A Reading List on US National Policy For Management of Severe Acute and Chronic Pain

A Reading List on US National Policy For Management of Severe Acute and Chronic Pain

Richard A. Lawhern, PhD

Information Cutoff Date:?April 2023?

This reading list provides information on the vast misdirection of US Federal and State public health policy for management of severe acute and chronic pain.?This is intended as self-education for clinicians, citizens and advocates who wish to lobby their legislators to demand policy change. It may also be useful for staffs of legislators and senior policy makers in American public health and law enforcement, as background for preparation of legislative hearings and changes to public law.? This is a focused extract from over 7,000 bookmarks accumulated during 15 years of active research in public health policy. It has been released on multiple social media platforms.

From time to time, this reading list may be updated as current events unfold.

This document will be released on June 5, 2023 to multiple US Government authorities including the Secretary of HHS, the Administrator of the Board of Scientific Counselors of the CDC Center for Injury Prevention and Control, the Office of the Executive Secretary for US CDC, and all member organizatoins of the AMA Opioid Task Force.

SCOPE OF THE READING LIST

·????????US CDC and Veterans Administration Opioid Prescribing Guidelines

·????????Related Government Documents

·????????Impacts of Opioid Policy on Patients

·????????Conflicts of Interest Among CDC Guideline Writers

·????????Medical Research -- Correcting False Narratives

o??The Mythology of Morphine Milligram Equivalent Daily Doses

o??The Myth of Opioid Induced Hyperalgesia

o??Genetics of Opioid Metabolism

o??Opioid Effectiveness and Side Effects

o??Demographics of Overdose and Mortality

o??Alternatives to Opioids?

·????????Law Enforcement Versus ?Evidence Based Medicine

·????????Alternatives to CDC and VA Guidelines

·????????Where Do We Go From Here?

Readers may clip and drop to follow embedded links to their published sources.

US CDC AND VETERANS ADMINISTRATION OPIOID PRESCRIBING GUIDELINES

Deborah Dowell, MD1; Kathleen R. Ragan, MSPH1; Christopher M. Jones, PharmD, DrPH2; Grant T. Baldwin, PhD1; Roger Chou, MD, “CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022”?Centers for Disease Control and Prevention,?Recommendations and Reports / November 4, 2022 / 71(3);1–95 https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm

US Department of Veterans Affairs, “Use of Opioids in the Management of Chronic Pain (2022)” https://www.healthquality.va.gov/guidelines/Pain/cot/

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RELATED GOVERNMENT DOCUMENTS

Christina Porucznik, “Opioid Guideline Workgroup” January 28, 2016, https://www.cdc.gov/injury/pdfs/bsc/BSC_summary.pdf

US CDC, “CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic Pain”?April 24, 2019, https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html

Chinazo Cunningham, “ Observations on CDC Guideline for Prescribing Opioids – United States, 2022” July 2, 2021, https://www.cdc.gov/injury/pdfs/bsc/OWG-Report-of-Recs-1-12-06.30.21-FINAL-508.pdf

Skelly AC, et al. “Noninvasive nonpharmacological treatment for chronic pain: a systematic review”. Prepared for AHRQ, HHS, Publication No.18-EHC013-EF, Rockville, MD, June 2018.?https://effectivehealthcare.ahrq.gov/products/nonpharma-treatment-pain/research-2018

?“Systematic Review Update: Noninvasive Nonpharmacologic Treatments for Chronic Pain” ?March 1, 2019, https://effectivehealthcare.ahrq.gov/products/noninvasive-nonpharm-pain-update/protocol

Chou R, Deyo R, Devine B, Hansen R, Sullivan S, Jarvik JG, Blazina I, Dana T, Bougatsos C, Turner J. “The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain.” ?Evidence Report/Technology Assessment No. 218. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2012-00014-I.) AHRQ Publication No. 14-E005-EF. Rockville, MD: Agency for Healthcare Research and Quality; September 2014, www.effectivehealthcare.ahrq.gov/reports/final.cfm.

