Interview with Robert Twillman, M.D. – Question #4

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, Congress and many state legislators are proposing various types of legislation that they hope will solve the prescription drug crisis. Why do you suppose that all of the attention is on the harm from opioids, and there seems to be very little attention towards the needs of people in pain? I’ve heard you discuss this in terms of evidence‑based policy. What do you mean by that?

Dr. Twillman: In terms of evidence‑based policy, what I think about is we have a big push to use evidence‑based medicine, to look at the evidence that we’ve accumulated and use that, not as a cookbook, but as a guide when we work with patients to try to figure out what might be the best options for a given patient. If that doesn’t work, what does the evidence say is the next best option and so forth.

So much of policy is based on something other than that kind of evidence, it’s more anecdote based. In fact it’s something that I was told by a policy maker years ago that I’ve always loved and found to be unfortunately true in in lots of cases, “The plural of anecdote is policy.” I think that, so many times, what happens is that the policy makers don’t have a good understanding of the problem that they are trying to solve.

That’s particularly true for legislators who, ‑‑ remember, most of them don’t work in the medical profession, they can be lawyers, the can be home makers, they can be farmers ‑‑ and so trying to understand all of this is a challenge for them. What happens is that rather than base decisions on whatever the evidence says, what they base decisions on is more the emotional aspect of decision making.

They’ll have someone come in and they’ll talk about how horrific it was for their family to experience an overdose death or for their family to be impacted by someone with a disease of addiction. They’ll want to respond to that on an emotional basis rather than on a rational, logical basis.

What concerns me is that we haven’t done as good a job communicating to them the consequences of poor pain control, we haven’t gone in and said, “Look, here’s someone who, because they had poor pain control, became suicidal. Someone who, because they had poor pain control, actually sought out illicit drugs and began abusing them because they weren’t getting adequate pain control in the first place.”

I think we haven’t done a very good job of communicating to policy makers what the negative impact is of, first of all, the policies that they are making, and secondly, the lack of treatment, the lack of effective treatment for chronic pain.

I really wish at times that we could get policy makers to engage, as you mentioned, the evidence‑based policy. But one of the challenges, too, is that we don’t have any particularly good evidence‑based to take to them. Even when we do have evidence, we have to remember to present it in ways that they can understand and present to them, “Because this is what the evidence says, this is what it suggests that should be the policy solution.”

So we make it easy for them to do the right thing rather than just saying, “Well, here’s the study. Why don’t you go read it and figure out what to do?” We need to help them along by helping them take the next step

Dr. Webster: I’ve often said that, “Much of what we do is equal to an Olympian challenge,” the phrase that I sometimes use. I think that’s essentially what you just said.

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. Kelly on January 25, 2018 at 4:18 pm

    I have noticed more families of a loved one, whether it be a relative or friend coming forward to tell their heartbreaking stories. And yes this is. Very difficult to listen too. I realize. We dont have this absolute proof that would help lawmakers decide. But what we should have is some common sense and any science based proof needs to be accomplished by studies unfortunately the cdc has created more confusion than i dont believe they were expecting. Creating fear in so many physicians even ones who treat cancer patients, these drs are closing clinics. Most family physicians are tappering patients down so low that. It is no longer helping patients pain. Dr red lawhern in one of his many informative articles explains how the cdc has mislead actually outright lied pertaining to the 90 mmed equivalent of morphine. Dr. Lawhern explains how the cdc arrived at this unreasonable limit. So their is some sscience based evidence against them. I just pray they will soon be exposed for starting all this misconception where legal opiod prescrions are the sole reason for this chrisis!! The over prescribing im sure has caused problems and what needs to be changed is the guidelines, once they are exposed for the controversial. Guidelines that i believe are to the point of fraud!!!!! Lawmakers need to see clearly these guidelines were 100% biased written by addiction specialists. They left out pain patiens and pain management drs. They also know the pain meds currently used is the only option right now for many chronic pain patients. Other options didnt work or are not covered by insurances. What our lawmakers need to be 100 % aware of is people are living with pain and many had productive lives which have now been strippedd from their lives. This is what controversy does, confuses drs. To the extent of what they have been no less than threatened by the dea and all repercussions which will happen if they continue to prescribe these kinds of addictive medications. What is this country doing and the oath. This is for another time. I have so many more instances where these helpful pain meds have helped me over the years. I was 40 years old before i began taking pain meds. I waited years until my pain became so bad i couldnt tolerate it anymore. Their is science and proof it just takes lots of research but truth be told we need these lawmakers to know people in chronic pain personally. It is the emotional feelings which can dictate how they make laws. The key is its emotionally on both sides of this debate of opioid prescribing. I say education, education, education on both sides of the spectrum.

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