Opioids, Evidence Based Medicine, and Public Policy; The Art of Creating an Unnecessary Public Health Crisis

Opioids, Evidence Based Medicine, and Public Policy; The Art of Creating an Unnecessary Public Health Crisis

By David Nagel, MD.

There are three kinds of lies: lies, damned lies, and statistics.

- Benjamin Disraeli

A few days ago I met with my doctor for my annual physical.  Despite 57 years of use and abuse, my body is in pretty good shape, and our discussion was directed more at prevention than treatment.  We talked a great deal about the utility of the prostate specific antigen (PSA) test which has been used for a few decades to predict and, hopefully, prevent prostate cancer.  It came as a bit of a surprise to me that this widely touted test was no longer recommended.  Without explaining why, he told me that it was up to me if I wanted to have the yearly test done.   I needed more information, so I pressed him.  He told me that the evidence for the test was level 3 or level 4, which is not particularly good.  I thought that one might want to have the test done to err on the side of caution.  He quickly responded that the test has a high false positive rate which led to unnecessary biopsy and therapy, too often harming the patient.   In saying that, he was speaking to the choir.  My father, based on a false positive PSA, submitted to an unnecessary radical prostatectomy which left him incontinent and impotent the last 23 years of his life.  Case made.  Still, I know many who had early detection of their prostate cancer by PSA.  So, what is one to do?

*  *  *

In 2016, the Centers for Disease Control (CDC), faced with what has been described as an opioid epidemic, felt it was within their purview to assess the cause(s) of this epidemic and create guidelines to control it.  Their report, published in the Morbidity and Mortality Weekly Report (MMWR) on March 18, 2016, outlined twelve guidelines to assist primary care physicians safely prescribe opioids for adults.  The authors opened the report with a preface which re-stated what had been said by the Institute of Medicine (“Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,” June, 2011),

David Nagel, MD

the Federation of State Medical Boards (“Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain,” July, 2013), and the National Pain Strategy (released by the US Department of Health and Human Services in March, 2016), that we are faced with two parallel public crises, one of poorly managed pain and one of addiction, each of which harms too many, the former greatly out-numbering the latter, and the solutions for each often conflicting.  In constructing public policy, the needs of each must be acknowledged and balanced.  The authors took great lengths to explain the strength of the evidence on which the guidelines were based, in effect their limitations.  In sum, it was poor.  The evidence for eleven of the twelve guidelines was graded as level 3 or 4, with only medication assisted treatment for opioid addiction receiving level 2 evidence.

Sound like PSA?  The story gets much worse.

In acknowledging the weakness of the evidence, the authors emphasized that the recommendations should be viewed as guidelines.  Failing to heed the law of un-intended consequences, public policy makers in many states, armed with a passionate, perhaps, mis-guided need to do something, turned the guidelines into rules, ones which must be obeyed by physicians at the risk of loss of licensure or arrest.  In many states, such as my state of New Hampshire, the rules enacted went beyond the CDC guidelines, making them more onerous.  In effect, they were deferring the needs of the many, those who suffer from pain, for the needs of the few, those who abuse or mis-use opioids, failing to understand that poorly managed pain also has the potential to kill.  The rules and the record keeping entailed stressed the limits physicians already face from other governmental interventions in the health care sector.  In response, too many physicians decided to respond in one of two ways.   Some chose to stop writing opioid prescriptions.  Others chose to not treat pain patients at all, deferring that to the 5000 pain physicians in the US.  One of my patients who had been receiving a relatively small and effective opioid prescription for over 20 years from the same physician was informed by that doctor he could no longer do so, citing our governor’s rules as the reason.  I hear similar stories almost every day.

