Interview with Robert Twillman, M.D. – Question #2

Dr. Lynn Webster: Hello, this is Dr. Lynn Webster. Thank you for listening to this pain topic series of interviews on Today I’m proud to have Dr. Bob Twillman, most of you probably are aware of Dr. Twillman.

He is executive director for the American Academy of Pain Management and I believe is probably the most knowledgeable person about federal and state pain policies in the country. That’s going to be primarily our topic today. Let me just get started. Bob, thank you for joining us and thank you for participating in this podcast.

Bob, you have been across the country and I consider you to be very knowledgeable about what seems to work and what doesn’t seem to work in addressing both problems, actually, the crisis with drug abuse and the endemic problem of chronic pain. Tell me what major observations you’ve made and what works and what doesn’t work? What did you learn?

Dr. Bob Twillman: I think the first thing that we’ve learned is that, what doesn’t work is trying to control the problem of prescription drug abuse by reducing the overall supply of opioids. The CDC can show you some very nice graphs that shows that there’s a correlation between the amount of opioids that are prescribed and rate of overdose deaths and so forth. Correlation and causation are two different things and I think we need a more granular analysis of that to really understand it because not everyone who is prescribed an opioid goes off and dies of an overdose.

Many times, the people who are dying of overdose are those who don’t even have a prescription in the first place. What happens is, policy makers reach for what seems like the simple obvious solution, because it’s something that they can do and they’re considered by the constituents to have done something. Unfortunately, when you start restricting the supplies, you restrict the supplies not only to the people who are misusing the drugs but also the people who need them for a legitimate medical purpose.

The problem has gotten so bad that we get calls from people in various parts of the country, from Florida in particular, who tell us, “I had this prescription and I’ve been filling it every month at the same pharmacy for years. Then I went in this month and they wouldn’t fill it for me. Now I’ve been to two dozen more pharmacies and I still haven’t got my prescription filled.” It’s certainly well intentioned, but the problem is that the unintended negative consequences for people with pain can be tremendous.

What that means is that we have to be much smarter and use much more complex kinds of interventions. The good news is that what works best to treat chronic pain, the multidisciplinary multimodal integrative type approach to pain using a biopsychosocial model is also a way of helping to avoid the problems with prescription drug abuse. If you use that model, first of all you are less likely to rely on opioids as the only thing that you are providing to a patient, and it’s likely that you’ll probably need less opioids for individual patients and overall. Therefore reducing people’s exposure, and therefore their risk.

It also points out that what we’ve done for the last 40 years, is to focus on the supplies of prescription drugs and we haven’t focused on the demand. I think that’s the other thing. We have to do a much better job at providing treatment for people who have the disease of addiction so that they stop going out looking for these medications and they get that particular chronic illness under control as well.

The places where I’ve seen successes are cases where they have done all of that. They focused on appropriate treatment of pain and focused on appropriate treatment and prevention of drug abuse in general, prescription drug abuse in particular. They approached it at the community level because this really is a community problem, it’s not just an individual problem. Things like the project Lazarus in North Carolina are just fantastic because of what they have been able to do using that approach.

Dr. Webster: Bob, I want to thank you very much for participating over the last couple of weeks answering the questions and contributing to, I think, a knowledge base for a lot of the listeners. I also want to thank the listeners to this Pains Topics interview on If you aren’t already, please follow me on twitter @lynnrwebstermd.

Also, stay tuned to my blog for more information about my upcoming book and documentary both titled “The Painful Truth” to be released this fall. The book will be available September 1. Have a great day.


  1. Richard Bruce on April 12, 2016 at 9:19 am

    Thank you for your article. I have full blown ankylosing spondylitis, syrnx that goes from T2 to T9, wraps around my chord , and ends @ L5. I’m on disability. I’ve done many things for vocations . from construction, pro-rodeo, and most areas of R.N.. Mostly ICU and ER Trauma. I have done bio-feedback, acupuncture, trigger point injections ( which are a gimmick unless around digits), NSAID’s ,exercise. It goes on. After my 4th course of trigger point injections I gained 29 lbs. in 1and 1/2 days. I also have TB. Non diabetic. I spent 30 days out of 8 months in 2015. 11 days with a silver dollar size hole in the pad going into my great toe. that was in March, then a severe concussion after slipping while mopping the floor. No one knew I was unconscious for 2 days. Woke up and thought I was in France. Rhabdo,organ failure and more. Then in Sep. I spent 11 more days in hospital and had my 5th toe R foot amputated. I have SEVERE neropathy, HLA-B27, non-diabetic, peptic ulcer disease, IBS, UC, Uveitis. I can’t take TNF drugs. A good friend of mine here in Tucson designs them for his company, Southern Az. Pharmaceutical Research. It’s a REAL mess. What am I supposed to do? Go to PT and have hot packs tid/7 days. SURE. I don’t know what to do. There are 4 siblings in my family and all but 1 of us have HLA-B27. Other 3 have AS. Middle brother (I,m youngest) has RA and 3 incidents around the time I was in and out of hospital. Rushed to cath lab and found to have RA with CAD. 90% blockage of descending coronary artery. Protocol not followed. After stent, he went home the next day and wasn’t given proper follow med. After 2 more visits in next 2 wks. he went into cardiac tamponade. colistin. I venting and wondering what the hell I’m going to do after taking over 3 million mg’s of opiates over a 25 yr. period. Nothing to brag or be ashamed of. It is what it is. I have taken every opiate there is for chronic pain. What I feel doc’s don’t understand is they have become a part of my physiological makeup. Not a laughing matter and contrary to many doc’s thinking it can’t be. Well, I’m a walking(barely), talking, good liver enzymes, high SED rate, low H&H 60 yr. old male. I don’t like the 60 part of this huge equation. HaHaHa Thank you for your time and have a most happy, safe tear for you and your family and team………..Best, Richard

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