How Pain Became Profitable

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.”

Why I Keep Quiet About My Use of Prescription Opioids

By Crystal Lindell

When I first started taking prescription opioids on a daily basis in 2013, I didn’t hide that information from anyone. I told my friends at church, my family, and even my then-boss.

I was in way too much pain to spend any energy worrying about what anyone thought about me or the pills I was popping.

At the time, I was still working in the corporate world. And I quickly began to see and experience the stigma that comes with opioids. It wasn’t long before every mistake I made and every emotion I had were blamed on the fact that I was taking Norco.

I still remember the time a man at work lost his temper on me. When I felt like I had the very appropriate reaction of sobbing at my desk, my then-boss immediately dismissed it to both me and the man who had screamed at me by explaining that I was “on lots of new medications.”

So, over the years, I have learned to withhold my pain medication use to new people. Sadly, this decision has only been reinforced by the fact that things have gotten worse over the last decade when it comes to opioids being a taboo. 

The media narrative that a 5 mg hydrocodone tablet is the same thing as a baggie of street fentanyl has caught on. Now, people who may not have even known what hydrocodone was in 2013 are hyper aware that it’s part of the “opioid epidemic.”

So, I hide my pain pill usage in real life. It may sound paranoid, but I have been undercover enough times to see the truth. 

When people think I’m healthy, they open up about how they really feel about opioid users. There are lots of comments dismissing us as lazy, saying things like, “Maybe he should stop getting high all the time” anytime they make even a small mistake.

I’m then put in the awkward position of having to decide whether to let it slide or defend them.

There’s a very strong part of me that wants to be the “good” opioid user. I want to show others what it looks like when people take opioids “responsibly.” I want to defend other people who take pain pills.

The problem is, once I admit that I use them too, I’m immediately moved out of the “good” opioid user category, because in their minds there’s no such thing. Going forward, everything I do would be seen through the lens of them thinking I’m high all the time.

It’s an impossible situation.

For now, I have found that the best way to navigate it in real life is to hide my health issues and my pain medication usage as long as possible. 

Yes, I write about all of it very openly online, and anyone looking for “dirt” on me would have no problem finding the truth. But most people lack such levels of information-seeking determination.

So, as long as I show up, seem alert, and come across as put together, there’s no reason anyone has to know that the pills I keep in the Tylenol bottle in my purse are actually prescription Norco.

How ‘Toxic Narratives’ Fueled the Opioid Crisis

By Pat Anson

Dr. Lynn Webster has a unique perspective on the opioid crisis. As a pain management expert and prolific researcher, Webster was elected by his peers as president of the American Academy of Pain Medicine (AAPM) and developed the first Opioid Risk Tool, a questionnaire designed to assess a pain sufferer’s risk of opioid abuse.

Like many other doctors involved in pain management, Webster was also named as a defendant in dozens of lawsuits, alleging he was a “key opinion leader” in helping drug companies use deceptive tactics to market opioids – allegations that Webster says are inaccurate and misleading.

All of this happened over a decade ago, but many of the myths about the causes of the opioid crisis still persist today – what Webster calls “toxic narratives.” And they are still harming patients and doctors.

“A toxic narrative is a narrative that, when repeated continuously, can lead to harm. And the example here is that our opioid crisis was entirely due to excessive supply or overprescribing opioids,” Webster explains.

“As a result, the policies that were implemented led to patient abandonment, patients not having access to medicine, and in some cases patients committing suicide or going to the street to get more harmful substances. So it is a narrative that is incomplete, sometimes false, but it takes on such a hold that it leads to harmful outcomes.”

Dr. Webster and co-author Sarah Eichberg, PhD, recently released a new book called “Deconstructing Toxic Narratives: Data, Disparities, and a New Path Forward in the Opioid Crisis.”

As the name suggests, Webster and Eichberg analyze how we got to where we are today, with the pain of millions of patients going untreated, doctors reluctant to prescribe opioids, and an overdose crisis largely fueled by illicit fentanyl and stimulants, not pain medication.

Behind it all is the simple fact that many people who struggle with addiction are trying to escape from a changing and challenging world that doesn’t seem to have a place for them.  

These are complex issues that have been poorly explained by the media, regulators, politicians and litigators – who all latched onto the theme that opioid pain medication was the root cause for soaring rates of addiction and overdoses.

“Everyone wanted a simple answer. And if people want a simple answer, then pharmaceutical companies are a good target and physicians are a good target, and they're pretty identifiable,” Webster told PNN. “As I write in my book, it's easier to say something that is kind of interesting, sexy, and fits a narrative that people want to believe, and then it becomes repeated without any challenge or with very little challenge. It's a simple way to address a very complex problem, which has been harmful.”

Asked to explain who was most responsible for spreading this incomplete narrative, Webster identifies two: the Center for Disease Control and Prevention (CDC), which released its disastrous opioid prescribing guideline in 2016, and Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group that played an influential role in the drafting the CDC guideline.

“The CDC is very much responsible for initiating the narratives. I mean, the head of the CDC said this was a physician-driven crisis exclusively, and then the Surgeon General at the same time basically was focusing on physicians and overprescribing without taking a look at the more complex part of the problem,” says Webster.