I do not wish to trivialize the effects of the opioid crisis on those addicted or the role poor prescribing practices have played in creating it.  However, the net effect of these rules was the creation of a third public health crisis, now referred to as “pain and/or opioid refugees,” meaning patients who have not been abusing their medications or their treatment who no longer can find someone to care for them.  The irony is that two reports, one form the University of Alabama  (Stefan G. Kertesz, MD, Substance Abuse Vol. 38 , Iss. 1, 2017) and one from the Massachusetts Department of Public Health (https://www.mass.gov/eohhs/docs/dph/stop-addiction/dph-legislative-report-chapter-55-opioid-overdose-study-9-15-2016.pdf), both conclude that prescription opioid abuse is now an infrequent cause of opioid related death (<10%), that the bulk of deaths are due to an illegally acquired cocktail of opioids and other drugs increasingly including heroin and fentanyl, and the reasons for the epidemic of opioid related death is much more complicated than an increase in physician prescribing.

*  *  *

In medical discussions everywhere, it has become chic, almost biblical, to refer to evidence based medicine (EBM).  It is striking to note that many do not even understand what EBM is.  In my book, Needless Suffering, How Society Fails Those Who Suffer from Chronic Pain, I discuss the pitfalls of EBM, which is defined as: “

the conscientious, explicit and judicious use of CURRENT BEST EVIDENCE in making decisions about the care of INDVIDUAL PATIENTS.  (Sacket, DL et al. “Evidenced based medicine:  what it is and what it isn’t.”  British Medical Journal, 312: 71-2, 1996)

There are four elements to EBM:

  1. The personal, clinical, objective experience of the doctor.
  2. Lessons learned from mentors.
  3. The body of medical literature
  4. The practical application of the above three to the unique circumstances of the individual patient.

Too often, EBM is falsely assumed to be synonymous with number 3, and number 4 doesn’t matter.  However, that assumption implies there is sufficient evidence to make therapeutic recommendations for most medical conditions.  That is not even close to being true.  In fact, only a small number of conditions have such evidence (El Dib, RP, Atallah, AN, Andriolo, RB, “Mapping the Cochrane evidence for decision making in health care,” J Eval Clin Pract, 13(4):  689-692, 2007).  Many questions have never even been addressed, especially those pertaining to complex biopsychosocial, multi-variate problems such as chronic pain and addiction.

To complicate matters, it is incorrect to assume that presence of even good medical evidence means the evidence base is accurate.  For example, early in my career in the late 1980’s, I came to see post-concussive syndrome (PCS) as something real, and began to treat it as such.  What I discerned from personal experience and common sense put me at odds with the published medical evidence base which referred to PCS with de-meaning terms such as “litigation neurosis.”  It is anti-intellectual to assume that problems we don’t understand to be merely psychological tricks of the mind, but too often that is what we do, and when the evidence base supports that false premise, too many suffer needlessly.

Therein lays the problem with turning EBM from guidelines to rules.  The reality is that lack of evidence does not mean lack of efficacy, and presence of evidence does not mean efficacy for all patients.  While the CDC guidelines have value, they have limits.   As the definition of EBM above states, evidence needs to be interpreted within the context the individual patient presents when making clinical decisions.  Failure to acknowledge this individuality has the potential to harm too many, and that is what is happening as a result of poorly thought out public policy.

Primum non nocere…First, do no harm…

That ethos of Hippocrates applies to physicians.  Does it not apply to public policy makers as well?  In their act of desperation, they have harmed millions.  In pointing out their error, the cries of my colleagues and my patients too often fall on deaf ears.

*   *   *

There is hope.  The National Pain Strategy is the first attempt to comprehensively address the problems created by chronic pain and addiction, and to find a balanced solution that will meet the needs of each.  The problem is that too few know it exists.  Hopefully that will change.  While there are many steps to this process, one of the first is a willingness to acknowledge what we don’t understand, and, related, accept EBM for what it is, a potentially beneficial tool which only has value when one understands what it is, what it may be used for, and, more importantly, what its limits are.

David Nagel is an MD, author and frequent contributor to National Pain Report.

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Authored by: David Nagel, MD

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Keep chipping away! This crisis for people in pain needs every poster and every commenter!

