Is the Opioid Epidemic Really Ending?

By Dr. Charles LeBaron 

From all the self-congratulations by outgoing Biden administration officials about a 15% decrease in overdose deaths last year, one might conclude that the opioid epidemic is coming to an end. However, drug overdoses remain the #1 killer of adults aged 15 to 45, causing more deaths than automobiles and firearms combined.

So even if this “disappearing epidemic” continues at its current pace – about 98,000 fatal overdoses annually -- nearly a million Americans will die of overdoses within the next ten years. 

The carnage is taking place amid a startling paradox: many severely ill persons with a clearly legitimate need for pain control have grave difficulties obtaining opioid medications adequate to make their existence less of a living hell. This worst-case scenario is the legacy of past policy failures – failures that need not be repeated, if incoming Trump administration officials can take a moment to consult our history and apply its lessons. 

In the 1990s, as has been extensively chronicled, large pharmaceutical companies began aggressively promoting proprietary opioid preparations. By the mid-2010s, the United States, with 5% of the world’s population, was estimated to consume 80% of the world’s opioids. For Americans recovering from surgery, 91% received opioids, compared to just 5% in the rest of the world for the same operations.  

Opioid overdose deaths rose in parallel to opioid prescriptions – which became so numerous that the number of pills prescribed was technically enough to kill every American. Whereupon the Centers for Disease Control and Prevention (CDC) stepped in. The CDC’s 2016 opioid guideline, developed with almost no meaningful input from clinicians who treat pain, laid out a series of recommendations on who should get opioids, at what dosage, and for what duration. 

Essentially no attention was paid at the time to antidotes for overdoses or the treatment of dependence. Public and private insurers, eager for cost savings, rapidly adopted the CDC’s dosage restrictions, as did pharmacy chains under attack for their lucrative role in opioid sales. The Drug Enforcement Administration also lent a hand by imposing manufacturing caps on the five major opioid pain medications.  

Within two years, opioid prescribing rates had decreased dramatically in major specialties: for primary care clinicians they dropped 40%, cancer specialists down 60%, and ER docs down 71%. Overall prescription rates fell back to 1990s levels. Success was proclaimed. 

‘Inhuman Punishment’

Then the full consequences of inflexible dosage limits by non-clinicians became apparent. More than 80% of chronic pain patients said they now had more pain and a worse quality of life. The number of cancer patients and survivors with opioid prescriptions decreased by more than half. Suicides by patients cut off from opioids increased. And almost 80% of primary care physicians reported they were reluctant to prescribe opioids for any reason.  

Even when opioids were prescribed, patients often found that their opioid medication was unavailable because of the artificial scarcity created by opioid litigation and the DEA’s manufacturing caps. Patient and professional organizations protested. A group of 274 academic experts (including two former “drug czars”) sent a protest petition to CDC.  

Human Rights Watch, an organization best known for exposing torture by totalitarian regimes, issued a hundred-page report, suggesting that CDC policies could be considered to violate basic human rights by imposing “cruel, degrading, and inhuman punishment” on those whose only crime was to be in severe pain.  

But CDC held the line, pointing proudly to a drop of a few percent in the 2018 overdose rate. Lost in the triumphalism was the fact that the overdose rate was creeping up from a little-known opioid called fentanyl, which is 100 times more potent than morphine.

The 2018 overdose downturn proved to be a pause, during which a new set of entrepreneurs entered the market, acquiring fentanyl components from suppliers in China, using pill presses to make them look like FDA-approved medications, and then transporting them to a gig distribution system in the US.

The Mexican cartels were meeting an unmet need. The pharmaceutical companies had helped create the need. And rigid implementation of the restrictive CDC guidelines, aided by DEA manufacturing caps, helped assure the need went unmet.

Overdoses, primarily from illicit fentanyl, exploded after the 2018 pause, doubling in the six years following implementation of the CDC recommendations, a surge particularly acute right in the CDC’s own backyard of Georgia.

So here we are in 2025, with a few percent reduction in overdoses and once again a repetition of 2018 triumphalism.

Meanwhile, overdoses have increased seven-fold from illicit carfentanil, a veterinary opioid so potent that a delivery box could overdose the entire US population.

We remain in the paradoxical situation where evermore dangerous illicit opioids from abroad are easily purchased on a street corner, while medically-prescribed opioids, manufactured under the FDA’s safety and purity standards, are hard to obtain by those who legitimately need them.

We Could Do Better

I worked for more than 28 years at CDC as an epidemic control specialist, during which time I also did clinical work with addicts and drug dealers in Appalachia and in the federal penal system.

Several years ago, as a patient with life-threatening staph spinal abscesses, I received months of high-dose opioids for severe pain. Many pain patients wake up each morning, as I did then, praying that the day’s struggle for some semblance of pain control will succeed against odds that seem so perversely, so specifically, so implacably stacked against them.

Out of these personal and professional experiences, I concluded that we could do better by the millions currently in severe inescapable pain, as well as the million projected to die by overdose in the upcoming decade. I wrote a book about the opioid crisis, "Greed to Do Good: The Untold Story of CDC's Disastrous War on Opioids."

In brief, here’s what I suggest should be minimal elements of an effective opioid epidemic response:

• We have an ongoing mass poisoning. We have an antidote. Naloxone (Narcan) should be deployed on a scale equivalent to the mass poisoning.

• For the estimated 50 million Americans with chronic pain, and especially the 17 million for whom pain limits life and basic functioning, opioids prescribed by a physician should not be so difficult to obtain that patients turn to cartels as America’s pharmacist.

• Standards guiding pain treatment should come from medical organizations with clinical expertise – not from pharmaceutical marketers, government bureaucrats, or the police.

• Artificial scarcity for legitimate opioids through DEA caps on manufacturing merely shifts demand to illicit opioids. This policy should be abandoned.

• For the estimated 6 million Americans with opioid use disorder, only 20% are in treatment. Addiction is a relapsing-remitting condition, with treatment outcomes similar to those for other chronic conditions, such as diabetes, asthma and hypertension, where behavioral setbacks are also common. To really wreak havoc on cartel profits, while saving American taxpayers millions of dollars in unnecessary incarceration costs, treatment needs to be made as accessible as it is for other chronic conditions

One-in-ten American families has lost an immediate family member to a drug overdose. The dead are our brothers, sisters, husbands, wives, children and newborns. The sooner we recognize that our policies result in more deaths and more persons in pain, the sooner we will bring this self-inflicted massacre to a close. 

A graduate of Princeton University and Harvard Medical School, Charles W. LeBaron, MD, is board certified in both internal medicine and pediatrics. For more than 28 years, he worked as a medical epidemiologist at the CDC.  

Dr. LeBaron’s book “Greed to Do Good: The Untold Story of CDC’s Disastrous War on Opioids” can be purchased from online booksellers or the publisher (Amplify Publishing in Herndon VA). For book reviews, see Kirkus or BlueInk.

Where Have All the Pain Doctors Gone?

By Pat Anson

In recent years, it’s become increasingly difficult for a patient in pain to find a new doctor. Many physicians have stopped treating pain, retired early or switched specialties, rather than run the risk of being investigated or even put in prison for prescribing opioids.

In a recent PNN survey, one in five patients said they couldn’t find a doctor to treat their pain. Others said they were abandoned or discharged by a physician (12%) or had a doctor who retired from clinical practice (14%).   

“All the doctors in this area are justifiably terrified to involve themselves at all with opiates,” one patient told us. “It's now going on 6 months that I've been hunting for a doctor who isn't afraid to continue my former opiate regimen, which only made my pain tolerable, allowing me some small quality of life. I don't know what to do next and I am truly at my wits end.”

“This year my doctor retired, then 8 months later the hospital closed the pain clinic. I'm waiting to get into a new pain clinic that is 200 miles away. Every local doctor refuses to prescribe my pain meds, so now I'm forced to travel 4 hours each way to see a new doctor,” another patient said.

“I have to fly to another state for my medical care,” said another person in pain. “Many patients I’ve met over the last ten years have not had the same care. They can’t afford the medical treatment and can’t find doctors to help.”

A new study suggests the problem is only going to get worse, because medical schools are seeing fewer anesthesiology residents applying for fellowships in pain medicine. The number of applications fell 45% from 2019 to 2023.

“While the demand for pain specialists is growing in the U.S., the pipeline of new doctors to fill these roles is drying up,” says lead author Scott Pritzlaff, MD, an associate professor in the UC Davis Department of Anesthesiology and Pain Medicine and director of the school’s Pain Medicine Fellowship program.