“There are other organizations, like PROP, that continued that narrative because it fulfilled their belief. I don't think most of the people in PROP intentionally meant to harm people, but it led to harm because of the incomplete story that their position took.”

‘That’s How You Make Money’

Others with financial interests took advantage of the situation, such as medical device makers and drug companies who hurriedly developed and marketed “non-opioid” pain treatments that were often more expensive and don’t work nearly as well.

“I think it really gets back to a deeper issue, which is free market capitalism and the lack of guardrails, basically free market capitalism. I call it neoliberalism, and that started back in the 1980s, primarily where the incentive is to make money,” said Webster. “The money to be made on finding an alternative to opioids was certainly an incentive to create and help sustain the toxic narrative.

“We've learned that false narratives are reinforcing to the people who want to believe them, and that's how you make money. It is not that we've been able to convey more accurate stories or truth. It is a means by which people can elevate themselves, be promoted, and make money.”

Free market capitalism also extended to the news media, which discovered that the opioid crisis was catnip for readers, viewers and listeners.

“Without a doubt, that's what's happened. There are thousands of examples where people see what was written in the Washington Post, New York Times, Time Magazine, Newsweek, anywhere, and because of the stature of those platforms, people just assume everything that they said has been researched and is accurate. But it's not,” says Webster, who adds that it was common for news organizations to conflate illicit opioids with prescription opioids, without explaining the difference.  

“That was repeated in every publication that talked about this. I cannot think of an exception where they separated the two. And in fact, I remember reviewing a couple of medical journal articles for publications, academic publications, where they did the same thing.”

Webster and Eichberg’s book is deeply researched and fact-based. Chapters explore various aspects of the opioid crisis; from addiction trends, patient stigma, and the criminalization of medicine to socioeconomic factors, childhood trauma, and the CDC’s misclassification of illicit fentanyl.

In effect, they’re trying to set the record straight on decades of incomplete and inaccurate information – and hoping clinicians, researchers, journalists and public health experts will learn from a more nuanced view of the opioid crisis.  

“The way in which we have been addressing it is to look at how to reduce access to drugs. That’s not going to solve the problem. The only way that we can dramatically reduce harm is for us to look upstream, to look at those factors that really contribute to the vulnerability of people,” Webster explained.

“We're at a difficult time, you know. The country is divided politically, and that feeds into almost every topic. We want to be emotionally rewarded for our anger about different things, rather than trying to understand the nuance and the truth behind a topic, and that's very, very much true with regard to addiction and pain treatment.”

South Korea Stops Sales of Trader Joe’s Seasoning Due to Opioid Contamination

By Pat Anson

A popular seasoning blend sold at Trader Joe’s is a bit too spicy as far as police in South Korea are concerned.

“Everything but the Bagel Sesame Seasoning Blend” is made with sesame seeds, dried garlic and onion, sea salt, and poppy seeds. 

Those poppy seeds come with “trace amounts of morphine and codeine” according to forensics tests, which is a violation of South Korea’s Narcotics Control Act. When not washed thoroughly, the seeds can become contaminated with opium alkaloids from the sap of poppy plants during harvesting.

While the amount of opium is minuscule, it’s enough to worry South Korean police, who recently warned the online marketplace Karrot to stop reselling the Trader Joe’s seasoning. 

The seasoning blend was banned in South Korea in 2022, but some South Korean tourists visiting the U.S. buy it as a souvenir and when they get home list the seasoning for sale on Karrot, often at inflated prices due to its notoriety.    

“Even if a product is legally sold overseas, it may be classified as a narcotic substance or a prohibited import in Korea, so particular caution is required,” a Seoul police official told The Korea Herald. "Not only sellers but also buyers can be subject to criminal punishment."

Karrot agreed to remove all listings for the seasoning blend on July 27, and its website now displays warning pop-ups when users try to list it for sale.

In 2019, the U.S. Drug Enforcement Administration classified unwashed poppy seeds as Schedule II controlled substances, claiming they were “qualitatively similar” to opioid pain medications. 

Poppy seeds that are properly washed and used as food are legal in the United States, but contaminated seeds occasionally slip through and cause trouble.  

Eating a muffin or bagel with poppy seeds is risky for someone about to take a drug test, since it takes only a few poorly washed seeds to result in a positive drug test for opiates. That could lead to a patient being dismissed by their doctor or an employer refusing to hire someone.

Some patients with poorly treated pain grow their own poppies and make a tea from the seeds to use as an analgesic. It’s a risky process, since it's hard to control the opioid strength of the tea – which has led to addiction and even some fatal overdoses. Potentially lethal doses of morphine have been found in some poppy seed teas.

The Center for Science and Public Interest (CSPI) has been urging the FDA for years to more tightly regulate poppy seeds by setting a limit for opiate contamination, but so far the agency has yet to set any guidelines.

“FDA is not advising consumers to avoid consuming poppy seed-containing foods. Although FDA is aware of some reports of consumption of poppy seed-containing foods being associated with negative health effects, FDA is particularly concerned about the misuse of poppy seeds,” the agency says on its website. “To date, FDA has received 11 reports of deaths purportedly associated with the consumption of homemade poppy seed tea.” 