NEWS FLASH- PAIN RELIEF DENIED AT DUKE REGIONAL HOSPITAL BECAUSE I HAVE A PAIN CONTRACT SIGNED AT MY FAMILY DOCTORS OFFICE! Went to NC Duke ER room. Diagnosed with multiple kidney stones, 2 too large to pass. Second kidney tumor found. Sent/pushed out to waiting room, DENIED CARE, DENIED ANY PAIN RELIEF.
Was then taken to another hospital by a friend who admitted me, treated me pain, did surgical procedure to put a tube in my back with drainage bag attached. Needless to say - TORTURED PAIN LEVEL.
Discharged with tube and back and 15 Roxicet. Any of you who’ve been through kidney stones can imagine my pain. Told to contact a urologist for followup.

I am horrified to know that by signing that paper at my doctors Office, I signed away pain medicine at an Emergency Room!


Truthfully there are too many of us that can barely hold on from one day to the next, we can’t wait for some commission of “more studies”. We know what worked for us to remain functional and it has all been taken away on the basis of the lies and low quality evidence as well as passed by people who have personal bias and known financial industry connections. Why arent the policy makers halting the implementation of all these restrictive rules? they know they are hurting people theyve even stated that RX medications werent driving the “opiod crisis” so where the heck are the ethics commitees that are suppossed to review and revoke this kind of unscientific and harmful guidelines? Are we really nothing to these people? I demand that my rights as a human being in pain be taken into consideration.!

Melody Woolf

And there are clean needle exchanges and even safe houses where you can go shoot up heroin. Some even have people on duty to administer narcan in case you overdose. I am not saying those are bad and shouldn’t be done. They’re done because addicts can help themselves that they didn’t choose to and addicts ( we could discuss that in detail too but that’s not the point of this post ). Well chronic pain patients didn’t choose chronic pain and we aren’t being catered to. In fact many are casualties of the war not on drugs but on chronic pain patients. Yes I realize that perhaps somebody made a choice to text while driving so they got into an accident and now I have chronic pain for the rest of their life. That would be the exception not the rule. Chronic pain patients did not choose to have chronic pain 24 hours a day 365 days a year. And we outnumber addicts by millions. Just does not make sense at all. I am starting a new paragraph because this is a really important point. I was so desperate for pain relief at one time they call the methadone clinic. I explain to them that I knew that you had to come every day and I was OK with that. We talked for a little bit more and when the person on the other end of the line realized that I wanted pain relief I was told they could not be helped. I asked if I tested positive for heroin could you help me and they said yes. At this point I had never even tried marijuana but I was ready to try heroin just to get some pain relief. Thank goodness I found Kratom before I did heroin. It’s a deciduous tree in Southeast Asia in the leaves are dried to a powder. It is in the coffee being family and it’s not a narcotic. It has help me so much that anything I have ever taken before.… Again because this is important. The DEA tried to ban it in September 2016. We were able to fight them and we want because there are approximately 3 to 5,000,000 people being helped by this. They underestimated us. The average person that takes it is between 30 and 60 years old and has some college education. Just wanted to throw that in. It is banned in six states. Thank goodness our community got organized and we have been able to be back over 15 bans in committee. But anyhow they say no can I have your legitimate pain prescriptions and oh you found something else that helps you well you can’t have that either. And since run the subject of plants let’s talk about marijuana. Sessions is ready to target states that have made it legal. He says that it is a federal law that it is illegal. And that it could be medicinal is just nonsense. I think he is… Read more »

[…] Opioids, Evidence Based Medicine, and Public Policy; The Art of Creating an Unnecessary Public Healt… - By David Nagel, MD. - May 2017 […]

