By Neen Monty
Why have prescription opioids become virtually verboten?
Is it safety? Partly. Evidence? Allegedly. The evidence is pretty thin.
But let’s not overlook the less noble explanation: research dollars, commercial opportunity, institution building and careers.
There is now an enormous scientific and commercial industry devoted to solving “the opioid crisis.” And that industry depends, at least partly, on maintaining a particular story: Opioids are dangerously addictive, fundamentally unsuitable for chronic pain, and urgently need to be replaced.
The United States National Institutes of Health launched its HEAL Initiative in 2018, nearly doubling annual funding for opioid and pain research from approximately $600 million to $1.1 billion.
By 2023, HEAL had invested $3.2 billion across more than 1,800 research projects. That is an awful lot of laboratories, salaries, grants, publications and careers attached to an “urgent public-health emergency.”
This does not mean researchers are gathering in dark rooms, twirling their moustaches and plotting against pain patients.
They don’t need to. The incentives do the work perfectly well.
Declare an existing treatment unacceptable and you create an urgent scientific problem.
Urgent scientific problems attract grants, investment, patents, clinical trials, prestige and promotions. They also create a potentially enormous market for whichever company produces the replacement.
That is not a conspiracy theory. It is an incentive structure. It's capitalism.
The Awkward Truth Behind the Sales Pitch
A recent Science article asks: “Can a new, safer class of pain drugs ever rival opioids?”
It sounds like another story about escaping the horrors of opioid medicine. But the headline accidentally admits something important: Opioids are extremely difficult to rival. That is why scientists are still trying.
If opioids were useless painkillers, as some modern pain rhetoric would have us believe, there would be no need for new drugs to “rival” them. Researchers would merely need to produce something better than useless. Apparently, this has proved surprisingly difficult.
In 2025, the U.S. Food and Drug Administration approved suzetrigine, marketed as Journavx, as the first drug in a new non-opioid class for moderate-to-severe acute pain. It blocks NaV1.8 sodium channels in peripheral nerves, interrupting pain signals before they reach the brain.
Its manufacturer, Vertex, is investing heavily in its commercial launch and development across further pain indications.
Good.
We desperately need more effective pain medications. We need different medicines for different pain mechanisms, different bodies and different medical circumstances. We need options for people who cannot tolerate opioids and better treatments for people whose pain does not respond to them.
Research and development is good. Obviously.
But developing new analgesics does not require pretending that existing ones do not work. Nor does it require sacrificing the patients who already use them successfully.
How Dangerous Is an Opioid Prescription, Really?
We are constantly told that prescribing an opioid exposes every patient to an intolerable risk of addiction and overdose.
The actual numbers are much less theatrical.
A 2023 systematic review and meta-analysis examined 28 observational studies involving almost 24 million patients prescribed opioids for chronic pain. It found a pooled prevalence of:
1.3 fatal overdoses per 1,000 patients
3.2 nonfatal overdoses per 1,000 patients
That is approximately 4.5 fatal or nonfatal overdose events per 1,000 patients prescribed opioids for chronic pain. Not zero. Not irrelevant. But a very long way from the impression that catastrophe inevitably follows the first prescription.
More importantly, the risk was not distributed evenly.
Overdoses were strongly associated with identifiable risk factors, including a previous overdose, current substance-use disorder, multiple prescribers, multiple dispensing pharmacies, higher doses, certain mental-health diagnoses and particular medication combinations.
In other words, “a person prescribed an opioid” is not one uniform risk category.
That should be obvious. Apparently, it needed a meta-analysis involving 24 million people to elucidate.
A stable patient taking one medication, prescribed by one doctor and dispensed by one pharmacy is not medically interchangeable with a person obtaining drugs from multiple sources, combining them with sedatives or living with an active substance-use disorder.
Yet much public discussion places all of these people into one ominous bucket labelled “opioid users.”