New Non-Opioid Analgesic Works Better Than Vicodin

By Crystal Lindell

An experimental non-opioid pain medication appears to outperform a low dose of Vicodin for patients who just had tummy-tuck surgery.

Latigo Biotherapeutics recently published results from its Phase 2 clinical trial in The New England Journal of Medicine, looking at the effectiveness of their new analgesic, which goes by the name LTG-001.

Like other new non-opioid analgesics, LTG-001 works differently than opioids because it blocks pain signals in the body’s peripheral nervous system before they reach the brain. Opioids act on nerve receptors in the brain, where they can slow down breathing and have a “euphoric” effect at high doses.    

In the clinical trial, 343 patients with moderate-to-severe post-operative pain after abdominoplasty surgery were randomly assigned to four groups. One group received low-dose LTG-001; another took high-dose LTG-001; a third took tablets of 5 mg hydrocodone and 325 mg acetaminophen (Vicodin); and the fourth group received a placebo. 

The LTG-001 doses were given orally every 12 hours, while the Vicodin tablets were taken every six hours, for a daily dose of 20 MMEs (morphine milligram equivalents). Patients also had the option to request oxycodone if their pain was getting too severe.  

When researchers asked patients about their pain levels, they found that the high-dose LTG-001 had a 50% greater analgesic effect than Vicodin. “Meaningful pain relief” was also achieved faster with high-dose LTG-001 than with Vicodin (52 minutes vs. 83 minutes).

But many in the high dose LTG-001 group were not able to stay “opioid free.” In a press release, Latigo highlighted the fact that over half (52%) of the patients taking LTG-001 didn’t need the oxycodone “rescue” medication.

Another way to look at that statistic is that the other 48% of patients did not have pain that was well controlled and wound up using opioids anyway. On average, patients in the high dose LTG-001 group still needed 11 MME of oxycodone for pain relief.

Despite the lackluster results, company officials said the clinical trial was “an important milestone for Latigo.”

“The publication of these findings adds to the growing scientific understanding of non-opioid approaches to pain management and comes at a time when there is broad recognition of the need for additional treatment options in the context of the ongoing opioid crisis,” Neil Singla, MD, Chief Medical Officer of Latigo, said in a statement.

Based on discussions with the FDA, Latigo believes the study may serve as one of the well-controlled trials needed to demonstrate the efficacy of LTG-001 to support its approval as a treatment of moderate to severe acute pain, including postoperative pain. 

The company’s next step is to initiate a placebo-controlled Phase 3 trial in participants undergoing bunionectomy and an open-label Phase 3 safety trial. Latigo is also investigating LTG-001 as a pain reliever after wisdom tooth removal.

Last year the FDA approved a similar non-opioid analgesic, Journavx. Although it is only approved for moderate to severe acute pain, it didn’t take long for Jourvanx  to be used off label for chronic pain.  A recent analysis of prescription data found that Jourvanx is prescribed about 33% of the time for chronic pain. In fact, it’s prescribed more often for chronic pain than opioids are.  

New Pain Reliever Combines Tylenol and Naproxen

By Crystal Lindell

Pain sufferers will soon be able to buy a new over-the-counter medication that combines acetaminophen with naproxen. 

That’s thanks to the FDA approving new “Tylenol with Naproxen.” A two-tablet dose contains 650 mg of acetaminophen and 220 mg of naproxen sodium. Many consumers know acetaminophen as the brand name Tylenol, while naproxen is known by the brand name Aleve. 

The non-prescription pain reliever is approved for minor aches and pains such as headaches, backaches, sore muscles, toothaches, menstrual cramps, and arthritis pain in adults and children 12 years and older. 

The new tablets start working within about 30 minutes because of the acetaminophen, while the non-steroidal anti-inflammatory drug (NSAID) naproxen provides 12 hours of extended pain relief.

Acetaminophen is believed to work more quickly to reduce pain signals, while naproxen provides longer-lasting relief by targeting pain caused by inflammation.

The FDA granted Kenvue, which makes the Tylenol brand, a three-year period of exclusivity for this new OTC formulation. That means there will be no generic alternative available in that time.

In a press release, Kenvue cited a recent company survey showing that 75% of pain sufferers report dissatisfaction with their current options.

“Persistent pain often leaves people trapped in a cycle of trial and error, navigating between choosing short-term relief or more complex treatment options,” said Rajesh Mishra, MD, Chief Medical Officer of Kenvue. “Tylenol with Naproxen simplifies that choice, offering fast onset, 12-hour duration, and the safety profile of two well-established non-opioid ingredients in one fixed-dose.”

The company said its research showed that Tylenol with Naproxen demonstrated superior pain relief versus using either medication alone. It didn’t provide a price or date for when the tablets will be available, only that they are “coming soon to major U.S. retailers nationwide.”

Company Touts ‘Opioid-Free’ Label

The press release touts the fact that the medication is "opioid-free" multiple times and claims "up to 1 in 4 patients prescribed opioids are at risk of addiction."