Roberta Glick

Thank you for your article and for publishing the 22 comments that come before mine. As a patient who has had 21 back surgeries, both cervical and lumbar fusions with instrumentation, Ehlers- Danlos Syndrome, Fibromyalgia, scoliosis, kyphosis, spinal stenosis, and chronic sciatica, I live with chronic pain. Over the course of years I have been through every treatment modality, every NSAID, various narcotics, etc. I have never misused, abused, or been addicted to any medicine prescribed to me. ( I refuse to use the word ” drug” as it has become value- laden and applied, it appears, only to medicines prescribed for pain. It carries with it a stigma that treats those of us who legitimately use and benefit from opioids as addicts who have made life style choices and dismisses the legitimacy of our pain. However, I understand that recently a diagnostic code for chronic pain was assigned and categorized under ” psychiatric disorders”! Nothing could be farther from the truth. My physician is a nationally recognized expert in EDS. He has been my physician for more than 8 years. He and I have worked together to try every regimen known and finally, finally came to one that gives me sufficient pain management to allow some quality of life. It does not give me wretched side effects. I have been able to stay at the same dosage for over 2 years now. AND my Plan D carrier refuses to cover it ( it is in their formulary) as I am not an addict! The medicine is Buprenorphine HCL sublingual. What is astounding is they will cover it in film form ( melts in cheek ). However that form gives me horrid side effects. This has been through 3 levels of appeal, and seems like we are going to have to go on with more levels. What my physician has to say is of no matter to the insurer (SilverScript). They claim it hasn’t been approved for chronic pain only for addicts. Yet, before I switched carriers in a January 2017, the very same opioid was covered by Express Scripts. It truly feels like we’ve fallen down the rabbit hole and are sitting at Alice’s tea party listening to an insane presentation of facts. I do not deny that people can get addicted, but those who take opioids for pain don’t know what getting ” high ” is. We only know that we can get out of bed each day and function reasonably well. And there is yet another aspect of this so called problem. While those of us in chronic pain cannot be adequately treated, according to ” guidelines” with medicines that help, have few side effects and low risk for addiction, the current ” trend” is the dispensing of ketamine in ERs, yet ! Ketamine, originally developed to euthanize horses, ketamine, known as the street drug “Special K” the date rape drug! A highly hallucinagetic, addictive, and potentially lethal drug! Does this make any sense?


I have pain all over one side of my body due to a thalamic stroke that occurred during a septic infection. For three years I struggled to get adequate pain relief. Finnaly my PCP agreed to handle the prescriptions for opioids. It did not enable me to return to work. It did allow me to dress and bath, do light cooking, and handle my finances. I could read a book or watch a movie. Now the guidelines have changed and as I have tapered to a fifteen percent of my previous dose over a six month period, my life has deteriorated to not worth living. Maybe thirty minutes of partial relief, a few times a day. The in between is agony. I had no physical symptoms tapering off. I only had more pain. In seven years I never lost, misplaced, etc., a prescription or bottle. Only got scripts from one doc and used the same pharmacy unless they quit stocking my medication and I informed my PCP of the change. Never did I seek an early refill and requested reduced doses at least three times. I really do not know how long before I will shatter and my mind will break.


Terry you should know by now that government and professionals “other” the rest of society and have as much regard for their opinions as pirates have for rats on their ship. There is no regard for dialectical populism as our society is not based on consociational values but on social darwinism.
And so nih dhhs cdc fda dod are dominated by big brother professionals who are much more concerned with themselves and their colleagues then the rest of society.
People in pain are best served by recognizing the cruel politics of pain care and many are. Creating and joining smos are in my estimation the best hope people in pain have to reform our disempathic and ineffective pain care system.
Big brother understands power and not right. People in pain need politic power then big brother may be compelled to make reforms. But if you believe in big brothers better angels coming out spontaneously some day soon then i have a deed to the brooklyn bridge id like to sell you.

Terri Lewis

I so appreciate David Nagel. We DO need a national pain strategy just like we need a national conversation on public health overall. It serves no purpose to blame any single actor in this wicked problem. There are many factors working in concert that support this chaotic state of affairs.
Medical education is driven by international agreements designed to standardize knowledge and skills around the world. They may be insufficient on their face when it comes to complex disease and chronic pain.
Without a comprehensive approach to preventing and treating illness, we cannot have an effective approach to the care of chronic pain.
We must have agreement on our objectives - we don’t.
Without an agreement we can’t allocate resources.
Without an agreement we can’t collect effective data to inform our decisions and policies.
We must demand that faulty, biased research studies be removed from the realm of policy development.
We must insist that conflicts of interest be removed from influencing public outcomes.
We must deny policies that turn patients into commodities used to reward faulty practices that install patient harm.
We need a national pain strategy.
It will probably be up to patients to design it and hold others accountable to it.