Not very scientific. Can you say bias? Stigma? Stereotyping? Profiling?
For a well-selected and well-monitored patient on long term opioid therapy, the risk of overdose is very, very low. That’s what the evidence says.
Many pain management doctors are keen to advertise “evidence-based treatment for chronic pain” without ever reading the evidence.
A Swamp of Addiction Statistics
The estimates of addiction following opioid treatment vary wildly.
That is not because addiction is a mysterious force capable of changing its prevalence depending on the phase of the moon. It is because researchers frequently measure different things and give them similar names. What constitutes “addiction” varies wildly.
And overdose statistics often include non-fatal overdoses. Or even overdose deaths where an opioid was detected, but was not the main cause of death.
Some studies only measure diagnosed opioid-use disorder. Others measure abuse, misuse, physical dependence, administrative billing codes, unexpected urine results, requesting an early prescription, or a vaguely defined “aberrant behaviour.”
None of these are the same thing. They are thrown together to inflate the outcomes. To keep the panic alive.
One 2018 meta-analysis reported an incidence of opioid “dependence or abuse” in 4.7% among patients prescribed opioids for pain. But the included studies used different diagnostic systems and produced a “substantial heterogeneity” of 99.78%.
For non-statisticians, that is roughly the scientific equivalent of throwing apples, wombats and garden furniture into a blender and reporting the average fruit content.
Physical dependence is an expected physiological adaptation to many medicines, including opioids. I don’t believe it’s avoidable. It means abrupt cessation may cause withdrawal. This is a normal response to suddenly stopping a medication. By choice or otherwise. It is not addiction.
Addiction - or opioid-use disorder - requires a pattern of use that involves impaired control, compulsive use or continued use despite evidence of harm.
A patient who takes a medicine consistently because it relieves severe pain and improves their ability to function is not demonstrating compulsive use despite harm. They are using a medicine for its intended purpose.
Needing insulin does not prove an unhealthy fixation on insulin.
Needing anti-hypertensive medication does not reveal a worrying psychological attachment to blood-pressure control.
Needing anti-depressants to live a functional life does not show a pattern of compulsive behaviour.
But needing ongoing pain relief? Suspicious. Apparently.
What Happened When Opioid Prescribing Fell?
If opioid prescribing were the principal driving force of the U.S. opioid epidemic, we should have seen precipitous reductions in prescribing to be followed by a substantial drop in opioid deaths.
But that is not what happened.
U.S. opioid prescribing has been declining since 2012. The percentage of adults filling an opioid prescription fell by 31% between 2008 and 2018, while the national dispensing rate continued falling to 35.4 prescriptions per 100 people by 2024.
Meanwhile, illegally manufactured fentanyl spread through the illicit drug supply.
The CDC reports that approximately 70% of U.S. overdose deaths in 2023 involved illegally manufactured fentanyl. It states that illicit fentanyl entered the illegal drug supply around 2013 and subsequently replaced heroin as the dominant illegal opioid in the United States.
Even the FDA acknowledges that prescription opioids are no longer driving the opioid overdose epidemic.
That sentence deserves to be printed in very large letters.
The truth that remains unsaid – and will never be admitted – is that prescription opioids were never the driving force behind the opioid crisis. Never. It was always about illicit drug use.
But prescription opioids are a much easier target than Mexican cartels and curbing illicit supply. Easy target, big wins, media headlines.
Who cares about the tens of thousands of patients who suffered and even died because their life saving pain medications were taken away? Very few.
Prescribed pain medication and illicit fentanyl are not completely separate worlds. There is some crossover. But most prescription opioid abuse is due to diversion. Yes, some people with opioid-use disorder were initially exposed to opioids through a medical prescription. But the vast majority of those already had a history of substance abuse.
And that crossover is very, very small. As can be seen from the major, large scale, systemic review already cited.