"Tylenol with Naproxen addresses this gap by combining two well-established non-opioid pain relievers into a single, clinically proven OTC therapeutic solution that requires no prescription and carries no opioid risk," the company said.

Most studies show the risk of opioid addiction is very low. Neither Kenvue or the FDA shared any research on whether the new medication was comparable to pain relief from opioids.

And just because there is no opioid-related risk, that doesn't mean there is zero risk. The FDA warned consumers not to use Tylenol with Naproxen with other drugs containing acetaminophen, as doing so may cause liver damage.

And, as with all NSAID-containing products, the labeling includes warnings for stomach bleeding and for increased risk of heart attack, heart failure, and stroke — risks that are higher when NSAIDs are used more than directed or for longer than directed.

While this is the first OTC combination of Tylenol with Naproxen, it is not the first time acetaminophen has been combined with an NSAID in an OTC medication. In 2020, the FDA approved the first over-the-counter pain reliever that combines acetaminophen with ibuprofen, Advil Dual Action.

Hydrocodone Is Better Than Oxycodone for Post-Operative Pain

By Pat Anson

When it comes to treating post-operative pain, hydrocodone works better than oxycodone in relieving pain and does it with smaller doses, according to a new study that compared the effectiveness of the two opioids.

A team of researchers evaluated health data for 663 patients who had elective joint arthroplasty on their hips or knees, a major surgical procedure where a damaged or arthritic joint is removed and replaced with an artificial one. About a third of the patients took oxycodone for post-operative pain, while the rest received hydrocodone. 

Nearly 1.25 million joint arthroplasty procedures are performed annually in the US, and many patients experience significant pain during recovery. Oxycodone is generally considered more potent than hydrocodone, and is typically prescribed more often for post-operative pain.

The study findings, published in JAMA Network Open, show that patients on hydrocodone had slightly lower pain scores 10 days after surgery than those who took oxycodone. 

They also needed significantly less morphine milligram equivalents (MMEs) over the course of their post-op recovery (93.2 MME for hydrocodone vs 134.8 MME for oxycodone).  

“We observed that patients prescribed hydrocodone had lower composite pain scores over the 10-day postoperative period, and their total opioid consumption (in MME) was significantly lower, compared with patients prescribed oxycodone. Therefore, we rejected our initial hypothesis that oxycodone provides better pain control than hydrocodone,” wrote lead author Julie Johnson, PharmD, Director of the Clinical and Translational Science Institute at The Ohio State University. 

It’s important to note that all of the participants in this study had the CYP2D6 gene, which makes them normal metabolizers (NMs) of opioids. Had they had a variation of the gene, oxycodone may have performed better, according to researchers. About 10% to 15% of individuals have those variants.

“Our findings have practical implications for postoperative pain management, especially in the context of personalized medicine and opioid-sparing strategies. For patients who are CYP2D6 NMs, a multimodal approach with hydrocodone appears to be a safe and effective option for managing acute post–total joint arthroplasty pain, achieving pain relief that was comparable to or better than oxycodone, with a lower MME,” Johnson wrote.

The hydrocodone and oxycodone formulations used in the study contained acetaminophen. Both groups also utilized other pain relievers, such as NSAIDs, nerve blocks and tramadol during their recovery. There were no significant differences in mobility, anxiety, and depression between the hydrocodone and oxycodone groups.

Non-Opioid Journavx Is Being Prescribed Off Label for Chronic Pain

By Crystal Lindell 

Here’s some news that many pain patients could have predicted: A non-opioid medication recently approved for acute, short-term pain is already being prescribed off-label for chronic pain. In fact, it’s prescribed more often for chronic pain than opioids!

Suzetrigine, which goes by the brand name Journavx, was approved by the Food and Drug Administration in January 2025. Unlike opioids, Journavx blocks pain signals in the peripheral nervous system, not in the brain, so it doesn’t have the same “liking” effects of opioids, which can lead to dependence or addiction.

Developed by Vertex Pharmaceuticals, Journavx was the first new medication for acute pain in over two decades, and is primarily intended for post-operative pain or emergency trauma care. 

But 15 months later, new data published in Epic Research shows that Journavx is often being prescribed for chronic, long-term pain instead.

The researchers studied health records for more than 3.6 million U.S. adults who received a new prescription for either Journavx or an opioid between February 2025 and April 2026.

They found that chronic pain accounted for 33% of the Journavx prescriptions. By comparison, opioids were prescribed just 6.7% of the time for chronic pain.

Opioid prescribing was concentrated in patients who had surgery (48.8%) or acute pain (19.8%), which together accounted for over two-thirds of the opioid prescriptions.

Only 10.2% of the Journavx prescriptions were for surgery and 31.8% were for acute pain.

"Suzetrigine adoption has been concentrated in specialties that manage chronic and surgical pain longitudinally rather than in the acute-care settings where opioids are most commonly initiated," the study found.

The Epic researchers found that patients prescribed Journavx were often older and more likely to be female than patients prescribed opioids. Specifically, 43% of Journavx patients were 65 or older, compared with 31.4% of opioid recipients. 

Off-label prescribing of a medication is perfectly legal and, in some cases, appropriate. But drugs are rarely put through clinical trials for those off-label purposes.

