As a physician managing patients with chronic pain in California, I’ve witnessed the tension between necessary regulations and the daily reality of helping people in genuine distress. In the meantime, as a chairman for the National Campaign to Protect People in Pain (NCP3), I know how important it is to advocate for our patients. While foundational reviews on prescription drug oversight provide helpful context on opioids and NSAIDs (for details, refer to Chapter 1 of the book Legal Mind in Medicine), real-world practice requires integrating actual risk data with California’s requirements and the Medical Board’s emphasis on individualized care.

The double-edged sword of pain medications

Opioids remain among the most effective tools for moderate to severe pain. Their potential misuse contributed to a public health crisis that prompted regulatory responses, including Prescription Drug Monitoring Programs (PDMPs), stricter guidelines, and FDA oversight. Universal Precautions offer a strong framework: thorough assessment, risk stratification (using tools like the Opioid Risk Tool or SOAPP-R), informed consent, treatment agreements, multimodal therapy, ongoing monitoring, documentation, and careful tapering.

What the evidence actually shows about risk

Large-scale studies presented provide an important perspective:

• The risk of iatrogenic addiction or overdose from properly prescribed opioids for pain patients is very low, likely less than 1 in 1,000.
• Mental health history is a far stronger predictor of overdose or suicide than the opioid prescription itself.
• A 2010 Cochrane systematic review of long-term opioid therapy found iatrogenic addiction rates around 0.27 percent.
• A 2018 BMJ study of over 1 million opioid-naive post-surgical patients reported misuse rates of approximately 0.6 percent.
• The VA’s STORM analysis of 1.1 million patients showed overdose/suicide events around 2 percent, driven primarily by mental health and prior event history.
• Analyses by Jalal et al. and by Aubry and Carr demonstrate that the U.S. opioid crisis was not primarily driven by doctors’ prescribing and is not sustained by it. Prescription opioids appear in roughly 12 percent of recent overdose deaths, typically alongside illicit substances.

Practicing in California: What the rules actually require

California maintains strict oversight through the mandatory CURES (Controlled Substance Utilization Review and Evaluation System) program. Physicians must check CURES before prescribing Schedule II-IV controlled substances and at least every few months thereafter. The Medical Board of California’s July 2023 Guidelines support individualized, patient-centered care and clinical judgment rather than rigid, one-size-fits-all standards.

Practical framework for pain management

• Initial evaluation: Thorough history, focused exam, risk assessment (including mental health), mandatory CURES review, and urine drug screening as indicated. Set realistic functional goals.
• Treatment planning: Emphasize multimodal approaches. When opioids are medically necessary, use the lowest effective dose. Obtain informed consent, use a controlled substance agreement, and co-prescribe naloxone for higher-risk patients. Document your clinical rationale.
• Ongoing monitoring: Conduct regular follow-ups assessing pain, function, and adherence. Perform periodic CURES checks and urine drug screens. Adjust the plan based on the patient’s response.
• Handling red flags: Factors include, but are not limited to, long-distance travel, cash payments, “Trinity” or high-risk medication combinations, and unexpected urine screens. These are signals to investigate and document, but not automatic violations.
• Tapering and continuity: Taper gradually when appropriate. Avoid abrupt discontinuation, which can increase harm. Provide bridge prescriptions and referrals to prevent patient abandonment.

Quick reference checklist for daily practice

• CURES reviewed (mandatory)
• History, exam, and risk assessment completed
• Functional goals and rationale documented
• Informed consent and agreement in chart
• Naloxone considered or prescribed if indicated

Moving forward

The evidence is clear: Physician over-prescribing was never the primary driver of the opioid crisis, and mental health factors are far more predictive of adverse outcomes. California physicians can deliver compassionate, evidence-based pain care while remaining compliant through thoughtful, individualized decision-making and strong documentation. Regulations should protect patients without creating unnecessary barriers to legitimate care.

Kayvan Haddadan is a physiatrist and pain management physician, and president and medical director of Advanced Pain Diagnostic & Solutions, a multidisciplinary pain management practice in California that he founded in 2012. A physician and surgeon licensed by the Medical Board of California, he is double board-certified in pain medicine and physical medicine and rehabilitation. He is also certified in controlled substance registration through the DEA and serves as a qualified medical examiner through California’s Department of Industrial Relations Division of Workers’ Compensation.

Dr. Haddadan earned his Bachelor of Science degree from the College of Alborz in Tehran, Iran, and his medical degree from Shahid Beheshti University of Medical Sciences. He later received his Educational Commission for Foreign Medical Graduates certification in Philadelphia, completed an internship in medical surgery at Loyola University Medical Center’s Stritch School of Medicine in Illinois, and finished his residency in physical medicine and rehabilitation at the same institution. He completed his fellowship in pain medicine at California Pacific Medical Center’s Pacific Pain Treatment Center and also trained in medical acupuncture for physicians at the University of California, Los Angeles David Geffen School of Medicine.

Dr. Haddadan has contributed to 29 research publications across multiple specialties, including pain management, cardiology, pulmonology, endocrinology, gastroenterology, and infectious disease. His work has examined topics such as hyperlipidemia in high cardiovascular risk patients, hyperuricemia and gout management, type 2 diabetes and hypertension, chronic obstructive pulmonary disease and asthma therapies, influenza treatment, irritable bowel syndrome, and opioid related complications in chronic pain care. His research has also included clinical outcome studies in spinal cord stimulation and award-winning presentations on neuropathic pain management and neuromuscular disorders.