Stable therapeutic use, physical dependence, medication misuse, opioid-use disorder and exposure to an unpredictable illicit fentanyl supply are very different situations. Treating them as one big problem has not only failed to solve the illicit drug crisis; it has inflicted another crisis on people living with severe pain.
The Patients Who Spoil the Story
There is one group largely missing from the replacement narrative: patients for whom opioids work.
They are not getting “high.” They are not escalating their dose uncontrollably. They are not visiting six doctors or four pharmacies. They are not searching for euphoria.
They are searching for enough pain relief to shower, sleep, work, prepare food, and care for their children. To keep living a full and functional life despite moderate to severe pain due to disease or injury.
Some patients find opioids effective, but not remotely pleasurable. Many experience nausea, itching, sedation or mental fog. Others experience pain relief with few side effects.
Individual responses vary, as they do with every other class of medicine. For every person, it’s a case of weighing up the risks and benefits.
Opioids have unpleasant side effects, but there are few things as unpleasant as living with constant, severe, pain. I’d prefer some itching and a bit of nausea than a knife twisting in every joint, and my arms and legs feeling like they are on fire.
What would you choose?
In people with chronic low-back pain, research has shown that those with previous prescription opioid use got greater pain relief from morphine. But they were not more likely to feel “high.” In other words, stronger pain relief did not mean stronger euphoria.
But acknowledging those patients creates a problem.
If opioids are effective and acceptably safe for a properly selected and monitored group, then the scientific mission should not be to “replace opioids.”
It is “develop more choices while identifying who benefits from each one.”
Still very worthy. Still very important. Still very deserving of funding.
But we’re no longer talking about a “crisis.” Not quite as dramatic, and not as likely to receive that sweet, sweet funding for non-opioid alternatives.
Develop Better Drugs. But Stop Destroying Patients
To be clear, I am in no way saying that opioids are harmless. Opioids can have serious side effects. Patients need to be well screened and well monitored.
Opioids can cause adverse effects, physical dependence, respiratory depression, overdose and opioid-use disorder. Higher doses and dangerous medication combinations require particular care. Patients should receive honest information, individual risk assessment and proper monitoring.
Doctors are highly skilled and the very low overdose rate in chronic pain patients shows that doctors managed this risk very well. Right up until 2016 in the U.S and about 2020 in Australia.
But saying something “has risks” is not synonymous with “must never be used.”
I take many high-risk medications to treat my complex autoimmune diseases – medications that are much higher risk than any opioid could ever be. Yet taking that risk is allowed. Encouraged. Even insisted upon.
Why are opioids singled out and denied when Xeljanz or Rituximab are much more dangerous?
It makes no sense. Scientific sense, medical sense or common sense.
Of course better pain medications should be funded. Safer analgesics is a lofty goal that should be celebrated. New treatments that are as good as, or even better than opioids, without opioid-related risks would be a genuine medical achievement.
But we should not be taking opioids away from those who need them, who have been stable and doing well for years, before those new non-opioid pain medications are available. That means leaving people to suffer needlessly, on the promise that something better is being researched.
Pain patients should not be treated like expendable research targets. They should not be forced to surrender their pain relief and functional lives to fortify the commercial and scientific case for tomorrow’s medication.
Develop the alternatives. Fund the research. Build the careers. Make the money, even. All good.
But stop denying people who need access to long term opioid therapy for any kind of quality-of-life. Put the risk/benefit equation where it belongs, where it is with all other medications – in the hands of the informed patient.
And stop pretending that scientific progress requires opioids to fail, along with the patients who benefit from them.
Neen Monty is a patient advocate in Australia who lives with rheumatoid arthritis and Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), a progressive neurological disease that attacks the nerves.
Neen is dedicated to challenging misinformation and promoting access to safe, effective pain relief. For more information on chronic pain, the science, the politics and the lived experience, go to Pain Patient Advocacy Australia.
You can also subscribe to Neen’s free newsletter on Substack, “Arthritic Chick on Chronic Pain.”