Results from clinical trials suggest that Journavx is a mild pain reliever, at best, for acute or chronic pain.

In Phase 3 clinical studies of acute pain after minimally invasive surgeries, Journavx was no more effective than a low-dose combination of hydrocodone and acetaminophen, more commonly known as Vicodin.

In a Phase 2 study, Journavx was essentially no better than a placebo in relieving chronic back and hip pain caused by lumbosacral radiculopathy.

Journavx is priced by Vertex Pharmaceuticals at a wholesale cost of $15.50 for a 50mg pill. When taken twice a day for acute pain, that works out to $420 for a one-week supply. By comparison, a supply of 100 Vicodin tablets costs about $142.

Journavx is currently only available in an oral formulation, which severely limits its use for post-surgical pain, where injectable or intravenous analgesics are often preferred. 

Short-Term Opioid Prescribing Should Be Tailored to Patient Needs

By Crystal Lindell

A new study has found something that every pain patient already knows: Opioid prescriptions “should be tailored to address individual patients’ needs.”

The research findings, which were published in JAMA, looked at how well opioids worked for 1,708 patients with short-term acute pain from a wide variety of conditions; from dental procedures and knee replacements to low back pain and cesarean sections.

The findings debunk common myths that many patients quickly become dependent on opioids and are unable to regulate their opioid use.

Overall, most of the patients used opioids for only a short amount of time – about 7 days –  and at low doses (10 MME). Only 10% of patients used opioids for 90 days or more, which is generally considered the threshold for acute pain becoming chronic.  

Overall, opioids were effective at relieving pain, with patients reporting a 55% reduction in pain on average. The median time to pain resolution was 20 days, although patients with low back pain or recovering from surgery took longer than that.

Most patients continued to use non-opioid pain relievers such as acetaminophen or ibuprofen, and also used ice or heat as part of a “multimodal treatment” approach.

About two-thirds of patients had leftover opioids. Interestingly, they were often patients with the longest-lasting pain conditions, which suggests they chose “not to continue using the opioids they had available” even when their pain persisted.   

Current guidelines from the CDC and FDA for acute pain recommend opioids only for severe pain or when non-opioid pain medications are ineffective.

Given the wide variety in outcomes and patient preferences, researchers say their findings demonstrate that guidelines for short-term opioids should be tailored to each patient. Most patients in the study were pretty good about moderating their opioid use. 

“Patients generally reported taking opioids on their worst pain days, in small amounts, for short periods, and in combination with other pharmacologic and nonpharmacologic treatments, with many patients limiting their opioid use to less than the amount prescribed by their clinician,” wrote lead author Molly Moore Jeffery, PhD, of the Mayo Clinic.  

“The findings suggest current guidelines for multimodal treatment and short-duration opioid prescriptions, if needed, will serve many patients but not all and that treatment should be tailored to address individual patients’ needs.” 

A recent study found that opioids are effective for many acute pain conditions and come with little risk. In a review of 59 clinical studies, researchers at the University of Sydney found that opioids were effective for “the vast majority of acute pain conditions,” with no significant risk of serious adverse events.

More Non-Opioid Drugs Recommended for ER Pain Relief

By Pat Anson

Would you take an anti-depressant for back pain? 

An anti-psychotic medication for headache?

What about an anti-anxiety drug for stomach pain? 

Those are some of the non-opioid alternatives being recommended for pain relief in emergency rooms, as the healthcare industry continues to move away from using opioids.

The latest example is a study by researchers at University of California, San Francisco (UCSF), who recommend over a dozen non-opioid medications for five acute pain conditions commonly treated in emergency departments: back pain, abdominal pain, chest pain, fracture pain and headache. 

The findings are published in the Western Journal of Emergency Medicine.  

Researchers initially screened 246 clinical studies to prepare their non-opioid list, but narrowed it down to 23 of the most promising studies. First author Akash Shanmugam, a UCSF medical student, told The Guardian that the goal was to “create a very targeted list for specific pain conditions” to be utilized by ER physicians.

Many of the drugs that made the list, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are already widely used for acute pain. But some of the selections are puzzling, as they are psychotropic drugs not typically used to treat pain and are not fast-acting.

For example, the anti-psychotic drug haloperidol is recommended for both headaches and abdominal pain. Haloperidol is usually prescribed for schizophrenia or acute agitation, and is sometimes used off-label for conditions like psychosis and Tourette's syndrome.

Venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI), is typically used to treat depression and anxiety, but UCSF researchers think it could be used for back pain.

Other oddities that made the non-opioid list are ketamine for chest pain, abdominal pain and headache; benzodiazepines for abdominal pain; and the anti-nausea drug metoclopramide for headaches. 

Gabapentin would have made the list of non-opioid alternatives, but researchers decided the evidence was too weak to support its use for the five conditions they evaluated.  

“Our findings hold significant implications for pain management approaches in the ED and public health efforts aiming to address the opioid epidemic. By providing alternatives to opioid prescriptions, this review supports efforts to reduce opioid overexposure in the ED while helping to manage patient pain,” researchers said.