Pritzlaff and his colleagues analyzed data from the National Resident Matching Program (NRMP), Electronic Residency Application Service (ERAS) and a special report from the American Association of Medical Colleagues (AAMC) to see trends in medical specialties.

Their findings, recently published in the journal Pain Practice, show significant changes in specialties that are being driven by market forces and professional preferences. While demand and pay scales for general anesthesiologists have increased, the number of anesthesiology trainees applying for pain medicine fellowships is dropping. The trend is most notable among female residents applying for the specialty, which has fallen by 27.5%, compared to a 9.8% decline in male applicants.

“Fewer doctors choosing pain medicine means longer wait times, rushed care and fewer treatment options for patients suffering from chronic pain,” Pritzlaff said. “In a country already grappling with an opioid crisis, this could leave millions without the specialized care they need to manage their pain safely and effectively.”

Co-author Chinar Sanghvi, MD, says the drop in applications is partially driven by opioid lawsuits against drug makers and criminal cases against doctors, which have made medical residents and trainees leery about practicing pain medicine.

“For trainees observing this during their formative years, it may have created a perception of pain medicine as a high-risk specialty — both legally and ethically,” said Sanghvi, an assistant clinical professor in the UC Davis Department of Anesthesiology who mentors first and second year-medical students. “This fear of litigation, coupled with the stigma surrounding opioid prescribing, could discourage aspiring physicians from entering the field.”

The data also revealed some upward trends. Applications from residents for physical medicine and rehabilitation fellowships rose almost 33%, while residents specializing in emergency medicine increased by 190%.

General anesthesiologists have some of the best paying jobs in medicine, with median salaries of nearly $499,000 a year. For an anesthesiologist to specialize in pain medicine requires an additional year of training and pays less. With high demand and higher salaries, many doctors skip the extra training and enter the workforce right after completing their anesthesiology residency.

To help attract new residents, the UC Davis Health Division of Pain Medicine increased its recruiting efforts and became more active on social media. The efforts helped UC Davis fill its fellowship slots in pain medicine despite the national downturn.

“Pain medicine is caught in a strange paradox. On one hand, pain is one of the biggest public health problems in America, costing billions annually. On the other, the field is underappreciated and underfunded,” said senior author David Copenhaver, MD, a professor in the UC Davis Department of Anesthesiology and Pain Medicine and chief of the Division of Pain Medicine. “This decline isn’t just about numbers — it’s a wake-up call for the future of pain care in America.”

Walgreens Joins CVS in Fighting DOJ Opioid Lawsuits

By Crystal Lindel

Walgreens is fighting back against a new Department of Justice lawsuit, using a tactic that mirrors CVS’s public response to a similar DOJ lawsuit filed last month. 

In both lawsuits, the DOJ claims that Walgreens and CVS knowingly filled “unlawful prescriptions” for opioids and other controlled substances, and then sought reimbursement for them from federal healthcare programs like Medicaid and Medicare.

CVS and Walgreens are also accused of pressuring their pharmacists into filling prescriptions for opioids and other controlled substances without a thorough review. 

In a statement however, Walgreens said many of the federal rules governing pharmacies are so vague as to be impossible to follow. 

“We are asking the court to clarify the responsibilities of pharmacies and pharmacists and to protect against the government’s attempt to enforce arbitrary ‘rules’ that do not appear in any law or regulation and never went through any official rulemaking process,” Walgreens said. “We will not stand by and allow the government to put our pharmacists in a no-win situation, trying to comply with ‘rules’ that simply do not exist.

“Walgreens stands behind our pharmacists, dedicated healthcare professionals who live in the communities they serve, filling legitimate prescriptions for FDA-approved medications written by DEA-licensed prescribers in accordance with all applicable laws and regulations.”

Both CVS and Walgreens are accused of filling prescriptions for “dangerous and excessive quantities of opioids,” filling prescriptions too early, and filling prescriptions for opioids, benzodiazepines and muscle relaxants, a three-drug combination known as the “Holy Trinity” that the feds consider dangerous.

The DOJ alleges that, from 2012 through the present, Walgreens knowingly filled millions of prescriptions for controlled substances that lacked a “legitimate medical purpose, were not valid, and/or were not issued in the usual course of professional practice.” The complaint against CVS is nearly identical.

It’s noteworthy that the DOJ claims that both Walgreens and CVS have been filling these prescriptions “through the present,” because when it comes to getting an opioid prescription filled, pain patients find CVS and Walgreens to be the two most difficult pharmacies to work with. 

In 2023, PNN conducted a large survey of nearly 3,000 pain patients, and when respondents were asked which pharmacy chain was the most difficult to get an opioid prescription filled, more than half the patients in our survey selected either Walgreens (30%) or CVS (26%). 

“Every month when I have to get my medication renewed there is always an issue,” explained one patient. “Walgreens always give people a hard time. I've seen many people standing in line and just walk out.” 

“CVS continually gives me a hard time to fill my Rx even though I have been on it for over 7 years. It is either out of stock, or they argue with me about filling it,” another patient told us.

That difficulty is likely tied to the fact that Walgreens and CVS signed the National Opioid Settlement in 2022. As part of the settlement, they agreed to pay more than $10 billion to states, cities and counties that sued them for their alleged roles in causing the opioid epidemic. 

The nation’s two biggest pharmacy chains also agreed to watch for suspicious orders, report any “problematic” prescribers, and to strictly limit the amount of opioid pain medication they can dispense in any given month.

Opioids, in effect, are now being rationed to their customers, yet the DOJ is claiming that both pharmacies continue to fill opioid prescriptions too easily. 

As a pain patient, I use a small local pharmacy specifically to avoid the issues that are common for patients at large pharmacy chains like Walgreens and CVS. However, that alone doesn’t protect me. When the DOJ goes after large pharmacies, the fear trickles down to the smaller ones as well. 

Nearly every month I have some issue getting my prescription filled. They claim they can’t find the prescription in their system, and only “find it” after I go back and forth with them and my doctor on multiple phone calls. Or they claim it’s out of stock, which unfortunately I have no way of checking to see if they’re telling the truth. 

Just yesterday I spent all day trying to get my pain medication refilled because the pharmacist claimed she accidentally deleted it from the system. I had to get my doctor to resend it. 

Dealing with chronic pain is a struggle in and of itself. The last thing pain patients need is another battle to fight at the pharmacy. If Walgreens and CVS are unsuccessful in fighting back against their respective DOJ lawsuits, it’s likely that pain patients will suffer even more as a result. 

Opioid Pain Medication Used Infrequently by NFL Players

By Pat Anson

As many football fans know, the odds of a National Football League player getting injured during a practice or game are high. A concussion, Achilles rupture, ligament tear or musculoskeletal injury can cause a player to miss a game or even an entire season.

Given the pressure to compete and be ready to play, perhaps it’s not surprising then that nearly 70% of NFL players were prescribed a pain medication during the 2021-2022 seasons.

What is surprising is the type of analgesics they were using.

A new study found that only 2.9% of the pain medications used by NFL players were opioids. The vast majority (86%) of medications, both prescribed and over-the-counter, were nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen or diclofenac. Other non-opioids used by players were muscle relaxants, corticosteroids, gabapentin, acetaminophen and migraine medication.  

The study, recently published in Current Sports Medicine Reports, is based on data from a prescription drug monitoring program (PDMP) that was launched by the NFL in 2019 for all players.

“NFL athletes are exposed to very physical contact and to the development of pain during or after games due to injuries. There’s always been a concern from a safety and health perspective about what are they using to treat their pain,” said co-author Kurt Kroenke, MD, a researcher-clinician at the Regenstrief Institute and Indiana University School of Medicine.

“The good news is of all medicines prescribed to league players for pain, opioids account for only 3 percent. Moreover, only 10 percent of NFL athletes received even a single prescription for an opioid during a one-year period. I think there's been much greater attention to what can be done in the training room for NFL athletes for their injuries and pain that doesn't rely on medicines.”

The findings are remarkable, given the long history of opioid use in the NFL. A 2010 survey of retired players found that over half (52%) used prescription opioids during their careers, with 71% of them reporting misuse. Many continued to use opioids after they stopped playing, with 81% of the retired players reporting their chronic pain was moderate to severe.

Hall of Fame quarterback Brett Farve, an iron man who often played through injuries, admitted taking 15 hydrocodone (Vicodin) pills at a time, and even resorted to asking teammates for their pills.