The nps doesnt represent real hope for people on pain and its tragic that dr nagel fails to see the excesses and deficiencies of his pain specialist colleagues who largely created the nps.
Last year all of 3 million was allocated to nps. As of this date there are no auditable goals to the ever changing nps. Other than several meetings of experts the nps has created some educational videos.
The nps remains an underpowered underfunded underdeveloped rough beast. It is an effort of pain specialists who lack planning skills and criticality to dominate pain care and people in pain. It is not only a false hope to believe in the nps it is a barrier to developing a sensible plan that will work for all stakeholders. But frankly the nps is a power grab by pain specialists whose efforts have failed to lower the prevalence of pain or to make pain care much different or better than it is. The pain specialists have failed to improve their ways since the time of their hero john bonica. And its only too apparent they arent really trying to broaden their approach to pain or make themselves more serviceable to people in pain or the larger society. Power profit position define their professional interests and vision.
If there are any pain specialists who care to have a real conversation on the nps or on the merits of their paradigm and profession id be happy to oblige.

Kahty C

“Evidence Based Medicine” is a marketing catch phrase. We are now Post Science. The Industries that profit from this mess are the ones directing the research. They are still trying to prove that patients don’t get better not because of postponed care, misdiagnosis, or lack Of insurance and income, but because they had the wrong attitude. Over stated and unfounded “Studies” get mentioned in Medical Journals, as if they were factual or Scientific.
There is no Scientific proof of “Catastrophizing” but that does not stop them from researching it again. All they have to do is make the Statement, and refer to the fact that they are doing another “Study.” They have laredy studied this and the findings were inconclusive, and negative so they threw them out. They don’t mention that part they don’t have to Physician are gullible too. This is the end of Science.


I will recount a situation that recently occurred with a family member. After suffering at home in acute abdominal pain, my family member called an ambulance. She was taken to a local hospital screaming in pain the whole way. Upon arrival, while doing the assessment m, her acute pain was IGNORED. I don’t know if the pain scale question was asked, ” on a scale of 1-10 how would you rate your pain?” Or those cute really stupid faces showing a smiling patient to a patient in agony, where you just point to the wall. Her pain was a 10, as knowing her the way I do, a call to 911 and an ambulance ride is not something anyone chooses unless acutely hurting.
So, back to the er room. She was not treated for her pain so she could even communicate effectively with Staff members. She was given Tylenol ( regular) and that’s it!
She did not get any pain meds till 6 hrs later which consisted of 1 mg of morphine, i.v..
When those in positions of power, lean so far over as to cause Pain & Suffering for no reason except ignorance and not accessing those unintended consequences. This must be stopped and this article very clearly demonstrated the outcome of panic driven overeach. Pain is very subjective and there are many kinds of pain, acute, like in an Emergency Room from an accident or injury, end of life pain management where we treat animal with more humanity than people sadly., and Chronic Pain., where one has a disease, illness or disability, that will not kill you, but severity impact and limit quality of life. All of these kinds of pain need to be managed, with medical Oversite and compassion. What my family member SUFFERED THROUGH WAS TOTALLY UNNECESSARY!!
The oath Quoted above, ” First do no harm”‘was ignored and violated.
I suffer from Chronic Pain from an progressive autoimmune disease and a bad car accident (that was no fault of mine} and
Under the care of a fully educated, licensed, trained & compliant pain management Doctor. This Madness inflicted on anyone in pain MUST BE STOPPED & the war on Dr.’s and those sick, ill and hurting must revised. Pain Patients has civil rights and denying care is a A CRIME. The stats are wrong and those who broke the system, must be forced to fix it. If I loose my access to care so I can live my life the best way so can, it will destroy my life.
My family member suffered in a HOSPITAL NEEDLESSLY!!! Because as written in this assessment, this overreach is hurting REAL PEOPLE!! Wake up and tell your them you know your rights and fight back hard. K am and I won’t quit!!