“Encouraging the use of these alternatives aligns with broader initiatives aimed at optimizing pain management practices, improving patient outcomes, and contributing to the overall mitigation of the ED’s contribution to the opioid crisis.” 

‘Made Me Feel Worse’

But are the drugs effective for pain? Posters on Reddit are skeptical that antidepressants and anti-psychotics would be helpful.

“This is ironic because codeine does a better job of making my brain quiet than any antidepressant I've tried so far,” said one poster. “I've never developed an addiction to codeine and it's also never induced suicidal thoughts, unlike a couple of the antidepressants I've tried. It also didn't make me so physically sick that I almost went to hospital, unlike the SNRI I stopped taking.”

“Tried tons of antidepressants for pain and depression, nothing worked in fact many made me suicidal. And then had tramadol prescribed for my back pain, low dose but my depression also improved a huge amount,” wrote another.

“These types of medications have made me feel worse than anything else I’ve ever taken. If I had to choose between pain and feeling like that again, I would choose the pain. But maybe that’s what they’re after since doctors don’t like prescribing pain medicine anyway,” said another Reddit poster.

“That's just ridiculous. Antidepressants and antipsychotics are not going to do anything at all to relieve pain,” said another. “The war on drugs has gone too far.”

But researchers say there’s frequently an overlap between physical and emotional pain that justifies the use of psychotropic drugs.

“Chronic pain is often linked to things like poor sleep, depression, anxiety, fatigue,” co-author Kathy LeSaint, MD, Associate Professor of Emergency Medicine at UCSF, told The Guardian. “In chronic pain conditions, the nervous system can become highly sensitive, and it’s thought that antidepressants and antipsychotics can maybe reduce this heightened sensitivity in the brain.”

Although the risk of addiction and overdose are often cited as reasons to avoid using opioids, that risk is often exaggerated. A 2024 study found that the risk of long-term opioid use after being treated with intravenous opioids in the ER is quite low – less than two-tenths of one percent (0.19%).

That mirrors the findings of a 2017 Mayo Clinic study, which found that the risk of long-term opioid use is only 1.1% for ER patients — less than it is for patients treated in other medical settings.

Nevertheless, some pharmaceutical companies are betting that non-opioids are the future of pain relief. Eli Lilly today announced the purchase of 4E Therapeutics, a biotechnology company that’s developing MNK inhibitors, which interfere with pain signals by blocking enzymes in the peripheral nervous system. 4E is the second non-opioid drug developer to be acquired by Lilly in a little over a year.

A Fentanyl Vaccine Is a Horrible Idea

By Crystal Lindell

A few years ago, I saved a loved one’s life when he was overdosing on fentanyl.

His lips and fingertips were blue when I found him, and as I administered NARCAN (naloxone), all I could think at that moment was that if he was dead, I never got the chance to say good-bye.

It was one of the most traumatizing experiences of my life, and I’m forever grateful that my efforts to save him were successful.

Even with that experience, I’m here to tell you that a fentanyl vaccine is an absolutely horrible idea. And I pray that nobody I love ever takes it – even the man who’s life I saved.

This week, JAMA published an article about the current status of the fentanyl vaccine, which is in development.

In the article, Associate Managing Editor Kate Schweitzer interviews Collin Gage, a cofounder and chief executive officer of ARMR Sciences, which has begun early-phase human trials of a fentanyl vaccine in the Netherlands.

Schweitzer seems to think such a vaccine would be a net positive for the world.

"If proven safe and effective, it could become the first proactive pharmaceutical approach designed to prevent fentanyl overdose and, potentially, treat addiction," she writes.

However, as both a chronic pain sufferer and someone whose loved one struggled with fentanyl addiction, I’m here to tell you that this entire research project should be ended right now.  

First and foremost, my biggest concern is that such a vaccine would be pushed onto people who do not want or need it, including pain patients.

I can already see doctors having a policy where they won’t prescribe opioids unless the patient agrees to receive the fentanyl vaccine. They’ll claim the policy is meant to protect patients, when in reality, it would only cause them more harm.

The article even points out what those harms could look like. Schweitzer quotes Kathryn Frietze, PhD, associate professor of molecular genetics and microbiology at the University of New Mexico, who is one of many researchers working to develop vaccines against drugs of abuse.

Doctors, according to Frietze, have expressed concern about how a vaccine could complicate medical care, given that prescription fentanyl is a widely used medication for acute pain control and anesthesia.

“Can they increase the fentanyl dose medically if needed, or is it going to completely eliminate fentanyl as an option?” Fritze asked. 

Read that again. Do we really want to eliminate fentanyl as an option for pain control and anesthesia? This is a medication used in hospitals, usually on patients in severe trauma or undergoing surgery.

Do we really want a vaccine to make fentanyl ineffective for them? 

Do we really want a vaccine that requires more fentanyl to be administered?

In practice, either scenario could be disastrous, especially in an emergency situation where an unconscious patient would be unable to explain to doctors that they had the fentanyl vaccine.

The thing about fentanyl is that you have no idea that you might need it someday. We don’t usually know when we’ll need anesthesia or acute pain control.

