Most of us have heard the ancient Indian and Buddhist parable “the blind men and the elephant.” Regardless of source, the parable usually contains these elements:

A ruler assembles several blind men and brings an elephant before them. One feels the head and says the elephant is like a pot; another the ear and says it is like a fan; another the leg and says it is like a pillar; another the trunk and says it is like a snake or plow; another the side and says it is like a wall; another the tail and says it is like a rope. They then argue, sometimes even coming to blows, each insisting the others are wrong, though each has only partial experience of the same creature.

As a health care educator and patient advocate specializing in public health policy for treatment of pain and addiction, I am often disappointed by resemblances between the practice of modern pain management and this fable. Our overspecialized academics and public health officials very frequently lose track of the forest due to their overconcentration on (and defense of) their particular trees (beliefs).

There are broadly two competing medical models for pain and suffering. Historically, physical medicine, psychiatry, and counseling have attempted to distinguish between the two. Freud, Jung, and others in the early 1900s focused on pain and suffering as highly eclectic issues of “mind.” Pain and suffering were viewed as subjective experiences that might be reduced by changes in the patient’s attitude or focus.

Perhaps only with the third edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-III, 1980) did emphasis move toward pain and suffering as a brain disease curable by medication. General practitioners with limited training in psychological assessment began prescribing antidepressants and selective serotonin reuptake inhibitors (SSRIs) to replace earlier medications with much more dangerous side effects administered by psychiatrists.

The 1990s saw widespread pharmaceutical company advertising: “pain as the fifth vital sign” promoted opioid analgesics as safe and effective pain treatments. But soon, clinical opinion and practice once again reversed direction. In a new wave beginning about 2010, federal and state authorities asserted that opioid analgesics were “overprescribed” by clinicians and believed to cause large numbers of patients to become addicted or to die of accidental overdose.

U.S. CDC prescribing guidelines in 2016 and 2023 went so far as to suggest that nonpharmaceutical therapies were “preferable” to opioid analgesics in treating pain. However, CDC ignored the fact that among 5,000 published trials for such therapies, not one had compared outcomes of opioid treatment with nonpharmaceutical therapies on a head-to-head basis. That hasn’t kept many clinical practices from attempting to substitute such dubious therapies for opioid analgesics.

Layered across these medical models are multiple competing self-interests and bureaucracies.

In the 1990s, pharmaceutical companies advertised “pain as the fifth vital sign” to promote opioid analgesics to general practitioners. Arguably, this advertising produced a decade of pill mills, diverted large volumes of pharmaceutical drugs into nonmedical markets, and fostered addiction among people who were suffering from psychiatric problems, sometimes addressing physical pain, but also sometimes not.

However, pain is still today the symptom that most often brings patients to a doctor’s office. Currently, an estimated one in four U.S. adults experience pain every day. Of these, about 25 million have high-impact pain at a level that compromises daily quality of life. What are clinicians and politicians doing about that?

Increasingly in the 21st century, health care insurance companies resist reimbursement of ongoing expenses incurred by chronic patients, even for relatively inexpensive opioid analgesics. Indeed, a major impact of the 2016 CDC prescribing guidelines was to drive the medical community toward more expensive alternative treatments such as Rational Cognitive Therapy and ongoing interventional treatments such as spinal stimulators and nerve blocks.

From the perspective of suffering patients and families, “the profit goes in before the name goes on.”

Predictably, as prescription drug monitoring programs in all 50 states destroyed the business model of pill mills in 2010 to 2012, addicts and recreational users turned to other sources, including street markets tainted by counterfeit pills containing illicit fentanyl and its analogs. Clearly, some patients being denied pain care were and still are among those being killed by counterfeit pills.

As I and a colleague have written, we face not one “opioid crisis,” but two. One crisis grows from people seeking oblivion or relief from lives of quiet desperation. A second crisis was created by U.S. CDC, Veterans Administration, and other health agencies that have vastly mischaracterized risks of opioid analgesics in chronic pain management, largely ignoring benefits.

Restrictive public health policies have criminalized pain medicine, driven thousands of doctors out of medicine or into prison, and caused the desertion of tens of thousands of patients in agony. Also high on a long list of atrocities committed against patients and doctors are the National Opioid Settlement and its “injunctive relief” provisions restricting pharmacy inventories and driving some pharmacies out of business.

From the perspective of thousands of patients with whom I have corresponded for almost 30 years, a major casualty of modern medicine is its loss of connection to the standard of Hippocrates: “First do no harm.” These days, doctors focus very much more defensively than in the 1970s. Now they say “how can I avoid being sanctioned and losing my income… even if my patients’ care is compromised?”

In 1990, Ronald Melzack published a paper in Scientific American titled “The Tragedy of Needless Pain.” Many would regard Melzack as the “father” of pain science and the treatment of pain. His model for pain and suffering incorporated both the brain and mind. As he wrote:

“… the fact is that when patients take morphine to combat pain, it is rare to see addiction — which is characterized by a psychological craving for a substance and, when the substance is suddenly removed, by the development of withdrawal symptoms (for example, sweating, aches and nausea). Addiction seems to arise only in some fraction of morphine users who take the drug for its psychological effects….”

Melzack’s insights are validated by authorities in multiple academic venues. Reinforcing these insights has been the discovery that genetic factors play a significant role in individual vulnerability to addiction. Likewise, genetic mediation of opioid metabolism separately accounts for a very wide range in minimum effective dose and side effects between individuals treated for pain.

We know from outcomes of prison-based detox programs, that inmates and former inmates in addiction treatment programs routinely tolerate daily exposure exceeding 1,000 to 2,000 morphine milligram equivalents for decades. It is only after discharge from prison that addicts accidentally kill themselves by overdose before they have tapered up to their former tolerance. Self-administered polypharmacy and inappropriate mixing of opioids with alcohol may kill people. But opioids themselves are remarkably nontoxic.

Ask any doctor: What are the likely consequences of tapering up to 40 times the recommended dose of Prozac, Tylenol, or insulin? Death will be high on the list.

Alarmingly, none of the factors highlighted above are discussed in opioid prescribing guidelines issued by the U.S. CDC and Veterans Administration in 2022-2023. The existence of these factors was known both to guideline authors and reviewing officials charged with validating agency recommendations. Such omissions are properly viewed as fatal flaws that must prompt withdrawal and repudiation of such documents and of state prescribing standards derived from them.

In May of 2019, six nationally prominent organizations of clinicians, representing 560,000 doctors and medical students went on record calling upon law makers to “end political interference in the delivery of evidence based medicine.” That call is even more urgent six years later, as increasing numbers of people in agony are routinely denied safe and effective pain care with prescription opioid analgesics.

Patients are dying and doctors are languishing in prison, as blind men and women argue over the dimensions of the elephant in their room. Professionals seem to be operating within a framework of political belief and bias, not science. Nobody seems to be talking with practitioners in disciplines other than their own.

This is madness. And it is time for it to stop.

Richard A. Lawhern is a nationally recognized health care educator and patient advocate who has spent nearly three decades researching pain management and addiction policy. His extensive body of work, including over 300 published papers and interviews, reflects a deep critique of U.S. health care agencies and their approaches to chronic pain treatment. Now retired from formal academic and hospital affiliations, Richard continues to engage with professional and public audiences through platforms such as LinkedIn, Facebook, and his contributions to KevinMD. His advocacy extends to online communities like Protect People in Pain, where he works to elevate the voices of patients navigating restrictive opioid policies. Among his many publications is a guideline on opioid use for chronic non-cancer pain, reflecting his commitment to evidence-based reform in pain medicine.