jillianne willett

Please make this article and this issue more public! post it everywhere- send it to everyone you know. Make a youtube video featuring the article! The fact need to be known- Chrionic pain patients, those who have been on pain meds for years, so they may live at least part of a life, are not the people who are at risk of overdosing. These are probably the least likely to do so. Prescribed and monitored by our MD’s, we have to take regular urine screens which are at least monthly, or biweekly. These tests do not just test for illegal drugs, they check the AMOUNT of prescribed meds in your system. Too much, too little-they will know. Not to mention that those that have been taking them for years know what they have to do to be safe. And why would we abuse something that is literally our lifeline anywa? after so long we dont get a “high” from them , there is no reason to abuse them. It just doesnt make sense why established chronic pain patients are being forced to cut back or stop their meds. Why? What do they think doing that will solve? It will have zero results to the “epidemic”. The chronic pain patients are not the ones overdosing. So to say that this is a solution to the problem is utter nonsense. All it is politicians feeling pressure to “do something”. Yes, please, do something.Oh and while your at it, you might wanna “do something” that not only makes sense, but that actually has merit and applies to the issue at hand-

Guinevere Wright

Thank you!! I was an O.R. Nurse for over 25 years and I feel I worked on surgical teams that helped to save the lives of many people and improve many lives. Now that I am crippled with pain and retired I can’t find doctors now with any empathy or courage to stand up against the government agencies that want to take our patient rights away and scare physicians out of practice and take their rights away to practice medicine as a physician. It seems like the pharmacists have more power to tell our physicians how to prescribe for us nowadays and it’s not right! They don’t know my medical history nor do I pay them to treat me.
I am frightened by all the rules and regulations. I have always followed my doctor’s prescribing rules when taking my opiate medication. I am given a low dose of oxycodone and it does not free me of my pain, but it does take the edge off so that it’s bearable. I had to take an early retirement because pain caused my health to fail where I could no longer work in a job I loved. The quality of my life have diminished to a mere shadow of what it used to be. Yet I. wouldn’t dare tell my pain management doctor that or ask for for a change in my medication for fear of being cut off without nothing. I have heard and read the horror stories of patients and I am grateful for just getting some help. What a terrible state our healthcare is in now. Where did the empathy and compassion go for those of us that have chronic pain. How did we get lumped into the addiction crisis? Why can’t the DEA and CDC stop the supply chain of Heroin coming in from Mexico and the fake fentanyl coming from China that is being mixed with the Heroin and killing so many people? Doctors are NOT responsible for that poisin on the streets of America!
Where and when is this punishment of people with legitimate chronic pain who rely on opiates to live and the doctors who prescribe them going to stop? I wonder how many of our bodies will lie in its wake from the suicide of those who will be dead because the horrible life of living in pain killed them.

Truth Out

Patient input is needed in all policy changes and media reports going forward. This creation of pain/ opioid refugees by CDC declaring an “opioid epidemic” based on faulty statistics, weak evidence and media collusion is one of greatest humanitarian crises that is still unfolding. The media has been complicit in censoring the patient side of the story. Why are we suppressing the fact that many in pain are doing well on opioid medications, or more correctly -(were doing well before forced tapers)? Why is does this patient centered fact continue to be censored out of the media and legislative discourse? We can learn much by what is being censored. Why is the truth being so widely suppressed along with media censorship of the patient side of the story? Why the focus nothing short of removing opioid medications as a viable and life-saving option? Are people who’s pain is being treated adequately living too long? Could it be that correct pain control makes them productive and happy? Do opioids work too well? Are they perhaps some of the safest options when used correctly? Is it too expensive? Not enough addicts demanding treatment-so pain patients are “next in line” if their medications are systematically removed? Patients are being systematically silenced and their stories are still being censored. All the while deaths from heroin and other illegal drugs continue to rise.
There has to be more to this story than preventing overdose and addiction.

