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.


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