The NFL’s laissez-faire attitude about opioids started to change after 1,800 former players sued the league in 2016, alleging that team doctors routinely disregarded DEA rules about controlled substances and encouraged players to use opioids and anti-inflammatory drugs.  It was not uncommon at the time for a player to get 6-7 pain pills or injections per week.

Injuries are still common in the NFL, but the league watches drug use much more closely. Every NFL player is tested for drugs at least once a year, usually before the season starts. The league also relaxed its policy about marijuana, effectively allowing players to consume cannabis during the off-season. Moderate consumption is tolerated during the season, as long as a player doesn’t have high levels of THC.   

“Professional football is a very physical sport. But anyone who watches professional hockey or NBA basketball or big league soccer and even college and high school sports, realizes how these players also are prone to injuries and pain,” said Kroenke. “I think how we treat pain safely, using opioid pain medications very infrequently, applies across all sports.”

Exclusive: How CDC Will Evaluate the Impact of Its Opioid Guidelines

By Pat Anson

We’ve learned more about a research study the CDC plans to conduct on the impact of its opioid prescribing guideline, which took opioids off the table as a treatment option for millions of Americans suffering from chronic or acute pain. The study was briefly outlined in a public notice published in the Federal Register in October.

It’s been over 8 years since the CDC released its controversial guideline and two years since the agency revised it, after receiving many reports of patient harm, including rapid opioid tapering, withdrawal, poorly treated pain, and suicide.

The agency has released few details on the “mixed-method quasi-experimental design” of the study, the first attempt by the agency to get direct feedback from patients, caregivers and doctors about the guideline’s impact on pain management.

Further details of the study are not coming from the CDC, but from the Office of Management and Budget (OMB), which is evaluating whether the study meets the requirements of the Paperwork Reduction Act, a law that gives OMB broad authority over the collection of data by federal agencies. The CDC’s briefings for the OMB can be found here, here and here.        

“The goal of this research study is to conduct a rigorous, comprehensive evaluation to assess the 2022 CDC Clinical Practice Guideline implementation, uptake, and outcomes. The government will use this information collection to inform CDC efforts and interventions to ensure that Americans have access to safer, effective ways of managing their pain,” the CDC explained.

“We propose conducting an analysis of changes in public and private payers’ policies—e.g., those governing Medicaid, Medicare, private health plans—since late 2022 when the CDC released the Clinical Practice Guideline.”

The study will be conducted over a four-year period and cost nearly $4 million, with much of the work subcontracted to Abt Global, a private research and consulting firm. Abt Global will perform a series of interviews, surveys and focus groups involving patients, caregivers and doctors; as well as dentists, insurers, health system leaders, professional medical associations, and state medical boards.

The DEA and other law enforcement agencies that investigated and prosecuted doctors for “unlawful” opioid prescribing are not included in the study.

The CDC’s previous attempts at evaluating the 2016 and 2022 guidelines relied on data about opioid prescribing rates, not on patient welfare or even whether the guidelines met their primary goal of reducing opioid addiction and overdoses. In that respect, the guidelines have failed. While opioid prescribing has fallen to levels not seen in decades, opioid-related overdoses have nearly doubled since the 2016 guideline’s release.

‘What Has Been Most Effective in Managing Your Pain?’

The CDC is planning an online survey of about 600 doctors (with invitations sent to 3,000) and virtual interviews with 30 of them, asking about their pain management and opioid prescribing practices, as well as any “unintended consequences“ of the agency’s guidelines. Similar questions will be asked of the dentists, insurers, health systems, medical boards, and professional societies.

No interviews or surveys are planned with patients or caregivers. Instead, a series of one-hour focus groups will be conducted involving a total of 135 patients and 90 caregivers, who will receive a $75 gift card as an incentive to participate. The CDC says it will “partner with patient advocacy organizations” to identify participants from their membership lists.

Due to the nature of focus groups, the opinions gathered from patients and caregivers are likely to be viewed as anecdotal or qualitative “perceptions,” not quantitative research.

“We will conduct focus groups with patients to provide an in-depth understanding of a single or small number of cases set in their real-world contexts. Examining the experiences of patients can provide a deeper understanding of real-world behavior within a specific healthcare context to elucidate perceptions of whether and/or how changes occurred in overall treatment and/or pain management, including opioid prescribing,” the CDC said.

The focus groups will be led by Abt Global moderators, who will ask a series of open-ended questions to promote discussion. Notably, there are more questions in the “Patient Focus Group Guide” about non-opioid pain treatments than there are about opioids.

There are also no questions about the CDC’s 2016 guideline. The focus is only on pain management after November 2022, when the revised guideline was released in an attempt to give more flexibility to doctors in using opioids to manage pain.

Focus Group Questions for Patients  

1. What treatments and medications for pain have you tried? What has been most effective in managing your pain?

2. There are a lot of strategies to help with pain. Tell us about your experience with physical therapy or exercise therapy to help with your pain.

3. Counseling or behavioral therapy is often used to help with pain. What has your experience been receiving counseling for pain management?

4. Have you had experience with any other non-medication therapies for pain (e.g., acupuncture)? Can you share your experience with those?

5. Medications other than opioids, such as ibuprofen and acetaminophen, which can be both prescribed or over-the-counter, are also often used for pain management. Tell us your experience with these non-opioid medications to manage your pain.

6. Tell us about your first experience being prescribed opioids for pain. How was your pain after you began taking opioids? What side effects did you experience?

7. When were you initially prescribed opioids for pain? How long were you initially prescribed opioids for? Had you received additional refills for opioids after that first prescription?

8. Have you noticed any changes to how clinicians manage your pain since November 2022? If so, what have you noticed?

9. Give me an example of how the management of your pain has improved since November 2022?

10. Give me an example of how the management of your pain remained the same since November 2022?

11. How has your pain management gotten worse since November 2022?

12. Since November 2022, what other factors may have affected how your pain has been managed, such as a change in primary care clinician or changes in your insurance coverage or changing from a primary care clinician to a pain management specialist?

This kind of detail about the questions, participants and research methods has not been made public before. Only a brief overview of the study was provided in the October 2024 notice in the Federal Register, which the CDC made no effort to publicize to get broad public feedback.

As a result, the notice received only two public comments, one of them a letter from the American Society of Anesthesiologists (ASA). The ASA called the 2022 guideline a “significant improvement” over the 2016 guideline, but added that 40% of its members felt the updated guideline was “ineffective.” There were also criticisms that the guidelines “might lead to reduced access to necessary pain medications.”

The CDC was dismissive of both public comments and said no changes would be made to its study design or methodology.  

“The public comments received did not have specific suggestions that impact any evaluation instruments; therefore, no changes were made to the instruments,” CDC said.      

Chronic Pain Leading Risk Factor for Suicide by U.S. Veterans

By Pat Anson

Chronic pain is the leading risk factor for suicide by U.S. veterans, according to a comprehensive new report by the Department of Veterans Affairs that also identified poor sleep, declining physical activity, and other health problems that significantly raise the risk of a veteran dying by suicide.

VA researchers estimate there were over 6,400 veteran suicides in 2022, an average of 17.6 suicides per day. The suicide rate for veterans (34.7 per 100,000) is twice the rate among non-veterans (17.1 per 100,000).

While those are alarming figures, there are some signs of progress. The number of veteran suicides has been trending downward since 2018, with a notable decline in the suicide rate among female veterans (-24.1%), homeless veterans (-19.1%) and younger veterans (-3.8%) in 2022.

Dept. of Veterans Affairs

The VA report goes into great detail on the methods used to commit suicide (a firearm is the most likely), and whether a deceased veteran had social, financial, mental health, or substance abuse problems.

But surprisingly little attention is paid to the leading risk factor: chronic pain. Only on Page 44 of the report is it disclosed that 53.8% of veterans who died by suicide reported pain in the year prior to their death. Pain isn’t even mentioned in a VA news release on the report.

“Every veteran suicide is a tragedy,” said Secretary of Veterans Affairs Denis McDonough in that news release. “There is nothing more important to VA than ending veteran suicide — and that means providing veterans with the care they need, wherever they need it, whenever they need it.”

‘The Pain Is Forever’

Many veterans in pain say they can’t get the care they need in the VA health system, which has worked to reduce opioid prescribing and expand the use of non-opioid alternatives. The VA updated its clinical practice guideline in 2022 to strongly recommend against long-term opioid therapy, especially for younger veterans.

“The VA makes you go through re-education camp for pain meds for chronic pain for injuries and diseases,” one veteran told us. “They make doctors refuse to prescribe pain meds and they made a whole new industry punishing sick people. Anyone who joins the military should know the hell they will be put through if they are injured and the pain is forever.”