Richard A Lawhern, “Comments on AHRQ Technical Brief “Prevention, Diagnosis, and Management of Opioids, Opioid Misuse and Opioid Use Disorder in Older Adults"?https://www.dhirubhai.net/pulse/comments-ahrq-technical-brief-prevention-diagnosis-opioids-lawhern/

IMPACTS OF OPIOID POLICY ON PATIENTS

Maia Szalzvitz, “Opioid Addiction Is a Huge Problem, but Pain Prescriptions Are Not the Cause -- Cracking down on highly effective pain medications will make patients suffer for no good reason”?Scientific American, May 2016 https://blogs.scientificamerican.com/mind-guest-blog/opioid-addiction-is-a-huge-problem-but-pain-prescriptions-are-not-the-cause/

Maia Szalavitz, “Entire Body is Shaking”?Why Americans With Chronic Pain are Dying”, New York Times Opinion, January 3, 2023,?https://www.nytimes.com/2023/01/03/opinion/chronic-pain-suicides.html

Nita Ghey, “The Other Opioid Crisis:?How False Narratives Are Hurting Patients”,?Discourse, ?July 18, 2022. https://www.discoursemagazine.com/culture-and-society/2022/07/18/how-false-narratives-about-opioids-are-hurting-patients/

Leo Beletsky, JD, MPH, and Kate M. Nicholson, JD, ??“CDC's Updated Opioid Guidelines Are Necessary, but Not Sufficient ??Medscape, November 22, 2022?https://www.medpagetoday.com/opinion/second-opinions/101825

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Jacob Sullum, “Opioid Epidemic Myths” Reason Magazine, May 18, 2016 https://reason.com/2016/05/18/opioid-epidemic-myths/

Miranda Hitti, “Prescription Painkiller Addiction:?7 Myths”, WebMD, August 10, 2011, https://www.webmd.com/pain-management/features/prescription-painkiller-addiction-7-myths#5

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Roger Chriss, “The Myth of the Opioid Addicted Chronic Pain Patient”, Pain News Network, July 25, 2017, https://www.painnewsnetwork.org/stories/2017/7/25/the-myth-of-the-opioid-addicted-chronic-pain-patient

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Jeffrey A. Singer, “Opioid Myths”?Cato Institute Multimedia, November 9, 2017, https://www.cato.org/multimedia/cato-video/opioid-myths

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Sally Satel, “The Myth of What’s Driving The Opioid Crisis” Politico Magazine, February 21, 2018, https://www.politico.com/magazine/story/2018/02/21/the-myth-of-the-roots-of-the-opioid-crisis-217034/

Stanton Peele, PhD, “Overdose and Other Drug and Addiction Myths -- Everything you believe about drugs/addiction is wrong. EVERYTHING. It matters.” Psychology Today, January 20, 2018. https://www.psychologytoday.com/us/blog/addiction-in-society/201801/overdose-and-other-drug-and-addiction-myths

Josh Bloom, PhD, “JAMA Study: Forced Opioid Tapering Harms People. Gee, What a Surprise.”, American Council On Science and Health, August 3, 2021, https://www.acsh.org/news/2021/08/03/jama-study-forced-opioid-tapering-harms-people-gee-what-surprise-15712

Alicia?Agnoli,?MD, MPH, MHS1,2; Guibo?Xing,?PhD2; Daniel J.?Tancredi,?PhD2,3; et al “Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids”, JAMA. 2021;326(5):411-419.?https://jamanetwork.com/journals/jama/fullarticle/2782643

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Travis N Rieder “Is Non-Consensual Tapering of High Dose Opioid Therapy Justifiable?”?AMA Journal of Ethics, August, 2020, https://journalofethics.ama-assn.org/article/nonconsensual-tapering-high-dose-opioid-therapy-justifiable/2020-08

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James L. Madera, MD, “RE Proposed 2022 CDC Clinical Practice Guideline for Prescribing Opioids (Docket No. CDC-2022-0024”, American Medical Association, April 11, 2022, Letter to Captain Christopher M. Jones, … Acting Director National Center for Injury Prevention and Control Centers for Disease Control and Prevention.?https://searchlf.ama-assn.org/letter/documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2F2022-4-11-Letter-to-Jones-re-2022-CDC-Proposed-Clinical-Guidelines-for-Prescribing-Opioids-v2.pdf