That is particularly relevant in this situation, because the article quotes multiple experts who seem excited about pushing a fentanyl vaccine onto high-risk groups, such as college students and young adults, who are experimenting with drugs. They may not be aware that the counterfeit pill they bought or got from a friend has a lethal dose of fentanyl. 

“Overdose from fentanyl doesn’t just happen to people who are purposely taking fentanyl,” Frietze said. “People may be exposed without their knowledge.” 

So they want to go to college campuses and give students a vaccine against a very valid pain medication, when they have no idea if they will ever need it?

Schweitzer says a vaccine that specifically targets fentanyl could still allow for the use of other analgesics, such as morphine and propofol. 

As a pain patient, I’m skeptical about that. If a vaccine blocks the effects of one opioid, it may also dampen the effects of other ones.  

The other major issue with a potential fentanyl vaccine is a phrase coined by Richard Cowan in 1986: “The Iron Law of Prohibition.” That essentially means that when law enforcement targets a specific drug, the potency of other prohibited substances increases.

Or, as Cowan said, "The harder the enforcement, the harder the drugs."

If you give everyone fentanyl vaccines, people will just find even stronger drugs to take. And those drugs will likely be more deadly. It’s no coincidence that illicit fentanyl arrived on the black market just as opioid pain medication became harder to get. 

As such, a fentanyl vaccine could result in more overdose deaths, not less, as people seek substitute drugs that bypass the vaccine.

Gage’s response to that possibility is to call the fentanyl vaccine “a platform technology—one that we plan to adapt."

In other words, they will just make new vaccines for new drugs. But in practice, how long would it take to actually develop new ones? And how long would it take to get them to drug users, who are often difficult for the medical community to reach?

Trust me when I tell you that drug users and their dealers will move exponentially faster than any research and development team ever could.

In practice, the reason street fentanyl is so deadly is because it’s unregulated. Users don’t know how much they are taking or what is mixed in with it – and those two things make it more likely that the drug will cause an overdose.

The solution then is to offer drug users a regulated supply, which is what methadone treatment is. In a perfect world, if they really wanted to help fentanyl users, these researchers would be working to make methadone treatment more accessible.

Instead, they’d rather make it so patients can’t use one of the most effective pain and anesthesia medications on the market, while pushing them onto harder or less effective drugs.

It’s a bad idea, and I hope these researchers see the error of their ways before it’s too late.

Tell Me Who the Real Criminals Are

By Cathy Kean 

Close your eyes. Go back to the worst pain you have ever known. A broken bone. A car wreck. Surgery. Childbirth without relief. Stay there for fifteen seconds. 

Feel the desperation. The begging. The need for it to stop.

Now imagine never leaving that place. You feel that pain every second. Every day. No break. Not in sleep. Not ever.

That is my life. Millions of us live here.

There is something that helps. Prescription opioids do not erase my pain, but they turn down the volume enough for me to be able to shower. To work. To keep my home. To hug my grand child without screaming inside.

Then they took them away. They said it was for my own good.

Before my chronic pain worsened after the release of the CDC opioid guideline, I worked as a real estate agent and special education advocate. 

Now I cannot walk. I have lost my job. My home of 32 years is in foreclosure. Friends stopped calling. I need help to use the bathroom. My independence is a corpse they are still kicking.

And the final cruelty? The people who did this lied to you.

CATHY KEAN

The Lies Behind the ‘Opioid Crisis’

You have been told prescription opioids are killing America. In 2021, the CDC reported a 1,040% increase in overdose deaths involving synthetic opioids from 2013 to 2019. They said those deaths were largely caused by illicitly manufactured fentanyl.

Here is what they didn’t tell you in that report: For many years, CDC misclassified most of those overdoses as prescription opioid deaths, and those deaths were used to help justify the agency’s 2016 opioid guideline, which led to wholesale restrictions on opioid prescribing. 

Not until 2018 was the error quietly acknowledged by four CDC researchers. And that tens of thousands of illicit fentanyl deaths were misclassified for years as prescription opioid deaths. 

The error was so serious that in 2016 alone, over 15,000 deaths caused by illicit fentanyl were mistakenly attributed to prescription opioids. Millions of Americans were misled by these and other errors that inflated the overdose numbers.

The White House told you prescription painkillers were the enemy. The media screamed it. Meanwhile, the real causes – illicit fentanyl, heroin and methadone – were hidden inside the CDC's overdose numbers.

The Death Toll They Won't Count

Because of the CDC guideline, thousands of chronic pain patients killed themselves. 

Not because they wanted to die, but because they could no longer get the prescription opioids that made life bearable. The pain became more than they could endure. And suicide offered a way out.

Others died slowly. From heart failure. Stroke. Organ collapse. The brutal physics of untreated pain grinding a body into dust.

No one in power keeps track of those deaths or says a word about them. No government agency. No major news outlet. No one with a microphone stands up and says, "We made a mistake. We are killing innocent people."

Instead, they push Suboxone and “alternative treatments.” For money. Not thy fellow man.

We have lost our First Amendment rights in the doctor's office. If you speak up about your pain, you are labeled a drug seeker and abandoned as a patient. I would rather die at home than face contempt again in the ER.

What I Want You to Do

Now imagine those 15 seconds of the worst pain you’ve ever felt. Really do them. Feel that pain.