Michael G Langley, MD

Too bad we have suffered at the hands of doctors who don’t really care about us patients, I should have seen it coming! I was told “You care too much” in surgical residency. Having been through the gauntlet caused by medical ignorance, I now suffer on the other end. Having injured my cauda equina after a fall, I have had difficulty just getting partial relief from the resultant neuropathy. The truth expressed in this article, is sadly unknown to most doctors. Yet, knowing more than other doctors got me an early “retirement”! Thank you for putting the blame squarely on those who initiate “guidelines” that are turned into
“laws”. They did not know my patients. Yet, I was the one who was over-ruled by my competition! Does not matter. We all suffer. We all die!………(;-P

JB Robbinson

Why not say what is really going on? Pain specialists leaving treating pain patients to treating addicts. Thanks to the mess of obamacare(not) that allows $30,000 a year for addiction therapy Doctors are switching careers. Can’t blame them as it is easy money. My so-called pain specialist quit medicine giving patients just 30 days notice and not helping patients find another doctor. He opened a business that helps insurance companies DENY medications, especially pain meds, to patients. He brags on this website that he can stop a patient’s medications for 180 days which can save millions. In other words… We’ll screw the patient till they can get a review through. Nice isn’t it? Maybe it is time for pain patients to demand that all QuikStop-like stores close because they are robbed to many times. Same with Banks!

Ibin Aiken

I love this article by Dr. Nagel. With limited understanding of the complexity of opioid medicine control in prescribing, I do realize that the basis of prescribing should be left to our physicians in a “due diligence”, fact based, record kept AND even the doctors best based evidence that the a patient is truly in need of chronic pain treatment. With the CDC guideline “Robbing Peter”, and then disregarding the “payment of Paul”, is asinine. I can not understand how the actual benefit of appropriately, sufficiently, recorded examinations, using the least effective medication that does help the pain afflicted could be not taken as a very viable treatment of chronic pain patients that need be treated to receive sufficient pain relief, whatever their needed or desire goal with treatment is. Our physicians fully realize the goal and need of their patients. The CDC guideline is NOT benefiting ALL that need be treated with opioid medications. Many patients have already been through the “least treatment that benefits….first”. The last effective treatment for many chronic pain patients may very well be opioid medication treatment in sufficient strength dosage. I realized that when all other options for me after two back surgeries,after specially made back braces, injections, infusions, physical therapy, forced activity (by myself), exercise, and even continued employment was indeed therapeutic as well as beneficial, in my individual case. I also realize that there ARE debilitating disease with no other treatment options to make day to day activities within the individuals home necessary……available other then opioid treatment MEDICATION! When the CDC guideline was introduced, I truly thought that after 20 years of opioid medication therapy, I had reached a plateau of dosage and that any further strength or dosage would not be beneficial. I did not fathom that ALL chronic pain patients would not be placed into one “basket”. The saying never place all your eggs in ONE basket! After 14 years of opioid treatment with the same medication, (after many different ones), I found the one with my doctor advised that assisted me best. In the last 4 years, I willfully reduced my medication as for worry with my aging body that the dosage “could be” detrimental to my aging. I willfully requested my doctor to help me reduce my medication from 160 milligrams of medication. I finally achieved 100 milligrams per day, did not need any anti-depressant medication and I continued to be able to do what every person should be willing to do…….if possible. Earn my own living. I am work oriented and I consider work some of the best therapy I could do for my individual health condition. Yes, there were days that the 100 milligrams of medication were less than sufficient. I worked “through” these days and had MANY more days of adequate pain relief, than less. I can accept that. Now with an 80% reduction in dosage, to 20 milligrams per day in dosage of the SAME medication which I consider Is not adequate, I am… Read more »

D'Ann Roberts Jacobs

This is so wrong when non pain bureaucrats think they know what it’s really like to live with severe chronic pain where it affects your life to be able to work and live life freely. They have no clue how harmful they are attempting to make it for us! It’s something we need to fight. To me it’s like calling a plumber to do an electricians job. They don’t know what they are doing!

Jean Price

I’d say this is a fair and honest assessment of our situation now, and it’s refreshing to hear it from someone who has both A BRAIN AND COMMON SENSE! Plus he’s a physician! How novel! His knowledge and targeted evaluation of the issues surrounding pain care, and his ability to outline all of this so most people could understand would certainly make him MY choice for our Surgeon General!! Too bad he’s not! Too bad also those who instigated this opioid nightmare don’t seem to even want to understand! Their agenda isn’t about logic and making sense…or even good health care in general! If it was, the current abuse of so many patients would never have happened in the first place! Rather they seem highly to being self serving, maintaining their peers and lining their own pockets…and the pockets of those who either are…or could be…of use to them!