“It's amazing how VA loves to play with my treatment for chronic pain. If I get tapered down again (for the 5th time) I don't know what I will do. It makes the heroin option look like the best way to go,” said another veteran. “And they can't understand why so many vets are killing themselves.”

“Chronic pain is known to be both common amongst individuals who die by suicide and a frequent issue identified as a reason for ending one’s life,” says Anne Fuqua, a chronic pain sufferer who has been tracking pain patient suicides for several years.

“If VA claims preventing suicide is a top clinical priority, when chronic pain is present, they should treat it aggressively, employing whatever medications and interventions are needed to best treat an individual without being handicapped by artificial limits that have no relationship to the individual veteran’s clinical situation.”

More Research Needed

Risk factors that contribute to suicide are difficult to measure, largely due to the difficulty of assessing possible causes for a veteran who has passed away and can’t speak for themselves. Suicide is often a taboo topic for a veteran’s surviving family and loved ones.

One expert says the VA deserves credit for trying to tackle such a complex problem.    

“We have to demand that every health care system, not just the VA, recognize the special risk to suicide that occurs in people who have all of these risk factors, whether it’s sleep, impulsivity, an unsecured firearm, or pain,” said Stefan Kertesz, MD, an internist at the Birmingham VA Medical Center and Professor of Medicine at the University of Alabama at Birmingham.

“In many health care settings, efforts to quantify the pain experience have been made taboo. That's a horrible mistake. Not asking about something doesn't make the problem go away.” 

Kertesz is leading a study of suicides among veterans and civilians, and is trying to connect with survivors who can talk about changes in healthcare and social functioning that occurred prior to a loved one’s death.

“We need to ask, carefully and systematically, about what is going on in the lives of folks who are in distress. We need to ask how we can be of help,” said Kertesz.

“The prominence of pain in the VA’s statistical report does not mean pain is the primary driver of suicide. Most folks with pain, after all, don’t consider suicide. But it is a reminder that we can’t ignore pain or minimize it or pawn it off on the patient as their little problem to solve. We need to be present and we need to ask, relentlessly, what the heck is going wrong and how can we do better?”

If you have lost someone with pain to suicide, you can learn more about the study by clicking here or on the banner below. Participants who are interviewed may be eligible for a cash payment of $100.

The Most Popular Pain News Network Stories of 2024

By Crystal Lindell

Looking back at 2024, there was a lot of news to cover about chronic pain and illness. Access to opioids and new pain treatments were two issues that readers were most interested in over the last year. 

Below is a look at the top 6 most widely read articles that PNN published in 2024, a year that saw us reach nearly 550,000 readers around the world.

Kamala Harris’ Stepdaughter Draws Backlash for Advocating Pain Treatments

Our most widely read article — by far — discussed Ella Emhoff, the 25-year old stepdaughter of Vice President Kamala Harris, who was running for president at the time. 

Emhoff revealed on social media that she has chronic back pain and shared a list of ways that she tries to address it, including alternative treatments such as ketamine, exercise, and an anti-inflammatory diet. 

Emhoff’s lengthy list of potential treatments got some push back from our readers, in part because she never mentions opioids. Other readers were hopeful that Emhoff could help draw more attention to an issue that most politicians ignore.

“How much her stepmom is aware of her stepdaughter's trials & tribulations is an unknown, but there is a tiny ray of hope that she - the candidate - has at least some direct awareness of an issue that effects millions of Americans but remains unaddressed by anyone,” one reader commented.

Read the full article here.

New Mothers Lose Custody of Babies After False Positive Drug Tests

This article was about hospitals routinely giving urine drug tests to new moms — and then reporting them to child welfare agencies when the tests show false positives. One mother wasn’t allowed to take her newborn baby home because she ate a salad with poppy seeds and then falsely tested positive for codeine.

The article was based on an investigation by The Marshall Project, which interviewed dozens of mothers, medical providers, toxicologists and other experts to report the story. 

“People should be concerned,” Dr. Stephen Patrick, a neonatal researcher told The Marshall Project. “This could happen to any one of us.”

Read the full article here. 

DEA Finalizes More Cuts in Opioid Supply

For the 8th consecutive year, the U.S. Drug Enforcement Administration reduced the amount of opioid pain medication that drug makers can produce in 2024, ignoring complaints from thousands of patients that opioids are already difficult to obtain and many pharmacies are out of stock.

This article received more reader comments than any other in 2024.

“This is absolutely criminal, the DEA dictating how much painkillers are available? How much more do legitimate chronic pain sufferers need to suffer? Now I know why I couldn’t get my pain medication. This really pisses me off and it should piss off everybody!” one reader posted.

Read the full article here.

Many Doctors Hesitant to Accept Patients Using Opioids or Cannabis

This article delved into research at the University of Michigan showing that many primary care doctors are reluctant to accept new patients who use either opioids or cannabis.

Of the 852 physicians surveyed, nearly a third (32%) said they would not accept a patient using opioids daily, while 18% felt the same way about patients using medical cannabis.

“This lack of access could inadvertently encourage patients to seek nonmedical treatments for their chronic pain, given that relief of pain is the most commonly reported reason for misuse of controlled substances,” said lead author Mark Bicket, MD.

Read the full article here.

90% of Pain Patients Have Trouble Filling Opioid Prescriptions

This article looked at the results of a PNN survey of over 2,800 patients with an opioid prescription. 

We found that nine out of ten patients experienced delays or problems getting their prescription filled at a U.S. pharmacy. Even after contacting multiple pharmacies, nearly 20% were unable to get their prescription filled,

“My medication helps my pain be at a level I can tolerate. When I can't get it, I honestly feel like ending my life due to the pain. I wish they'd stop to realize there are those of us with a legitimate need,” one patient told us.

Read the full article here

‘Smart Opioid’ Relieves Pain with Lower Risk of Overdose

This article was about an experimental form of hydrocodone that relieves acute pain without the risks of traditional opioids. 

An early stage clinical trial by Elysium Therapeutics found that its “SMART” formulation of hydrocodone releases therapeutic levels of the pain medication when exposed to a digestive enzyme in the small intestine.

If a patient takes too high of a dose, the drug inhibits production of the enzyme, which slows the release of hydrocodone. In theory, that will reduce the risk of abuse and overdose. 

“I wonder how soon this might be available to the public by prescription? Our country desperately needs more pain control options,” said one reader.

Read the full article here.

We hope you enjoyed reading PNN in 2024 and found our stories informative and helpful. We look forward to continuing our coverage of chronic pain and other health issues in 2025. 

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DEA Keeping Supply of Rx Opioids Unchanged in 2025

By Pat Anson

The Drug Enforcement Administration says it can’t do anything about shortages of opioid pain medication at U.S. pharmacies and will keep the 2025 opioid supply essentially unchanged from this year’s levels.

Under the Controlled Substances Act (CSA), the DEA sets annual aggregate production quotas (APQs) for every drug maker, in effect telling them the amount of opioids and other controlled substances they can make every year.

The APQs for 2025 were recently published in the Federal Register after a public comment period that received nearly 1,900 responses, many from patients and providers worried about further cuts in the opioid supply.  

“DEA received a significant number of comments from pain advocacy groups, hospital associations, health professionals, and others who raised concerns over the proposed APQs for certain opioids in 2025,” DEA said. “After considering all of the relevant factors, DEA has determined… that U.S. manufacturers will need to manufacture approximately the same amount of those opioids in 2025 as in 2024 in order to meet legitimate needs.”

Although the FDA advised the DEA there will be a 6.6% decline in the medical need for opioids in 2025, the DEA adopted only minor reductions for several widely used opioid medications. They are the same amounts proposed by the agency in October.

DEA Opioid Production Quotas for 2025

• Oxycodone:  0.137% decrease

• Hydrocodone: 0.081% decrease

• Morphine: Unchanged

• Codeine: Unchanged

• Hydromorphone: 0.015% decrease

• Fentanyl: 0.0025% decrease

Although the reductions are tiny compared to previous years, 2025 will still be the ninth consecutive year that DEA has cut the supply of opioids. Since 2015, DEA has reduced production quotas for oxycodone by over 68% and hydrocodone by nearly 73%.

DEA acknowledged receiving many comments from pain patients who said their local pharmacies were often out of opioids, forcing them to contact additional pharmacies and travel further to get their prescriptions filled. DEA said those issues were out of its control.

“Drug shortages may occur due to factors outside of DEA's control such as manufacturing and quality problems, processing delays, supply chain disruptions, or discontinuations,” the agency said.  “Currently, FDA has not issued notice of any nationwide shortages of the types of opioid medications mentioned by these commenters.”

