There are hundreds of pain-patient advocates constantly fighting to overturn the cruel and misguided policies of withholding power pain medications from those truly in need. But it would be difficult (perhaps impossible) to find one who's dedicated his career to advocating for pain patients, now for a quarter of a century. An interview with Dr. Richard "Red" Lawhern, an ACSH advisor.
Last I counted I had 4,682 saved emails from Dr. Richard "Red" Lawhern. Let's double that to include the ones I didn't save. 9,000 emails from someone I've never met in person. Sounds like a stalker, right? In a sense, he is just that, but Red, who is a member of the ACSH Scientific Advisory Board, isn't stalking me. He's after policymakers and politicians, law enforcement, journalists, insurance companies, filmmakers, and a handful of physicians – just about anyone who may have anything to do with our obscene treatment of people in pain because of our opioid laws and policies. There cannot be a single person among the hordes of pain patient advocates who doesn't know his name.
Although he earned his Ph.D. in engineering, don't let that fool you. His acquired knowledge of medicine, addiction, public policy, and law is extraordinary; he can go toe-to-toe with anyone when it comes to pain and pain medicine. Of course, there could not be a "better" time to be a patient advocate than the past 15 years, during which time millions of people, some of whom had been functioning well for years on high doses of opioid painkillers lost access to the medications that were making their lives tolerable.
How is it possible that a 78-year-old man still works 60-hour weeks and has done so for 25 years? Perhaps he isn't human. Let's ask him.
JB: Red, thanks for taking some of your valuable time so that we at ACSH and our readers can learn about what it's like to be a full-time, non-paid advocate. First, are you human?
RL: Highly human, I assure you.... and I dare to give a damn about people who are struggling with pain, depression, and isolation. I cannot stand by and do nothing when I see such suffering in others. I've always been an over-achiever, so long work weeks aren't necessarily a burden. I've been mentoring and teaching young adults on online bulletin boards during my off-work hours, even longer than I've been working on behalf of pain patients. These days if you Google "Red Lawhern," you'll find about 16,000 hits.
JB: From a profile piece, The Making of a Pain Advocate, which you wrote in 2020 we know that the impetus behind your advocacy began in 1996 when your wife developed a terribly painful neurological facial condition (I know this because I had it once and it was hideous) called trigeminal neuralgia. Now, it is 25+ years later and we are in the middle of an opioid crisis, one that I now describe as "a war on pain patients." At what point did you begin to realize that something insidious was taking place?
RL: As early as 2012, I began to hear from patients whose doctors were growing anxious about prescribing opioid pain relievers. Several people in social media support groups asked me to do research on their behalf to understand what was going on. There was definitely a ramp-up in such questions after Andrew Kolodny and Physicians for Responsible Opioid Prescribing (PROP) petitioned the FDA in 2012 to impose black-box warnings and dosing restrictions on prescription opioid pain relievers.
JB: Of course, things got far worse. We went from a time when ethical doctors were able to practice pain medicine as they saw fit to an almost post-apocalyptic world where people in pain are treated like addicts (as if their injuries or conditions are no more than an excuse to get the pills they are "addicted" to), hospitals are using untested and ineffective post-surgical therapies and perhaps worst – even end-of-life care is now compromised by the bean counters at the DEA. How did we get here?
RL: This one is a toughie. Certainly, anti-opioid zealots began to have an effect with public smear campaigns from organizations like PROP and Shatterproof. A lot of pain patients also think that the health insurance industry (including the Centers for Medicare and Medicaid) began to weigh in -- not because they had any real data to offer, but because chronic patients are "loss leaders" on their ledgers. By this logic, insurers wanted to reduce their costs and increase profits, even if they brought harm to people who couldn't effectively defend themselves. However, in the years I've been researching these issues, I've never been able to find a definitive "trail of breadcrumbs" to a particular conspiracy or "cabal," as some patients have described it. So I'm led to believe that multiple "players' in this policy debacle have likely each contributed their own myths and misdirections out of their own perceived interests or biases.
JB: Many patients and advocates trace the beginning of opioid prohibition back to the time when Dr. Tom Frieden was the New York City Health Commissioner and worked together with Andrew Kolodny who had previously served in the office of the Executive Deputy Commissioner of the New York State Department of Health. Later, the two would collaborate on the disastrous 2016 CDC opioid prescribing advice. Do you have any theories about why this duo was given so much power in what was possibly the origin of the anti-opioid movement? What are your thoughts about what happened during this time?
RL: Theories, yes. Conclusive proof, no. I've never found a definitive explanation from Dr. Friedman, for why he or his CDC subordinates invited members of PROP into CDC deliberations on the development of opioid prescribing guidelines -- a mission that arguably lies outside the CDC legislative charter. What we do know, however, is that Friedman and others in CDC attempted to ram through a highly restrictive prescribing guideline with minimal visibility or comment from professional associations and the public. Without the intervention of the Washington Legal Foundation, they might have succeeded. WLF went to the Congressional Oversight Committee, which then directed CDC to circulate its draft guidelines for public comment. Regrettably, CDC seems to have ignored most of the input they received in thousands of comments.
We also know that CDC initially and later hired some writers for their guidelines who had a demonstrated history of anti-opioid publications co-authored with members of PROP. The "contributions" of Dr. Roger Chou have been particularly problematic. Dr. Chou was hired by the Agency for Healthcare Research and Quality to up or participate in multiple "outcomes reviews" for both opioid and non-opioid therapy in chronic and acute pain. But he was then permitted not only to help write CDC guidelines but also to review them and advocate for them as virtual standards of practice.
He had roles within both the Board of Scientific Counselors of the National Center for Injury Prevention and Control, and the "Opioid Workgroup" named by the Board to oversee recommendations of the guideline writers. In my view, this was a profound and obvious professional conflict of interests.
JB: What a mess. Where do you see things going from here?
RL: When we flash forward to 2022, we find multiple instances where the advocacy of medical experts seems to have exerted a subtle but corrective influence. Courts in Oklahoma, Orange County California, and West Virginia have rejected the notion that opioid prescriptions constitute a "public nuisance". One family in Oklahoma successfully sued a pain management center for their refusal to treat post-operative pain of a patient who then committed suicide because of their negligence. Another judge found that claims of a prominent "expert witness" and member of PROP were not in fact supported by the medical literature from which she quoted. And the US Supreme Court unanimously ruled in June 2022 that physicians accused of "over-prescribing" must be permitted to defend themselves on grounds of "good faith" in the management of their patients -- effectively putting US DEA on notice that it can no longer make up the law as they go along. This ruling will likely result in successful appeals by previously imprisoned doctors, and will certainly require revision of judicial instructions to grand juries and juries deliberating in cases involving opioid prescribing. Several US States -- notably California -- are deliberating on fundamental changes to their own guidelines on prescribing controlled substances.
We aren't home-free yet. As Dr. Lynn Webster ably wrote a few days ago in one of the most widely read medical news publications in the US, the draft revised CDC guideline of February 2022 "Falls Short of What People in Pain Need." Now the CDC must be forced to actively advocate for the repudiation of their own errors and repair of the damage they have done to millions of patients denied pain care by frightened and intimidated clinicians.
This battle is far from over. But finally, I believe that "there is a reason for hope."