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CONFLICTS OF INTEREST AMONG CDC GUIDELINE WRITERS

Chad D. Kollas, MD, “PROP’s Disproportionate Influence on US Opioid Policy:?The Harms of Intended Circumstances”,?Pallimed – A Hospice and Palliative Care Blog, ?May 2021, https://www.pallimed.org/2021/05/props-disproportionate-influence-on-us.html

Chad D. Kollas MD, Terri A. Lewis PhD, Beverly Schechtman and Carrie Judy,” Roger Chou’s Undisclosed Conflicts of Interest: How the CDC’s 2016 Guideline for Prescribing Opioids for Chronic Pain Lost Its Clinical and Professional Integrity “ Pallimed – A Hospice and Palliative Care Blog, September 2021, https://www.pallimed.org/2021/09/roger-chous-undisclosed-conflicts-of.html

Chad D. Kollas, MD, Beverly Schechtman and Carrie Judy ??“Undisclosed Conflicts of Interest by Physicians Creating the CDC Opioid Prescribing Guidelines: Bad Faith or Incompetence? “ Pallimed – A Hospice and Palliative Care Blog, September 2022,?https://www.pallimed.org/2022/09/undisclosed-conflicts-of-interest-by.html

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MEDICAL RESEARCH - CORRECTING?FALSE NARRATIVES

Larry Aubry and B Thomas Carr, “Overdose, opioid treatment admissions and prescription opioid pain reliever relationships: United States, 2010–2019” , Frontiers in Pain Medicine, Augusts 4, 2022, https://www.frontiersin.org/articles/10.3389/fpain.2022.884674/full

Nora Volkow and?A Thomas Mcmillan,?“Opioid Abuse in Chronic Pain -- Misconceptions and Mitigation Strategies, ” New England Journal of Medicine, March 31, 2016?https://www.nejm.org/doi/full/10.1056/NEJMra1507771?

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“Unlike tolerance and physical dependence, addiction is not a predictable result of opioid prescribing. Addiction occurs in only a small percentage of persons who are exposed to opioids — even among those with preexisting vulnerabilities (Table 3). Older medical texts and several versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) either overemphasized the role of tolerance and physical dependence in the definition of addiction or equated these processes (DSM-III and DSM-IV). However, more recent studies have shown that the molecular mechanisms underlying addiction are distinct from those responsible for tolerance and physical dependence, in that they evolve much more slowly, last much longer, and disrupt multiple brain processes.57

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Sally Satel, National Affairs, Nr 55, Spring 2023 “The Truth About Painkillers”, https://nationalaffairs.com/publications/detail/the-truth-about-painkillers

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Gabriel A Brat, et al, ??“Postsurgical prescriptions for opioid naive patients and association with overdose and misuse:?retrospective cohort study” British Medical Journal, 2018?https://www.bmj.com/content/360/bmj.j5790.long

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Steven E Nadeau, Natalie J DelRocco and Samuel S Wu,??“Opioid trials: time for a new approach? Enriched enrollment randomized gradual withdrawal designs”?Pain Management,?Vol. 12, No. 3 ?https://www.futuremedicine.com/doi/10.2217/pmt-2021-0112

Thomas Kline MD, “CDC 2006 paper falsely switches blame for opioid crisis from Heroin to prescription drugs”?https://www.youtube.com/watch?v=2gylppgW1oQ

Jennifer P Schneider MD, PhD, “Opioid Addiction is Not Opioid Dependence”, Practical Pain Management, January 5, 2022, https://www.practicalpainmanagement.com/treatments/addiction-medicine/opioid-use-disorder/what-name-case-which-we-call-addiction-not

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Jennifer P Schneider MD, PhD, “The Role of Opioid Prescription in Incident Opioid Abuse and Dependence Among Individuals With Chronic Non-Cancer Pain”, Practical Pain Management,??https://www.practicalpainmanagement.com/painscan/abstract/role-opioid-prescription-incident-opioid-abuse-dependence-among-individuals-which

