As a healthcare writer and patient advocate for nearly 30 years, I’ve witnessed a disturbing trend: doctors are being pushed out of medicine or jailed due to their use of opioid prescriptions to treat pain -- often based on testimony from so-called “experts” who lack a deep understanding of the complexities of medical practice. These "hired guns" are brought into courtrooms to support the prosecution, often with large financial incentives. But their knowledge is superficial and the legal system is ill-equipped to challenge them. Judges, juries, and media reporters often don’t understand the intricacies of medical literature, let alone its flaws.
I witnessed this issue firsthand at a conference of the Florida Society for Interventional Pain Physicians (FSIPP) where I was invited to speak. I asked a room of 100 doctors and nurse practitioners how many had recent training in evaluating clinical trials and study protocols.
Not a single hand was raised.
This shocked me, as these professionals are responsible for prescribing medications and interpreting the literature that justifies their use. Without proper training, even seasoned doctors can miss critical flaws in the studies they depend on. If doctors themselves struggle with understanding the medical literature, it’s easy to see how courts, judges, and journalists too often get it wrong.
This brings us to a deeper problem: the peer review system. In many fields, including medicine, psychology, and even physics, the peer review process is broken. We are in the midst of a "replication crisis," where many widely praised studies fail to produce the same results when repeated. This lack of replication calls into question the reliability of much of the published literature. Biases from journal editors, peer reviewers, and study authors may distort results, leading to flawed or incomplete conclusions that influence everything from medical guidelines to court cases against clinicians.
This is especially concerning when it comes to opioid prescriptions. Many doctors who treat chronic pain with opioids have been unfairly targeted by law enforcement and medical boards. These doctors face raids, seizure of their records, and public scrutiny, often based on misunderstandings of opioid dependence and addiction. Opioid dependence is a predictable physiological response to long-term use, not to be confused with addiction, which involves behavioral changes and cravings. Failure to distinguish between the two has contributed to criminalization of legitimate medical practice.
U.S. physicians have reported being prosecuted for prescribing opioids even within accepted guidelines, only to face ruin because of clerical errors or accusations from "expert" witnesses who lack practical experience in treating pain patients or evaluating literature claims. The result is not only the destruction of doctors' careers but also profound impacts on their patients. In some cases, patients left without proper pain management have resorted to suicide.
In response to this crisis, I suggest that courts and medical boards must begin asking more rigorous questions of expert witnesses. For example, how many patients has the expert personally treated for chronic pain? How many patients under their care have died from all causes? It's important to understand that patients with severe chronic pain often face higher mortality rates due to the underlying conditions — cancer, cardiovascular disease, respiratory problems, and even suicide — none of which are necessarily linked to opioid prescriptions.
Another key question: how many patients has the expert discharged or referred to an addiction specialist because of inadequate pain management? This gets to the heart of a key misconception: “pseudo-addiction.” Many doctors misinterpret a patient's plea for better pain control as a sign of addiction, when in reality it is a signal that the patient’s pain is undertreated. This confusion is further compounded by poorly researched government guidelines which discourage higher opioid doses that many patients need to function.
Risk of overdose-related deaths in patients receiving opioid therapy is also frequently exaggerated in court. Large-scale studies show that the incidence of overdose or suicide in chronic pain patients treated with opioids is low—estimated at less than 2%. Most patient deaths are linked to pre-existing psychiatric conditions, not opioid treatment. Yet, physicians are still being prosecuted as if opioids were the direct cause of these tragedies.
The 2022 CDC Clinical Practice Guidelines on opioid prescribing have further muddied the waters. Although intended as recommendations, the guidelines have been treated as hard rules by many regulatory bodies and legal authorities. Both CDC and Veterans Administration prescribing guidelines are widely criticized by clinicians for weak evidence, overemphasis on risks, and failure to account for individual variations in how patients metabolize opioids. These guidelines also push for non-opioid alternatives without strong supporting evidence, and they have led to non-consensual tapering of long-term patients who have been stable on high-dose opioids for years.
In this hostile climate, expert testimony in court must be rigorously examined. Questions should be mandatory about how often patients have died under an expert’s care, how many have been successfully treated, and how frequently opioid dependence is misunderstood. Only after considering these questions can judges and juries accurately assess whether a “subject matter expert” is actually an expert at all concerning whether a doctor’s prescribing practices fall outside accepted norms.
There is in fact no universally accepted standard of opioid prescribing, as the CDC guidelines themselves make clear. The judgment of a doctor should rely on their clinical experience and the specific needs of each patient, not arbitrary limits imposed by regulatory agencies. Dangerous practices — such as pill mills — deserve prosecution. But criminalizing occasional record-keeping errors or outlier prescribing practices only serves to harm patients and unfairly punish doctors.
In conclusion, the current system of persecuting doctors for the opioid prescriptions they write is deeply flawed. Paid predatory clinical “experts” with insufficient knowledge, weak guidelines, and government overreach are fueling a legal crisis that is driving doctors out of medicine and leaving chronic pain patients to suffer. It’s time to end the criminalization of medical practice and restore the ability of doctors to make decisions based on evidence and patient needs, without fear of prosecution. The burden of proof must lie with law enforcement to demonstrate clear harm.
Unless actual patient harms are established, these cases should be dismissed.
About the Author: Richard A. Lawhern is widely acknowledged as a widely published subject matter expert on US public health policy pertaining to pain medicine and addiction medicine. This paper is closely similar to others recently published by Clinical Medicine and Health Research Journal (CMHRJ) and by KevinMD.
