I once cared for a patient I’ll call Maria, a middle-aged professional with severe spinal disease and years of stable function on a carefully monitored opioid regimen. She’d never lost a prescription, never shown signs of misuse, and passed every urine drug screen. Then her clinic was acquired by a large health system, and new policies arrived with a single message: cut opioid doses or risk scrutiny. Within months, Maria’s dose was slashed. Her pain flared, her mobility collapsed, and she lost her job. No one accused her of diversion or addiction. The problem was that she needed opioids in an era when needing opioids has itself become suspicious.
Maria is not an outlier. She is a predictable product of how the War on Drugs has migrated into exam rooms and hospital committees. What began in the 1970s as a political campaign against illegal drugs has evolved into a web of laws, guidelines, and enforcement practices that make it unsafe (for patients and physicians alike) to treat severe pain with the full range of effective tools.
As clinicians, we are told we are fighting an “opioid epidemic” caused by overprescribing. We are monitored by prescription drug monitoring programs, payer algorithms, and sometimes law enforcement. The message is clear: if you err, err on the side of saying no. Yet when we look closely at what these policies have produced, a different picture emerges. Overdose deaths continue to climb, driven largely by illicit fentanyl and polysubstance use, while people with chronic pain struggle to obtain even basic analgesia.
In my clinic, and in the experiences shared by patient advocates, the pattern is strikingly consistent. Patients with long-standing, well-documented pain conditions face increasing scrutiny. They are labeled “drug seekers” when they ask for the medications that have kept them functional. Many report that their physicians have abruptly cut or discontinued opioids not because of clinical problems, but because of new risk-management directives, corporate policies, or fear of regulatory action.
Survey data echo what we see at the bedside: a large proportion of people living with chronic pain now report difficulty accessing adequate pain management because clinicians fear being perceived as overprescribing. Advocates like Richard Lawhern have documented thousands of accounts of involuntary tapering or abandonment of stable patients, with predictable consequences: escalating pain, loss of independence, and in some cases despair severe enough to lead to suicide. When our systems treat suffering patients as vectors of risk rather than as human beings, the result is not safety. It is iatrogenic harm.
The War on Drugs has also distorted how we respond to addiction. For decades, drug use has been treated more as a crime than a medical condition. Mandatory minimum sentences and aggressive policing fall disproportionately on marginalized communities, even as access to evidence-based treatment lags behind need. At the policy level, we speak the language of “public health,” but in practice we still rely heavily on punitive tools.
This punitive mentality infiltrates legitimate medical care. Federal restrictions on medications like methadone and buprenorphine, combined with stigma and administrative barriers, make it difficult for many patients with opioid use disorder to start and stay in treatment. At the same time, regulations and fear-driven guidelines discourage appropriate opioid therapy for severe pain. We have managed to build a system that underserves both people with addiction and people with pain.
The mental health toll is enormous on both sides of the stethoscope. Many people with chronic pain also live with depression, anxiety, and trauma that are worsened when their pain is dismissed or undertreated. They hear “we’re concerned about your safety” as “we don’t believe you.” On the clinician side, the relentless message that any opioid prescription could end a career creates a climate of moral injury. Physicians endure intrusive oversight, second-guessing by nonclinical entities, and, in some cases, investigations and legal action despite good-faith efforts to follow the rules. It is no surprise that burnout rates are high.
What, then, should change?
First, we must stop pretending that we can arrest our way out of overdose deaths or regulate our way out of suffering. Addiction is a chronic medical condition with social drivers, not a moral failing. Pain is a complex biopsychosocial experience, not a mere vital sign. Policies that reflexively restrict opioid prescribing without regard to individual clinical context confuse correlation with causation. They punish the sick for the failures of our broader drug policy.
Second, we need to re-center both pain and addiction care in evidence rather than politics. That means acknowledging that properly monitored prescription opioids are not the primary driver of today’s fentanyl-dominated overdose crisis, and that abrupt dose reductions in stable patients are dangerous. It also means expanding access to medications for opioid use disorder, integrating mental health care into pain management, and investing in nonpharmacologic therapies that patients can realistically access and afford.
Third, we must protect clinicians who practice patient-centered medicine. Clear, clinically grounded guidelines should support individualized care, not serve as rigid rules enforced with the threat of discipline. Prescription monitoring tools should help us identify genuine misuse and diversion, not function as blunt instruments that scare clinicians away from treating pain. Regulators and health systems should distinguish between careful, documented prescribing in high-risk populations and reckless practice.
Finally, we owe it to our patients and ourselves to name what is happening. When a policy designed to prevent misuse leads to a person in severe pain being cut off from effective treatment, that is not an unfortunate side effect. It is a preventable harm. When physicians are driven out of pain management because the legal risks are too high, that is a structural failure. When overdose deaths continue to rise despite decades of punitive policy, it is time to admit that our approach is not working. A more detailed version of this argument, with supporting data and references, is presented in a longer paper on the effects of the War on Drugs and regulatory overreach on pain and addiction care.
Maria’s story could have unfolded differently. In a saner system, her clinician would have been supported, not punished, for maintaining a stable opioid regimen that preserved her function. Her treatment plan would have incorporated mental health support and non-opioid options as adjuncts, not replacements imposed by decree. If she developed signs of opioid use disorder, she would have had timely access to effective medications and care rather than stigma and abandonment.
As physicians, we cannot single-handedly rewrite federal law or dismantle the War on Drugs. But we can speak plainly about what we see. We can insist that guidelines acknowledge the realities of both pain and addiction. We can refuse to accept a system in which people in severe pain are collateral damage in a political battle over drugs. And we can stand with our patients, as clinicians and as advocates, until policy finally reflects what good medicine has always demanded: first, do no harm.
Bill Bauer is a neurologist.