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Extract from Dr Schneider’s commentary :??“…The absolute rate of de novo addiction among patients who took low doses of opioids for more than 90 days was only 0.72%, less than 1%. How did the difference between a 15-fold risk and less than 1% come about? The answer is that “odds ratio” is a comparison of the actual risk of one group to the actual risk of another. In this case, the absolute risk of de novo addiction among 371,371 patients who were not prescribed opioids was only 4 per 100,000, or 0.004%, exceedingly low. The actual risk among low dose chronic users was 50/6902 or 0.72%, also low. But comparing the two gave a 14.92-fold increased risk. By not providing the actual risk in their abstract, only the odds ratio, Edlund, et al, were able to share what looks like a high risk”

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Jennifer P?Schneider, MD, “Editorial:?Why Are ER Opioids Out of Favor?”?Practical Pain Management, June 18, 2020, https://www.practicalpainmanagement.com/treatments/pharmacological/opioids/editorial-why-are-er-opioids-out-favor

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Author Note: ?“Jennifer P. Schneider, MD, PhD, is a physician certified in Internal Medicine, Addiction Medicine, and Pain Management. She is the author of 15 books and numerous articles in professional journals. Dr. Schneider, an executive member of the PPM Editorial Advisory Board, is a nationally recognized expert in two addiction-related fields: addictive sexual disorders and the management of chronic pain with opioids.”??

For other published work by Dr Schneider in this Journal, see https://www.practicalpainmanagement.com/author/2460/schneider

???????????The Mythology of Morphine Milligram Equivalent Daily Doses

Michael E Schatman and Jeffrey Fudin, “The Myth of Morphine Milligram Equivalent Daily Dosages”,?Medscape, May 24, 2016??https://www.medscape.com/viewarticle/863477

Fudin, J, Cleary J Pratt, M. Schattman, “The MEDD Myth:?the impact of pseudoscience on pain research and prescribing guideline development”?Journal of Pain Research, Vol. 9, pp 153-156, 23 March 2016,?https://www.dovepress.com/the-medd-myth-the-impact-of-pseudoscience-on-pain-research-and-prescri-peer-reviewed-fulltext-article-JPR

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Chuck Dinerstein, “The True Story of Morphine Milligram Equivalents”, American Council on Science and Health, March 1, 2022, https://www.acsh.org/news/2022/03/01/true-story-morphine-milligram-equivalents-mme-16154

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Josh Bloom, “Opioid Policies Based on Morphine Milligram Equivalents are Automatically Flawed,” American Council on Science and Health, October 23, 2018, https://www.acsh.org/news/2018/10/23/opioid-policies-based-morphine-milligram-equivalents-are-automatically-flawed-13529

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???????????The Myth of Opioid Induced Hyperalgesia

Donald C. Harper “Misuse of ‘Hyperalgesia’ to Limit Care”, Journal of Practical Pain Management, March 7, 2011.?https://www.practicalpainmanagement.com/treatments/pharmacological/opioids/misuse-hyperalgesia-limit-care

R Norman Hardin, “Opioid Induced Hyperalgesia – Exploring Myth and Reality”, Pain Week, 2016,??https://www.youtube.com/watch?v=1NpM8NTSVJI

???????????Genetics of Opioid Metabolism

Deepty Agrawal, Mercy A. Udoji, Andrea Trescot, “Genetic Testing for Opioid Pain Management: A Primer”?Pain Therapy, DOI 10.1007/s40122-017-0069-2 , February 5, 2017?https://pubmed.ncbi.nlm.nih.gov/28409480/

Carsten Skarke, “Genetic Predictors of the Clinical Response to Opioid Analgesics”, Clinical Pharmacokinetics,?2004, https://www.academia.edu/28334503/Genetic_Predictors_of_the_Clinical_Response_to_Opioid_Analgesics

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???????????Opioid Effectiveness and Side Effects

Steven E Nadeau, Jeffry K Wu, and Richard A Lawhern, “Opioids and Chronic Pain: An Analytical Review of the Clinical Evidence” Frontiers in Pain Research, ?August 17, 2021, https://www.frontiersin.org/articles/10.3389/fpain.2021.721357/full

Benjamin Ramsin, Andrea M Trescot, Sukdeb Data, et al, “Opioid Complications and Side Effects” Pain Physician, 2008:11, S105-S120, https://www.academia.edu/16660540/Effectiveness_of_opioids_in_the_treatment_of_chronic_non_cancer_pain

