As a pain management specialist, my intent is not to promote unchecked opioid prescribing or overlook the serious risks these medications pose. Instead, I advocate for viewing the full picture in patient care. Physicians, trained in medicine and its side effects, must be empowered to use their knowledge and direct observations, including subtle cues like body language and patient interactions during brief visits, to make tailored decisions. Documentation in charts serves as a clinical tool for continuity, not merely legal protection. External policies, while well-intentioned, often fail to account for individual variability since they are crafted without face-to-face patient encounters. By prioritizing patient-centered approaches, we can protect those we serve while addressing broader public health concerns.

Historical context: the evolution of opioid policies and unintended consequences

The opioid crisis has roots in complex factors, including rising overdose rates in the early 2000s. Efforts by agencies like the DEA and CDC aimed to curb perceived overprescribing, with the 2016 CDC guidelines highlighting risks and recommending caution. These guidelines, updated in 2022, were meant to be flexible but were sometimes applied rigidly by states, insurers, and medical boards, leading to a 60 percent drop in prescriptions from 2012 peaks. Despite this, overdose deaths have continued to rise, reaching over 105,000 in 2023, with nearly 80,000 involving opioids, predominantly illicit synthetics like fentanyl. This suggests that while prescription reduction was considered a logical response, it alone has not resolved the crisis, underscoring the need for multifaceted strategies beyond mere dose limitations.

A comparative perspective: opioids and antihypertensive therapy

To bring common sense to the discussion, consider the parallels between long-term opioid therapy for chronic non-cancer pain and antihypertensive treatment for chronic hypertension. Both involve medications with manageable risks that, when properly monitored, offer benefits far outweighing potential harms. For antihypertensives, particularly renin-angiotensin system (RAS) inhibitors, a 2021 guideline based on meta-analyses of over 280,000 participants showed an 18 percent increased risk of acute kidney injury and doubled hyperkalemia rates. Yet, these drugs reduce all-cause mortality by 7 percent, cardiovascular death by 8 percent, and stroke by 16 percent, preventing greater damage from untreated hypertension. Similarly, opioids carry risks such as increased cardiovascular events, fractures (relative risk 1.38), hospitalizations, and endocrine issues like hypogonadism, and opioid-induced hyperalgesia, as shown in a 2010 cohort study comparing opioids to NSAIDs. However, a 2016 review emphasizes that effective pain relief and functional improvements outweigh these when managed with tools like urine drug screening and abuse-deterrent formulations, with misuse rates at 15-26 percent and addiction affecting less than 8 percent under vigilant care. Overdose risks, like adverse events in antihypertensives, are multifactorial, not primarily from prescribed use alone. This analogy highlights the illogic of broadly restricting opioids due to risks, akin to withholding blood pressure medications over kidney concerns. Both approaches, when individualized and monitored, enhance quality of life and prevent worse outcomes.

Key facts on the opioid crisis: beyond prescription reduction

Evidence shows the crisis is driven by multiple elements, not solely legitimate prescribing:

• Prevalence of chronic pain: Over 50 million U.S. adults endure chronic pain, where appropriate medications support functionality and save the system around $100 billion yearly in reduced absenteeism and emergency care.
• Prescription trends vs. overdoses: Prescriptions have declined sharply, yet 2023 saw approximately 105,000 overdose deaths, with only a small fraction (approximately 13-14 percent based on recent patterns) involving prescription opioids alone; 70 percent or more stem from illicit fentanyl. Diversion rates are low (1-2 percent), and isolated prescription overdoses rarer still.
• Multifactorial risks: Overdoses often involve polypharmacy (e.g., with benzodiazepines or alcohol), illicit drugs, mental health issues, prescriber knowledge gaps, patient non-adherence, comorbidities like sleep apnea, and systemic factors such as payer-driven regimens (e.g., methadone, linked to one-third of deaths despite less than 5 percent of prescriptions). A 2024 CDC report notes 22 percent of 2022 overdose decedents had non-substance mental health disorders, including depression (13 percent), while a 2025 review links mood disorders to heightened risk via poor adherence or amplified pain.

These data illustrate that focusing solely on opioid reduction misses root causes, much like addressing hypertension only by limiting medications ignores lifestyle and monitoring.

Impacts on patients and physicians: the human cost of overly restrictive policies

• On patients: Chronic pain affects functionality, and abrupt restrictions can lead to desperation. For instance, policy-driven tapering in a 2022 study of 19,377 long-term users increased mental health crises (e.g., anxiety, suicide attempts) and overdoses by 52-57 percent for up to 24 months post-taper, especially in higher-dose cases. Suicide rates among pain patients have risen 20-30 percent since 2010, tied to untreated pain. Access has dropped 15 percent in underserved areas due to provider shortages.
• On physicians: Specialists face increased scrutiny, contributing to burnout (50 percent affected) and early retirements amid a projected 124,000 doctor shortage by 2034. Disciplinary actions have surged 300 percent since 2010, often without harm, costing $50,000-$200,000 in fees. Physician suicide rates, 1.5 times the norm, have increased 50 percent under this pressure.

Systemic challenges: aligning incentives for better outcomes

Regulatory bodies, tasked with safety, sometimes prioritize enforcement due to structural incentives, such as revenue from fines exceeding $100 million annually. With non-physicians comprising up to 50 percent of boards, decisions may lack clinical nuance. This can lead to selective audits and premature public accusations, encouraging settlements over fair processes. Reframing these systems to emphasize education and support could foster trust and effective care.

Calls for reform: common-sense, patient-centered solutions

Reducing opioids is not the sole answer; a balanced strategy is essential:

• Evidence-based guidelines: Update standards to prioritize individualized care, eliminating arbitrary limits like 90 morphine milligram equivalents.
• Enhanced oversight: Ensure transparent investigations with pain experts, limiting anonymous complaints and providing due process.
• Holistic focus: Invest in harm reduction (e.g., naloxone, addiction treatment), mental health integration, and targeting illicit supply chains.
• Support structures: Cap enforcement revenues, offer physician legal aid, and promote multidisciplinary teams for complex cases.
• Advocacy and education: Unite physicians, patients, and policymakers to bridge knowledge gaps and value clinical judgment.

By adopting this common-sense approach, recognizing opioids’ role in a broader toolkit, much like antihypertensives, we can mitigate the crisis without abandoning those in pain. The evidence demands nuance, not blanket restrictions, to truly protect public health.

Kayvan Haddadan is a physiatrist and pain management physician.