guideline for prescription of opioids in acute, sub-acute, and chronic pain.
The abstract and “plain language” summary in the paper provide an overview:
Aim: Since publication of the CDC 2016 Guideline, opioid-related mortality in the USA
has doubled and a crisis has developed among the 15–20 million Americans with chronic, moderate-to-severe, noncancer pain. Our aim was to develop a comprehensive alternative approach to management of chronic pain.
Methods: Analytic review of the clinical literature.
Results: Published science provides a solid framework for the management of chronic
non-cancer pain, detailed here, even as it leaves many knowledge gaps, which we fill
with insights from clinical experience.
Conclusion: There is a sufficient basis in science and in clinical experience to achieve adequate control of chronic pain in nearly all patients in a way that adequately balances
benefits and potential harms.
Plain language summary: Opioid-related mortality in the USA continues to increase
rapidly despite the decline in opioid prescriptions achieved by the CDC 2016 Guideline.
This Guideline has also created a crisis among the 15–20 million Americans with chronic, moderate-to-severe, noncancer pain. We offer a detailed framework for an alternative approach to management of chronic pain. We also offer some suggestions for solving the problem of illicit drug use, which now accounts for 84% of opioid-related deaths. To the extent possible, we have relied upon published science. However, we also identify many knowledge gaps that we address with insights from clinical experience and thousands of interactions with patients. These knowledge gaps will ultimately need to be addressed by further research.
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Resources for Patients and Advocates
For people in pain, some of the reading in Red’s Corner may seem a little complex and
technical. A lot of Red’s published work is briefer and directed to patients, family
caregivers, and advocates. The following are offered as resources:
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