Nicoletta Lanese, “Most People Don’t Actually Feel Euphoric When They Take Opioids, Study Finds”, LiveScience, Octrober 28, 2019, https://www.livescience.com/opioid-euphoria-mostly-a-myth.html

???????????Demographics of Overdose and Mortality

Nabarun Dasgupta,?Michele Jonsson Funk,?Scott Proescholdbell,?Annie Hirsch,?Kurt M Ribisl,?Steve Marshall ??“Cohort Study of the Impact of High-dose Opioid Analgesics on Overdose Mortality,?Journal of Pain Medicine, 2016 Jan;17(1):85-98. doi: 10.1111/pme.12907?https://pubmed.ncbi.nlm.nih.gov/26333030/

Jeffrey A Singer, Jacob Z Sullum, and Michael E Schatman, “Today’s nonmedical opioid users are not yesterday’s patients; implications of data indicating stable rates of nonmedical use and pain reliever use disorder”?Journal of Pain Research, February 7, 2019, ?https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6369835/

Richard A Lawhern, “Why Doctors Aren’t to Blame for the U.S. Opioid Crisis [PODCAST]?KevinMD?- Medpage, May 27, 2023, https://www.kevinmd.com/2023/05/why-doctors-arent-to-blame-for-the-u-s-opioid-crisis-podcast.html

Richard A Lawhern, “How Misused Terminology and Biased Studies May Be Misguiding Our Understanding of Opioid Addiction and Mortality”, Kevin-MD – Medpage, ?May 23, 2023, https://www.kevinmd.com/2023/05/how-misused-terminology-and-biased-studies-may-be-misguiding-our-understanding-of-opioid-addiction-and-mortality.html

???????????Alternatives to Opioids?

Richard A Lawhern and Stephen E Nadeau “Behind the AHRQ Report:?Understanding the Limitations of “Non Pharmaceutical, Non-Invasive Therapies for Chronic Pain”?Practical Pain Management, 2018; 18(7), October 3, 2018.?https://www.practicalpainmanagement.com/resources/practice-management/behind-ahrq-report

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LAW ENFORCEMENT VERSUS EVIDENCE-BASED MEDICINE

Jeffrey Singer and Colleen Cowles, “War on Us: How the War on Drugs and Myths about Addiction Have Created a?War on All of Us”, Cato Institute Events (Interview), March 18, 2020, https://www.cato.org/events/war-us-how-war-drugs-myths-about-addiction-have-created-war-all-us

Jeffrey Miron, Greg Sollenberger, and Laura Nicolae, “Overdosing on Regulation – How The Government Caused the Opioid Epidemic”,??Cato Institute, February 14, 2019, https://www.cato.org/policy-analysis/overdosing-regulation-how-government-caused-opioid-epidemic#

Jeffrey Singer and Trevor Burrus, “Cops Practicing Medicine – the Parallel Histories of Drug War I and Drug War II”, Cato Institute, November 29, 2022, https://www.cato.org/white-paper/cops-practicing-medicine#

Jacob Sullum, “A Scathing Rejection of the Case Against Four Drug Companies Highlights Misconceptions About the 'Opioid Crisis””, Reason Magazine, ?November 2, 2021, https://reason.com/2021/11/02/a-scathing-rejection-of-the-case-against-four-drug-companies-highlights-misconceptions-about-the-opioid-crisis/

Jacob Sullum, “Two Courts Debunk Widely Accepted Opioid Myths”, Reason Magazine, ?November 17, 2021, https://reason.com/2021/11/17/two-courts-debunk-widely-accepted-opioid-myths/

Cathleen London, MD, “DoJ Overreach – The Criminalization of Physicians”, Journal of Legal Medicine, Vol 41, 2021, Issue 3-4 https://www.tandfonline.com/eprint/NF3SWG9YPXWCIP77HFSD/full?target=10.1080/01947648.2022.2147366

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George Knapp, ??“I-Team:?Pain med prescriptions did not cause opioid epidemic, courts rule”??Las Vegas Now, Channel 8, November 24, 2021 https://www.8newsnow.com/news/local-news/i-team-pain-med-prescriptions-did-not-cause-opioid-epidemic-courts-rule/

