Title: A Crisis of Empathy and Evidence in U.S. Pain Management Guidelines
By: Richard A. Lawhern, patient advocate | May 2025
In response to the opioid overdose epidemic in the U.S., public and healthcare policies have swung remarkably—from a time of broad, often inappropriate opioid prescriptions in the 1990s and early 2000s to an excessively restrictive and fear-based climate that now routinely denies essential and safe care to millions of Americans enduring chronic pain. As a writer on health care and a data analyst, I have seen the distress caused by this transformation and the suppression of evidence-based counterarguments within the mainstream medical community.
One troubling development is the systematic abandonment of chronic pain patients by their providers, driven by fears of governmental penalties, reputational damage, and potential criminal charges. Thousands of healthcare professionals have exited pain management, leaving patients without proper care. For many individuals who endure severe, debilitating pain conditions, the impact has been disastrous—including heightened depression and, tragically, a number of suicides.
A Flawed Basis: The Kolodny-Bohler Hypothesis
Recently, a prominent editorial featured in the November 2024 edition of the New England Journal of Medicine (NEJM), authored by renowned anti-opioid advocate Andrew Kolodny, MD, and Robert M. Bohler, PhD, contends that iatrogenic (clinically-induced) opioid addiction is significantly underreported in federal data sources. The authors claim that excessive prescribing by physicians continues to be a major, undisclosed factor contributing to America’s opioid dependence crisis.
Such claims are not unprecedented. Dr. Kolodny, associated with the activist group Physicians for Responsible Opioid Prescribing (PROP), has consistently maintained that prescription opioids are a core instigator of addiction. Despite lacking certification in pain management and potential financial conflicts of interest linked to his consulting and expert testimony roles in litigation, Kolodny remains a pivotal figure influencing federal opioid policy.
However, when faced with data-driven and thoroughly referenced counterarguments—like our own in largely overlooked outlets—mainstream publications such as the NEJM have denied requests to share rebuttals. They declined our proposal to publish a response editorial presenting historiographic and peer-reviewed evidence that challenges many assertions made by Kolodny and Bohler.
Science that Contradicts the Narrative
Instead, we forwarded a comprehensive and referenced letter to the Medical Research Archives—a peer-reviewed, open-access academic journal—titled “Use of opioids for chronic noncancer pain: a recapitulation of the science.” The manuscript examines a substantial body of evidence indicating that prevalent views surrounding prescription opioids are either incomplete or misrepresented.
Among our significant findings:
– Proven Efficacy: Long-term clinical data and experience validate the closely monitored use of opioid medications for chronic, noncancer pain in select patients. When patients are assessed for accompanying issues such as severe depression and are systematically monitored, opioids can significantly enhance functionality and quality of life.
– Low Mortality Risk: Retrospective cohort studies published over a decade ago indicated that opioid-linked mortality, even at dosages surpassing 100 milligrams morphine equivalent per day (MMED), was approximately 0.25% annually in clinical populations—much lower than the estimates frequently provided by the media or policymakers.
– Addiction Risk is Uncertain: Diagnosing and predicting opioid use disorder (OUD) is rife with scientific ambiguity. The DSM-5 criteria for OUD often erroneously categorize patients who are dependent—but not addicted—due to using medications as prescribed for legitimate pain relief. Existing methods for accurately differentiating between appropriate use, misuse, and true addiction are still insufficient.
– Psychiatric Burden is Tied to Death, Not Opioids: A pivotal 2022 Veterans Administration study by Oliva et al. revealed that the risk of overdose and suicide was disproportionately high among patients with severe psychiatric comorbidities. Although prior OUD was a factor, opioid medications themselves—irrespective of dosage—accounted for minimal additional variance in patient outcomes.
– The Genuine History of the Crisis: Although loosely regulated “pill mills” did contribute to instances of overprescribing and diversion in the early 2000s, regulatory measures were implemented promptly. By 2012, most illicit operations had been shut down, and Prescription Drug Monitoring Programs (PDMPs) were introduced. Consequently, as access to pharmaceutical opioids diminished, those with addiction turned to illicit and significantly more hazardous substances such as heroin and fentanyl.
In summary, the evidence decisively illustrates that while opioids have been involved in the narrative of addiction and overdose, they are far from the primary, persistent instigator. Yet patients with chronic pain continue to face barriers to necessary medications due to an outdated and scientifically skewed perspective.
Medical Suppression and Unscientific Policy
The leading medical journals, including the NEJM, have declined to provide comprehensive coverage of this vital divergence.