The FDA and DEA may not be tracking opioid shortages, but the American Society of Health-System Pharmacists (ASHP) is.

Opioids currently listed in short supply by the ASHP include oxycodone/acetaminophen tablets, oxycodone immediate-release tablets, hydrocodone/acetaminophen tablets, hydromorphone tablets and solution, fentanyl solution, and morphine solution.

Most opioid medications are generic and cheap to make, but they have low profit margins and come with high risks. Teva Pharmaceuticals, a large generic drug maker, recently discontinued production of oxycodone and potent fentanyl lozenges. The medications were entangled in costly litigation that resulted in Teva paying $4.25 billion to settle opioid liability lawsuits.

Opioid shortages at the pharmacy level are also linked to litigation. Under the terms of a 2022 settlement with drug distributors, opioids are tightly rationed at many pharmacies, resulting in patients with opioid prescriptions being unable to get them filled because pharmacies are out of stock.

Here again, the DEA said the shortages are out of its control and claimed its prosecution of doctors for “unlawful” opioid prescribing was a non-issue.

“Patients and medical professionals may notice specific drug products are out of stock in particular areas; however, DEA cannot dictate DEA registrants' distributions of drug products,” the agency said.

“Additionally, DEA's regulations do not impose restrictions on the amount and the type of medication that licensed practitioners can prescribe. DEA has consistently emphasized and supported the authority of individual practitioners under the CSA to administer, dispense, and prescribe controlled substances for the legitimate treatment of pain within acceptable medical standards.”

Quotas Don’t Prevent Overdoses

For patients reliant on opioids, including those with late-stage cancer, being unable to fill a prescription means withdrawal, uncontrolled pain, and little quality of life.

A palliative care physician recently wrote an op/ed in STAT about “Teresa,” a patient in her mid-60’s with advanced cancer that spread to her abdomen.

“Only her prescription morphine gave her the relief she needed to function and enjoy some small pleasures, like walking her dog in the park,” wrote Dr. Rebecca Rodin, an assistant professor at the Icahn School of Medicine at Mount Sinai.

“But one day, her pharmacy didn’t have her morphine in stock, nor did five other neighborhood pharmacies that she went to. I called another three pharmacies before finding one with a two-week supply available — but it was a 40-minute drive from her home.”   

Rodin says the real culprits in the overdose crisis are illicit fentanyl and other street drugs – not prescription opioids. And no amount of buck passing by the DEA will fix that problem.

“Quotas and resulting shortages of prescription pain medicines are not helping to prevent overdose deaths,” said Rodin. “Quotas are simply turning vulnerable patients with serious illness into collateral damage in a misguided effort to address the opioid epidemic.”   

After Years of Foot Dragging, CDC Plans Review of Opioid Guideline

By Pat Anson

Eight years after releasing its controversial 2016 opioid guideline and two years after revising it, the CDC is finally making plans for a review of the guideline’s impact on patients, caregivers, doctors, and the practice of pain management.

In a notice published in the Federal Register, the CDC said it would open a 30-day public comment period on a “mixed-method quasi-experimental approach” to evaluating the updated 2022 guideline.

In plain English, the CDC plans a web-based survey of about 200 clinicians, and individual interviews with 10 clinicians, 2 dentists, 3 health system leaders, 3 insurers, 3 professional association leaders, and 3 medical board leaders. In addition, CDC will interview up to 15 patients and 15 caregivers in focus groups.

The agency did not indicate how the participants or organizations will be selected, or what questions will be asked.

“CDC is comprehensively evaluating the uptake, implementation, and outcomes of the 2022 CDC Clinical Practice Guideline on evidence-based care for pain management to understand its impact,” the agency said. “The evaluation includes dissemination and impact of the 2022 CDC Clinical Practice Guideline through population-wide changes in prescribing practices for opioids and medications for opioid use disorder.”

This is actually the second time CDC has published a public notice about the guideline review. Only two public comments were received after a similar notice was published in the Federal Register on October 1, which the CDC made no effort to publicize.

‘Timing Is Very Odd’

It’s not clear why a second notice was published during the holiday season and in the final weeks of the Biden administration. CDC did not immediately respond to a request for comment.

“The timing is very odd, and almost everyone missed the opportunity for open comments earlier this year,” said Chad Kollas, MD, a palliative care physician and pain policy expert.

“Few states have backed off from overly restrictive prescribing laws that were created based on the 2016 Guideline. I think that’s the main opportunity here, documenting the failure to implement the revised recommendations in the 2022 guidance. It’s unclear how CDC plans to determine who will get an opportunity to respond in the proposed study, so transparency remains troublesome for them.”

The CDC was slow to acknowledge the harm caused by the 2016 guideline. Although voluntary, the agency’s recommendations were widely implemented as mandatory by states and law enforcement agencies, resulting in patients having their opioid medication reduced or cutoff, and doctors being prosecuted for exceeding the guideline’s dosage recommendations.

To address those issues, CDC issued a revised guideline in 2022. But many of the problems caused by the original guideline linger.

“The 2016 guidelines led to a variety of restrictive policies, including limitations on opioid dosages. These measures created significant barriers for patients trying to access pain care and made it more challenging for physicians to prescribe necessary medications,” Donald Arnold, MD, President of the American Society of Anesthesiologists (ASA) wrote in a letter to the CDC, one of the two public comments made in response to the October 1 public notice.

The ASA surveyed its members on the impact of the 2022 revised guideline. Over half (56%) thought it was “somewhat effective” in reversing the harm caused by the 2016 guideline, while 40% thought it was ineffective.

A PNN survey of over 2,500 patients, providers and caregivers also found mixed reviews of the 2022 guideline. Only 39% of respondents thought it was “improved” or “much improved” over the original guideline.  Most respondents said it was about the same or even worse.

‘Same Problems Still Exist’

The CDC never conducted a comprehensive review on the impact of the 2016 guideline, but it did hire a consulting firm to improve its image after the agency was widely criticized for its secrecy and lack of transparency during the guideline’s development process.

A former CDC epidemiologist was so dismayed by the agency’s lack of accountability that he wrote a book about it, “Greed to Do Good: The Untold Story of CDC’s Disastrous War on Opioids.” Dr. Charles LeBaron says CDC leadership was blinded by its own hubris.

“The problem was not looking at the (guideline) sufficiently quantitatively and then not checking the consequences, or at least responding to the consequences when they're brought to your attention,” LeBaron told PNN. “Many of the same problems continue to exist, even though the personalities are completely different, and there are still significant restrictions on people in chronic pain for no apparent benefit.”

The personalities will change yet again when the Trump administration takes office on January 20. Conservative activists have made clear they want a major restructuring of the CDC, returning the agency to its core mission of collecting and disseminating data on communicable diseases. They want the CDC to stop telling people what to do, and to leave medical guidelines to professional societies and state medical boards.

CVS Pushes Back Against DOJ’s Latest Opioid Lawsuit

By Crystal Lindell

The U.S. Justice Department’s latest opioid lawsuit against CVS is getting some push back from the pharmacy chain. The DOJ alleges that CVS knowingly filled “unlawful prescriptions” for opioids and other controlled substances, and then sought reimbursement for them from federal healthcare programs like Medicaid and Medicare.

Specifically, the DOJ claims that CVS had “corporate-mandated performance metrics” that incentivized pharmacists to fill the prescriptions. The government also alleges that CVS “set staffing levels far too low” for pharmacists to meet their corporate goals and legal obligations.

“Our complaint alleges that CVS repeatedly filled controlled substance prescriptions that were unlawful and pressured its pharmacists to fill such prescriptions without taking the time needed to confirm their validity,” Deputy Assistant Attorney General Brian Boynton said in a statement. “The practices alleged contributed to the opioid crisis and opioid-related deaths.”

CVS issued a statement in response to the lawsuit that “strongly disagrees with the allegations and false narrative.” The company said the standards the DOJ is claiming CVS didn’t meet are so vague and ever-changing as to be useless. 

“The government’s lawsuit seeks to impose a shifting standard for pharmacy practice,” CVS said. “Many of the litigation theories laid out in the complaint are not found in any statute or regulation, and relate to topics on which the government has declined to provide guidance.

“Each of the prescriptions in question was for an FDA-approved opioid medication prescribed by a practitioner who the government itself licensed, authorized, and empowered to write controlled-substance prescriptions.”

I have to say, it’s good to see CVS defend itself in these situations. 