The only statement he makes which I DO have trouble agreeing on is when he says the National Pain Strategy is a beacon of hope (supposedly for those in pain who are being denied appropriate care due to the unnecessary and wrongful ban on opioids). I think we, the people..the patients with pain…ARE the primary ” stakeholders” in all of this…by far! Yet the financial bottom lines of big business and government seems to overshadow us in the Strategy’s plan! I have my doubts about this particular mindset of those who drew it up!, I can’t see this focus of their actually bringing GOOD care changes to the millions who are currently hurting (and are now without a multi-disciplined approach which would need to include opioids to be effective!) Plus, pain care and addiction MUST be considered medically separate! So, the issue of addiction really has very little place, IF ANY, in a Stratgy to help those with either acute or long term, daily, life limiting pain! Addiction care needs its own separate strategy…and the inference that these are combined issues must stop! Unti this principal fact is realized across the board, successful pain care will likely be manipulated with the addict who is abusing opioids…not THE PERSON WITH A DIAGNOSIS OF PAIN…in mind. And that’s truly not going to help anyone! Even the addicts!

Shirley hinton

Iam so sick right now ..no pain meds .. not the wat life should be ..thry took my life



Candice Hawkins

Than you David for a clarifying talk about how one step referring to those who are an all or nothing group, led to the plight of chronic pain patients who live in fear.


You say there is hope but mean time each day gets harder just to get through when our lives could be made easier. We are suffering because of mistakes other people made.


How can we get this specific article into the hands of state and federal lawmakers in a way that ensures it is actually read? This is the kind of fact-based, other side of the issue that is never presented by any of the media, whether it be local newspapers or national cable new networks.

This is an extremely valuable article that should be used by the national pain groups in as many ways as possible. The fact that it is presented in a scholarly, fact-based and non-argumentative approach, from a practicing physician’s point-of-view, should carry at least some weight with the anti-opiate crowd.

Thank you, Dr. Nagel. I hope and pray that there are others like you out there that will begin to speak up more often and with a stronger voice.

Mary Stephenson

This is a fact! Also killing everyday people. I read the people who made up the CDC rules aren’t even Drs or experts? Didn’t theses people know they were going to be a backlash.
I wish I was never on this medication, but was injured by a chiropractor in 1988 had 2 spine surgeries in 1990 and have been on opioids since then, have 8 horrible items still wrong with me. One thing I have is RSD in my right arm from a chunk of my disk laying on nerve root C5-C6 for 22 months. It’s still there after 28 Drs looked at it and didn’t do anything. Finally after 22 months a spine specialist went it to remove the gelatin like substance my chunk of disk had become and my arm was a mess, still is neck shoulders, left arm neck on and on. My dr. Gave me an option. Live on medication or not. He said quality or quantity and of course I wanted a quality of life so I’ve been on medication since 1988 when I went to the emergency room after I was injured by the chiropractor.
With the opioids I could function to a degree, never completely out of pain. I was on low dose of opioids but they helped more than the heavy duty opioids.
The CDC and DEA do not belong in a patients and doctors life. I’m not selling my medication. I’m a chronic pain patient and want medication to help me thru the rest of my life.


Verum ipsum factum. What doctors and medicine claim is truth based on ebm is assumed to be truth. And tragically this hubris has added to the suffering of people in pain with poor diagnoses and poor treatment for pain. The nps doesnt correct for the hubris in pain care on the contrary it adds to it as only a select few in medicine will decide what is good and bad in pain care with. almost no public input.
Instead of recognizing the need for more public input and more say for individuals in pain Dr Nagel wishes to continue the mistakes of the past in pain care.
The time to enlist people in pain in policy and practices in pain care has never been more evident yet medicine wishes to continue to enlarge their control over people in pain and continue to treat them as voiceless and mindless recipients of medicines infallible ways. This is the opposite of what people in pain and society need at this time.

Linda Godowsky-Bilka

Thank You. This article is the best explanation I have ever read! It goes straight to the heart of the matter that every physician and chronic pain patient should know.

If this article could ever be read and fully understood by doctors, it would change the lives of so so many.

God willing……

Thank You Again