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George Knapp, “What Will Nevada’s $285M ?Opioid Settlement Funds Go Towards?” Las Vegas Now – Channel 8, February 11, 2022

https://www.8newsnow.com/news/local-news/i-team-what-will-nevadas-285m-opioid-settlement-funds-go-towards/

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ALTERNATIVES TO ?CDC AND VA GUIDELINES

Aabha A. Anekar; Marco Cascella. “WHO Analgesic Ladder” Stat Pearls, National Library of Medicine, January 29, 2023, https://www.ncbi.nlm.nih.gov/books/NBK554435/

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Jennifer P Schneider, MD, “A Practical Introduction to the Use of Opioids For Chronic Pain”, adapted from a presentation given by the author at the annual meeting of the American Academy of Pain Management in Phoenix, Arizona on October 10, 2009. https://www.academia.edu/11338654/A_PRACTICAL_INTRODUCTION_TO_THE_USE_OF_OPIOIDS_FOR_CHRONIC_PAIN

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Federation of State Medical Boards “Guidelines for the Chronic Use of Opioid Analgesics”, ?April 2017 https://www.fsmb.org/siteassets/advocacy/policies/opioid_guidelines_as_adopted_april-2017_final.pdf

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Stephen E Nadeau MD and Richard A Lawhern PhD “Management of Chronic Non-Cancer Pain:?A Framework”?Pain Management – Future Medicine, Vol 12 No 6, June 2022, https://www.futuremedicine.com/doi/10.2217/pmt-2021-0112

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Richard A Lawhern, “How Would Opioid Prescription Guidelines Read if Pain Patients Wrote Them?”?National Pain Report, ?April 2017, Re-published June 2022 https://nationalpainreport.com/how-would-opioid-prescription-guidelines-read-if-pain-patients-wrote-them-8833330.html

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?? Featured in Pain Week as “What If Prescribing Guidelines Were Patient Centered”, Pain Week (Pain Policy), April 17, 2017?https://www.painweek.org/media/news/what-if-prescribing-guidelines-were-patient-centered

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WHERE DO WE GO FROM HERE?

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American Academy of Family Physicians, “Frontline Physicians Call on Politicians to End Political Interference in the Delivery of Evidence Based Medicine”, May 15, 2019?https://www.aafp.org/news/media-center/more-statements/physicians-call-on-politicians-to-end-political-interference-in-the-delivery-of-evidence-based-medicine.html

Extract:?

“Our organizations are firmly opposed to efforts in state legislatures across the United States that inappropriately interfere with the patient-physician relationship, unnecessarily regulate the evidence-based practice of medicine and, in some cases, even criminalize physicians who deliver safe, legal, and necessary medical care.

"Our organizations represent more than 560,000 physicians and medical students serving on the front-lines of health care. We care for patients in communities across America over the course of their lives, including when they need to make critical decisions about their futures and families. The insertion of politics between patients and their physicians undermines the foundation of trust this relationship is built on and inhibits the delivery of safe, timely, and comprehensive care. Outside interference endangers our patients’ health by limiting, and sometimes altogether eliminating, access to medically accurate information and to the full range of health care.

"Physicians should never face imprisonment or other penalties for providing necessary care. These laws force physicians to decide between their patients and facing criminal proceedings. Physicians must be able to practice medicine that is informed by their years of medical education, training, experience, and the available evidence, freely and without threat of criminal punishment.”

Richard A. Lawhern, “The Real Cause of America’s Opioid Crisis:?Doctors Are Not to Blame”??KevinMD, ?March 22, 2023, https://www.kevinmd.com/2023/03/the-real-cause-of-americas-opioid-crisis-doctors-are-not-to-blame.html

Richard A. Lawhern, “We Need New Laws To Protect People in Pain - The CDC’s revised prescribing guidelines retain an anti-opioid bias and do nothing to reverse the harmful policies inspired by the 2016 version.”?Reason Magazine, February 14, 2023,?https://reason.com/2023/02/14/we-need-new-laws-to-protect-people-in-pain/

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