Especially by pointing out the obvious: The prescriptions were written by doctors who were licensed by the government. Although pharmacists have a “corresponding authority” to make sure a prescription is legitimate, why should a private pharmacy chain be held to a higher standard than the government itself?

The government’s lawsuit intensifies a serious dilemma for the pharmacy industry, which is simultaneously second-guessed for dispensing too many opioids and for filling too few. 

Over the last few years, it seems like every government agency in existence has been looking for anyone they could possibly sue in relation to opioids. As a result, about $50 billion in opioid settlement money will be paid in coming years by opioid makers, distributors and pharmacies.

However, there’s one glaring aspect of this tactic that makes it clear the lawsuits aren’t about helping people hurt by opioids, but about finding ways for the government and plaintiff law firms to get more money. Much of the settlement money received so far has been earmarked for law enforcement and other government projects that have little to do with opioids.

‘We Will Defend Ourselves’

CVS has already agreed to pay about $5 billion to settle opioid litigation. The company says the latest lawsuit, which seeks unspecified additional penalties, is just another cash grab.

“We will defend ourselves vigorously against this misguided federal lawsuit, which follows on the heels of years of litigation over these issues by state and local governments — claims that already have been largely resolved by a global agreement with the participating state Attorneys General,” the company said. 

CVS says it has been an “industry leader” in developing programs to fight opioid misuse. In recent years, the nation’s largest pharmacy chain has refused to fill controlled substance prescriptions written by over 1,250 doctors, about half of whom the government continues to license. 

The company also points to its “Our Opioid Response” website, which features a telling headline about government regulations and the scrutiny faced by pharmacists: 

“Fill this opioid prescription. No, wait, actually you can’t do that. Or, maybe, you can: The dilemma for community pharmacists.”

The text on the site then goes on to again point out the DEA’s vague guidance and inconsistent stance on the issue. 

“Whichever decision they make, community pharmacists know they can – and will – be second-guessed later. Too often, we have seen government agencies and trial lawyers question the good-faith decisions made by pharmacists while a patient waits at the pharmacy counter, often in pain. While simultaneously being accused of dispensing too few opioids and too many, pharmacists and pharmacies face threats of liability no matter their actions,” CVS said.

A recent court case suggests that CVS and other pharmacy chains are making some headway in defending themselves. The Ohio Supreme Court ruled this week that CVS, Walmart and Walgreens are not “public nuisances” under the state’s product liability law. Similar rulings have also been made in West Virginia, California and Oklahoma, rejecting public nuisance claims that resulted in costly opioid settlements.

CVS says it is standing up for “patients enduring relentless pain,” and as a patient who faces relentless pain, I’m happy to see it. While I’m skeptical that the overall tide is turning when it comes to public attitudes about opioids, it’s good to know at least one company is pushing back. 

12 Holiday Gifts for People with Chronic Pain and Illness

By Pat Anson

Are doctors and pharmacists helping the DEA spy on pain patients? Does Big Pharma control how healthcare news is reported? Is the Epstein-Barr Virus the hidden cause of your chronic pain? Can kratom be used safely? Are you buzzed that Willie Nelson wrote a cannabis cookbook?

The answers to these and other questions can be found in PNN’s annual holiday gift guide. If you live with chronic pain and illness or have a friend or family member who does, here are 12 books that would make great gifts over the holidays. Or you can always “gift” one to yourself. Click on the book cover or title to see price and ordering information.

The Epstein-Barr Virus: A New Factor in the Care of Chronic Pain

Dr. Forest Tennant examines the Epstein-Barr Virus (EBV) and its hidden role in causing chronic pain. We are all carriers of EBV, which is normally harmless and dormant. But when the virus reactivates, it is carried throughout the body, infecting and damaging body tissues. Dr. Tennant says anyone with chronic pain severe enough to require daily pain medication may have EBV reactivation, and should take steps to diagnose and treat it. 

Policing Patients: Treatment and Surveillance of the Opioid Crisis

Prescription Drug Monitoring Programs (PDMPs) were launched across the country to help prevent drug abuse and save lives. In actuality, author Elizabeth Chiarello says PDMPs are “Trojan horse” surveillance tools used by law enforcement to spy on patients. PDMPs interfere with the practice of medicine by turning doctors and pharmacists into undercover agents — often pitting them against their own patients.

Greed to Do Good: The CDC’s Disastrous War on Opioids

Dr. Charles LeBaron worked for nearly three decades as an epidemiologist for the Centers for Disease Control and Prevention. Although not directly involved in the CDC’s opioid prescribing guideline, LeBaron recognized the disastrous consequences it had on patients. In this book, he gives an insider’s perspective on the CDC’s institutionalized arrogance and how its misguided strategy to reduce overdoses only made the opioid crisis worse.

Follow the Science: How Big Pharma Misleads, Obscures, and Prevails

Journalist Sharyl Attkisson exposes how the pharmaceutical industry infiltrated government and academia, enabling it to put profits over people by controlling how healthcare is covered by the news media. “We exist largely in an artificial reality brought to you by the makers of the latest pill or injection,” Attkisson writes. “Invisible forces work daily to hype fears about certain illnesses, and exaggerate the supposed benefits of treatments and cures.”

Lies I Taught in Medical School

Inspired by his own health problems, Dr. Robert Lufkin wrote this book to expose the “medical lies” that contribute to chronic illness — some of which he taught as a professor at UCLA and USC. Lufkin believes pills and procedures are prescribed too often to mask symptoms, when diet and lifestyle changes can resolve many chronic conditions like diabetes, hypertension, obesity, and cardiovascular disease.

The Big Book of Kratom: The Ultimate Manual to Understanding and Using Kratom

Author Fallon J. Smith takes a deep dive into the pros and cons of kratom, gleaned from many years of using it himself. New kratom users can learn about the various strains and methods of ingesting the herbal supplement to treat everything from chronic pain and anxiety to addiction and depression. Smith also shares important lessons about dosing, side effects, and the potential risks of kratom withdrawal and addiction.

Willie & Annie Nelson’s Cannabis Cookbook

Legendary singer/songwriter Willie Nelson and his wife Annie share their favorite recipes for getting high and full at the same time. Part travelogue and part cannabis cookbook, there’s a colorful story behind every recipe, such as Baked Eggs & Asparagus (with 17mg of THC), Vegan Cannabis Butter, Cannabis Chocolate Cake, and Buttermilk Fried Chicken (no THC).

On Call: A Doctor’s Journey in Public Service

In this memoir, Dr. Anthony Fauci shares some of the highlights — and lowlights — from nearly 40 years working for the National Institutes of Health, including the crucial roles he played in fighting AIDS, the Ebola virus, SARS, anthrax and, of course, Covid-19. Fauci grew up in modest circumstances, living above his father’s Brooklyn pharmacy, to become a health advisor to seven presidents and one of the most famous doctors in world.

Grown Woman Talk: Your Guide to Getting and Staying Healthy

Dr. Sharon Malone is an OB/GYN who wrote this book to help older women deal with the complexities of aging. Often ignored or gaslighted by the healthcare system, older women may have their chronic pain and discomfort dismissed as female hysteria caused by menopause. Dr. Malone has tips to end this “normalized suffering” and empower grown women to live better, age better, and get better medical treatment.

Long Illness: A Practical Guide to Surviving, Healing and Thriving

Drs. Meghan Jobson and Juliet Morgan wrote this book to give patients and providers a better understanding of long-lasting illnesses such as autoimmune disease, chronic fatigue, chronic pain, inflammation and Long Covid. They take a holistic approach to managing symptoms through cognitive behavioral therapy, traditional Eastern medicine, mindfulness and self-care — emphasizing that recovery is a process and not always a destination.

Toxic Stress: How Stress Is Making Us Ill

Dr. Lawson Wulsin is a psychiatrist who has found that toxic stress and childhood trauma often play hidden roles in the development of heart disease, diabetes, depression and chronic illnesses in midlife. In this book, Dr. Wulsin offers practical advice and tools to recognize signs of toxic stress in our lives, and learn how to help your mind and body recover from it.

The Long Covid Reader

Author Mary Ladd shares the stories of 45 people living with Long Covid, who recount in essays and poems how COVID-19 continues to impact their lives long after their initial infections. A long-hauler herself, Ladd spent a year gathering personal stories about Long Covid in an effort to humanize the neglected suffering of millions of people who live with a mysterious chronic illness from the “world's biggest mass-disabling event.”

These and other books about living with chronic pain and illness can be found in PNN’s Suggested Reading page.  PNN receives a small amount of the proceeds -- at no additional cost to you -- for orders placed through Amazon.

Low Dose Opioids Do Not Raise Dementia Risk, But High Doses Might

By Crystal Lindell

There’s a new study out showing that low-dose opioids are not linked to an increased risk of developing dementia, but higher doses might. 

Researchers followed the health of over 1.8 million people in Denmark aged 60 to 75, about 5% of whom developed dementia. They tracked the opioid use of those with and without dementia to see what role, if any, opioids may have in causing cognitive decline.

They found that low dose opioids prescribed for chronic non-cancer pain — which they defined as up to 90 total standardized doses (TSDs) — was not consistently associated with dementia risk. However, doses above 90 TSD were associated with a slightly elevated dementia risk before age 90. 

Interestingly, the strongest association between opioids and dementia was found with “weak” opioids such as tramadol.

Total standardized doses are a different way of measuring opioid use than what is typically used in the United States. Medical guidelines in the U.S. focus on morphine milligram equivalents (MME) per day. Depending on the guideline, anything over 50 or 90 MME would be considered a high dose.   

For the Danish study, 1 TSD is the equivalent of 30 MME. So someone with a TSD of 90 is getting the equivalent of 2,700 MME over time. Researchers used this method because they wanted to see what the cumulative effect of opioids would have on dementia.  

“This study found that opioid use of less than 90 TSDs was not significantly associated with increased dementia risk. Above 90 TSDs of opioid use was associated with an elevated dementia risk before age 90 years, which persisted in individuals with chronic noncancer pain and in individuals solely exposed to weak opioids,” researchers reported in JAMA Network Open,.

They also added the favorite caveat of medical researchers everywhere: “Further research should ascertain whether the findings denote causality between opioids and dementia risk.” 

In other words, it is still unclear if taking higher doses of opioids leads to dementia, or if chronic pain puts people at higher risk of dementia. It’s a chicken and egg question without any answers. 

A previous study also found that high doses of opioids slightly raise the risk of dementia, but so did nonsteroidal anti-inflammatory drugs (NSAIDs). So switching someone from opioids to NSAID pain relievers won’t lower their risk.  

Regardless, given the findings in the Danish study about the lower doses, I am glad to see some more definitive evidence that opioids aren’t the cause of every ailment ever. 

I do worry that the study even existing will perpetuate harmful opioid-phobia myths though. For example, the study’s headline – “Opioids and Dementia in the Danish Population” – is just vague enough that casual readers may assume that the research did show a link between opioids and dementia, regardless of the dose. 

It also irks me that researchers included the favorite sentence of opioid-phobia propagandists: "Opioids are frequently used to treat chronic noncancer pain, but evidence of the effect on pain management and quality of life is lacking." 

As usual, the fact that millions of people around the world have told doctors that opioids help their pain is apparently not “evidence.” They can’t trust any of us.  

As someone who’s been on what the researchers would consider “low dose” opioids since I was 29 years old, I can tell you they do help manage my pain and give me a better quality of life. If the researchers found a higher dementia risk for me, I’d still keep taking opioids. 

Opioids are the only thing that allows me to live my life today. I’m not going to give that up because I might have a higher risk of dementia decades from now. In fact, if I did give them up, I suspect there’s a high chance that I would not make it into my senior years anyway, seeing as how opioids are often the only thing that makes my daily pain endurable. 

I suspect I’m not alone. Research like this is unlikely to deter most pain patients from taking opioids, but it could make some doctors hesitant to prescribe them. And that’s a shame. Because a study showing that low-dose opioids aren’t as bad as some feared should make doctors more comfortable prescribing them.

ER Opioids ‘Extremely Unlikely’ to Lead to Addiction

By Pat Anson

Many patients in pain have horror stories to share about their experiences in hospital emergency rooms, where they’ve been treated as drug seekers and denied opioid medication.

“I had a broken arm and was given nothing for pain when leaving the emergency room,” one patient told us. “They now treat everyone like a drug seeking addict even if you have legitimate pain!”

“My last ER visit has caused me PTSD. It was awful they put me in a room and turned the light off and left me there for hours,” said another.

“The emergency rooms are horrible,” said a patient with a fractured rib. “I wasn’t even asking the ER for meds. I wanted an x-ray or something because I was in excruciating pain.”

Are fears about opioid addiction justified? A new study found that the risk of developing opioid use disorder after being treated with intravenous opioids in the ER is quite low – less than one-tenth of one percent (0.002%).

Out of 506 patients treated with IV opioids in two Bronx emergency rooms, only one met the criteria for long-term or persistent opioid use six months later.

“These data suggest that the use of IV opioids for acute pain among opioid-naive patients is extremely unlikely to result in persistent opioid use,” wrote lead author Eddie Irizarry, MD, an emergency medicine physician at Montefiore Medical Center.

“Opioid naïve” means the patients had never taken opioids before or only used the drugs infrequently.

The study, recently published in The Journal of Emergency Medicine, defines persistent use as filling six or more opioid prescriptions in the 6 months after an ER visit, or an average of one prescription per month.

The most frequently reported IV opioid administered in the ER was morphine (94%), followed by hydromorphone (4%) or a combination of both morphine and hydromorphone (2%). The researchers noted that most of the morphine doses were “relatively modest.”

After being treated in the ER, 63 of the patients (12%) received an opioid prescription on discharge.   

The researchers cautioned that opioids should be used “judiciously” and that many ER patients could be treated with non-opioid analgesics such as acetaminophen. But they could find no evidence that IV opioids should be routinely denied in the ER.

“We are not aware of compelling data to support denying parenteral opioids to opioid-naïve patients who are suffering from severe acute pain,” said Irizarry.   

The research mirrors the findings from a 2017 Mayo Clinic study, which found that the risk of long-term opioid use is lower for ER patients than it is for patients treated in other medical settings. In the Mayo study, 1.1% of opioid naive patients became long term users. That compares to 2% of patients who were prescribed opioids in non-emergency settings.

The Stress of Navigating Opioid Shortages As a Patient

By Crystal Lindell

At 9:30 am Monday morning, I got one of the most dreaded phone calls that someone taking a controlled substance can get – my pharmacy was completely out of my pain medication, Morphine Sul ER. 

Chronic shortages of prescription opioids were finally impacting me directly. 

At first, the pharmacist tried to make it sound like there was just a small delay, asking me, “How how many pills you have left?”

None. I had none left. Because pain medication refills usually aren’t filled until you completely run out. There’s not even a one-day leeway built in, because god forbid pain patients have one extra pill ever. 

Even if I did have some left, I couldn’t tell the pharmacist that, because it might risk having that used against me later. Afterall, if I had extras, that shows that I don’t need to be prescribed as many pills as I was getting. 

You’re always risking something as a pain patient. If you try to plan too far ahead by stockpiling extra pills, they could use that to reduce what you’re prescribed. And if you don’t plan ahead at all, you risk physical pain and withdrawal if there are any issues getting your refill – issues beyond your control like a drug shortage. 

As it turned out, it wouldn’t have mattered if I did have some pills leftover because the situation was worse than the pharmacist was initially letting on. This wasn’t an issue of waiting for an afternoon shipment or even a next-day restock. The pharmacist didn’t know when my medication would be back in stock at all. 

She said she had been requesting more pain medication every day, but their supplier wasn’t providing any updates on a timeline for when that would happen. So she suggested that I call around to other pharmacies to see if any of them had it in stock. 

There’s just one problem: the pain contract I had to sign to get a monthly opioid prescription technically bans me from getting refills at different pharmacies. I don’t think there are any exceptions in the contract. And if I break it, I risk losing access to the only medication that makes it possible for me to function on a daily basis. 

So even if I could find another pharmacy, I wasn’t sure if my doctor would let me get the medication filled there. 

The pharmacist was surprisingly understanding of this, and said that she had already called my doctor before calling me, so she was hopeful that they would be accommodating. 

At that point I realized that any plans I had for my Monday morning were now canceled, because I was going to have to spend the next few hours trying to navigate this. 

I made one last attempt to get the situation resolved without having to loop in another pharmacy, asking if they had an alternative medication that wasn’t too expensive because I don’t have health insurance. My medication is an extended release opioid, and the pharmacists said all they really had was the instant-release versions – which I knew my doctor would not want to swap in.

So, another pharmacy it would have to be. 

I did wonder for a moment if my pharmacy was lying to me about being out of stock. It was just last month that I had to negotiate the price of this same medication with them after they tried to increase the price by $50. 

Maybe they just didn’t want to deal with me, a long-term opioid patient, any more. So after the attempted price increase failed to deter me, they were trying a different tactic. 

The thing is, how would I even find that out? As far as I know, there’s no accountability for pharmacies that lie to patients about why they aren’t able to fill a prescription. Most people understand why that’s concerning when it comes to things like birth control or insulin, but when it’s pain medication, the general public tends to side with the pharmacist who doesn’t want to fill the prescription. 

At that point, I started calling other pharmacies. Thankfully, a locally owned one said they had the medication in stock and that they could fill it. I called my doctor to see if they’d transfer the prescription, and his receptionist took down the message. Then, I waited. 

I spent the next few hours anxious about whether this would all work out, and how long it would be until I got my refill. Finally, at about 1 pm, I saw in MyChart that the medication had been sent to the new pharmacy. 

Then I called the new pharmacy to make sure they saw my prescription come through and to ask what the cash price was. It was going to be $52, about $16 more than I paid at the other pharmacy. I probably could have asked them about using a GoodRx coupon, but I was already throwing a controlled substance prescription on them at the last minute, and they had it in stock, so I didn’t want to make waves. 

A few hours later it was finally filled, sort of. At 3 pm I arrived at the pharmacy to pick it up, after driving 25 minutes on rural roads to get there. 

They handed me the bottle and said, “Oh, by the way, we’re two pills short. Hopefully we will have those in for you later this week. So you can come back and pick them up then.”

Another 50 minutes of round-trip driving was suddenly in my future. 

I’m thankful that I found a pharmacy with any of my medication in stock, and I’m happy that my doctor seemed to handle the prescription transfer without issue. 

What Happens Next Month?

But the entire, stressful ordeal wiped out most of my day, and now I also have to figure out what will happen next month. 

Will the shortage impacting my medication be handled by then? Or should I try to have my doctor switch my prescription to something else? And if he did that, how much would that medication cost? Should I have my prescriptions permanently transferred to the other pharmacy? Is the one I normally go to going to give me a hassle every month now?

If medication shortages don’t impact you directly, it can be easy to gloss over reports like the one from the American Society of Health-System Pharmacists (ASHP), which found that shortages of drugs used for pain, anesthesia, chemotherapy and attention-deficit/hyperactivity disorder (ADHD) “continue to be problematic.” 

Those shortages impact real people. Despite a stressful morning, I was among the lucky ones, as I was able to get it worked out within just one day. Who knows if that will be the case next month though. 

The ASHP cited reduced DEA production quotas and the fallout from opioid litigation as some of the reasons for the drug shortages, which have led to rationing at many pharmacies. In a recent PNN survey, 90% of patients with an opioid prescription said they had trouble getting it filled at a pharmacy.

We need the government to start working on behalf of patients to get this resolved. I can’t just call up the manufacturer of Morphine Sul ER and tell them to make more. It has to be the government that intervenes. 

The best place to start would be to lift the DEA production quotas – although that’s really just a start. If we’re being realistic here, there should also be production minimums, with government funding and support if needed. 

People’s lives depend on these medications. It’s time to stop pretending that these drug shortages are just trivial inconveniences. They’re harmful, and sometimes even deadly.

Where Did the Opioid Settlement Money Go?

By Crystal Lindell

How are states spending their opioid settlement money? Unsurprisingly, it’s often hard to say – even when a state has promised transparency. 

Federal, state and local governments in the United States will collect about $50 billion in opioid settlement money in coming years from basically every sector of the health care industry, including drug makers, wholesale distributors and pharmacies. 

But an investigation of 12 states by NPR and KFF Health News found that it’s unclear how much of that money is being used to prevent addiction or to help people with substance abuse issues. 

As a pain patient, I have long assumed that none of the settlement money would be used to develop effective, non-opioid pain analgesics for patients who lost their medication as a result of opioid-phobia. Based on how everything around opioids has played out over the years, I also didn’t have high hopes for what it would actually get spent on.

The NPR/KFF Health News investigation shows that I was correct to worry. 

“There are no national requirements for jurisdictions to report money spent on opioid remediation,” Aneri Pattani reported.”In states that have not enacted stricter requirements on their own, the public is left in the dark or forced to rely on ad hoc efforts by advocates and journalists to fill the gap.”

Pattani shared a story about the situation in Idaho, where local governments were required to complete a form showing how they spent settlement money and whether it was for an approved purpose. But a process meant to show transparency seemed to do just the opposite. 

“In reality, it reads like this,”said Pattani. “In fiscal year 2023, the city of Chubbuck spent about $39,000 on Section G, Subsection 9. Public Health District No. 6 spent more than $26,000 on Section B, Subsection 2. Cracking that code requires a separate document. And even that provides only broad outlines.”

Pattani said that following the money trail just led to more intentionally confusing bureaucratic language. 

For example, she found that Subsection 9 refers to “school-based or youth-focused programs or strategies that have demonstrated effectiveness in preventing drug misuse.” 

Subsection 2 refers to “the full continuum of care of treatment and recovery services for OUD and any co-occurring SUD/MH conditions.” 

“What does that mean? How exactly are you doing that?” Corey Davis, a project director at the Network for Public Health Law, wondered when he first saw the Idaho reports. Without detailed descriptions of the projects the money was spent on, it’s impossible to track. 

“It’d be similar to saying 20% of your monthly salary goes to food,” Pattani wrote. “But does that mean grocery bills, eating out at restaurants, or hiring a cook?” 

Minnesota’s ‘Dashboard’

Some states are more transparent about where the money is going. Minnesota, for example, has an online dashboard and downloadable spreadsheet listing projects. One project was in Renville County, which used $100,000 to install a body scanner in its jail to help staff find drugs in the body cavities of inmates.

So, cops are getting the money. And when you look around on the Minnesota dashboard, it becomes clear that law enforcement agencies got some of the largest shares of the state’s opioid settlement money.  

So far, Minnesota has received over $74 million in settlement money. Of that, law enforcement-related categories received about $17 million, coming in fourth behind "American Indian" with $32.6 million, “African or African American" with $22.6 million, and "Child protection” which received $22.65 million. 

I was pleasantly surprised to see that Minnesota does have a "Chronic pain patients" category — but then was disappointed to learn that it got the least amount of money of any group, receiving just $290,180 of the state’s settlement funds.

When I drilled down deeper on the chronic pain category, things only got more depressing. 

The bulk of that money ($257,220) went to Hennepin Health System to "expand access to holistic chronic pain treatment through Heals on Wheels program,” which includes traveling clinics that provide training in mindfulness, stress management, mindful movement, acupressure, acupuncture and massage therapy.

The remaining $32,960 went to a group called Health Partners, which said it would use the money to, "Certify 10 clinicians to provide Empowered Relief, a one-session class that equips patients with pain management skills, draws on principals from mindfulness and cognitive behavior therapy.” 

As a pain patient, finding out that the very small amount of Minnesota’s opioid money going to pain patients is being used to fund BS about mindfulness is beyond infuriating. We need real treatments, not happy thoughts.

Of course, in other states, it’s hard to even know how much money is going to cops and if any is going to chronic pain patients, so I guess I should be happy that there’s at least some record of things in Minnesota.  

Interestingly, over $1.9 million of Minnesota’s settlement money went to the Steve Rummler Hope Foundation, primarily for opioid education and naloxone distribution. 

Coincidentally, the Rummler Foundation happens to be the fiscal sponsor of Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group that played an instrumental role in raising fears about opioid use and addiction.

Several PROP members worked as paid expert witnesses for plaintiff law firms that pursued opioid litigation on behalf of the states, and were paid as much as $850 an hour for their services. The law firms themselves will pocket billions of dollars in contingency fees once all the funds are paid. That kind of detail is rarely mentioned in reporting on how settlement money is used.   

So while some details of how opioid funds were spent are technically available to the public, Pattani says it doesn’t matter if finding them requires hours of research and wading through budgetary jargon.

“Not exactly a system friendly to the average person,” she said.

Of course, if any of the opioid settlement money was ever actually meant to help people who may have been harmed by opioids, it wouldn’t be going to governments – it would be going directly to opioid users or their surviving loved ones.

But it’s been clear from the beginning that these opioid settlements were primarily a cash grab for state and local governments, plaintiff law firms, and their expert witnesses. They don’t help patients and they don’t help their loved ones. 

I don’t expect any of the states to increase transparency about where the money has been going. Most of the general public doesn’t care, so the states can funnel a lot of the money into things like body scanners, because they don’t have the pesky public watching what they’re doing. 

Maybe next time when we decide to sue every pharmaceutical company and pharmacy chain in the country, we could at least make it class action lawsuits on behalf of patients, not governments.