Could you live like that? For one week? One year?

I am not asking for your pity. I am demanding your understanding. Your voice. Your outrage.

We are not criminals. We are not drug seekers. We are not addicts. We are not statistics on a CDC spreadsheet.

We are mothers and fathers. Veterans who served you. Construction workers who built your cities. Nurses who held your hand. Grandparents who babysat your children.

And we are dying. Some by suicide. And some by the slow, grinding destruction of our lives and bodies.

So here is what I need from you:

Do not look away. Say our names. Help us get our lives back.

Because if you could spend fifteen seconds in my body — really spent them — you would not need to be asked twice. You would be screaming with us.

Cathy Kean lives in California. She is a grandmother of 9 and mother of 4. Cathy lives with intractable pain from a botched surgery, along with fibromyalgia, arachnoiditis, stiff person syndrome, lupus, Parkinson's disease and insomnia. 

Cathy is the creator and administrator of the Facebook pages Chronic Illness Awareness and Advocacy Coalition and Pain is Pain. She writes to give a voice to the millions of chronic pain patients who have been silenced, stigmatized, and left to suffer—and to ensure her grandchildren never have to ask why Grandma couldn't be there. 

CBD Enhances Oxycodone’s Pain Relieving Effects

By Pat Anson

Some pain sufferers firmly believe that cannabis can help boost the pain relieving effects of prescription opioids. The evidence behind that belief is mostly anecdotal, but some new research lends some credence to it.

In studies on laboratory rats, researchers at the University of Florida and Texas A&M University College of Dentistry found that cannabidiol (CBD) appeared to enhance the pain-relieving effects of oxycodone without increasing the risk of addiction. 

CBD is one of the many cannabinoids found in cannabis. It does not have the same psychoactive effects of tetrahydrocannabinol (THC), but is believed to have some therapeutic benefits.

The rats were treated with CBD, oxycodone or a combination of the two daily for two weeks, while acute pain was induced in the laboratory.

The study findings, published in The Journal of Pain, found that CBD enhanced oxycodone’s antinociceptive effect, meaning it blocked pain signals from reaching sensory neurons in the brain. CBD also did not affect the “rearing behavior” or “place preference” of rats, activities that may have suggested they were becoming dependent or addicted to oxycodone.

“Together, these findings suggest that cannabidiol potentiates the analgesic effects of oxycodone without affecting its reward-related properties. These results support the potential of cannabidiol as an adjunctive, opioid-sparing agent in pain management,” researchers wrote.

A recent study of 21 people with knee osteoarthritis reached a very different conclusion, finding that a low-dose of opioids taken with a cannabis-based medicine did not relieve acute pain. 

That study, however, was deeply flawed. The cannabis-based medicine was dronabinol (Marinol), a synthetic version of THC. Dronabil is FDA-approved to treat nausea and improve appetite, but is not intended to provide pain relief. The medication also has little in common with the various forms of cannabis (edibles, smoking, vaping) used in the real world.  

Granted, the use of dronabil and laboratory rats are major weaknesses in both studies, which highlights how cannabis research has long been stifled in the U.S. by marijuana’s status as an illegal Schedule I controlled substance.     

The DEA is now allowing more cannabis to be used for research purposes and recently reclassified medical marijuana as a Schedule III drug, which allows for medical uses. It could be years, however, before we see more high-quality studies about the risks and benefits of cannabis products.  

A Simple Chart Destroys a Myth About the Opioid Crisis

By Neen Monty

There’s a simple reason the narrative around the “opioid crisis” falls apart when you actually look at the overdose data.

Because the data doesn’t show what they claim it shows. 

And that false narrative has been retrofitted to cover the deception and lies wrought by bad actors in the U.S. healthcare system.

The chart below tracking overdose deaths by opioid type tells two stories:

1. Prescription opioid deaths rose, stabilized, and then fell.

2. Fentanyl arrived… and everything exploded.

Those are not the same curve. Those are not the same problem.

There are two epidemics. And one deliberately blurred narrative.

In the United States, prescription opioid deaths peaked around 2012, at about 5 deaths per 100,000 Americans. 

Meanwhile, fentanyl-related deaths – almost non-existent before 2012 – began rising exponentially as illicit fentanyl entered the black market.

In 2023, they peaked at 22.2 deaths per 100,000 people. By then, overdoses linked to prescription opioids had fallen to 3.8 deaths per 100,000.

That means there are almost 6 times the number of overdose deaths caused by illicit fentanyl than prescription opioids.

Yet prescription opioids remain the target.

That “opioid crisis” curve?

That’s illicit fentanyl. Not pain patients. Not prescription opioids. Not doctors treating disease.

The Uncomfortable Truth

When overdose deaths skyrocketed, prescription opioid deaths were already flattening out and falling. That should have changed the narrative right there.

But the narrative stayed the same.

The explosion in deaths aligns with one thing: iIlicit fentanyl and its analogues flooded the U.S. drug supply with counterfeit pills of unknown, often lethal, potency.

That is why deaths surged, not because someone with intractable rheumatoid arthritis got oxycodone prescribed for their pain.

The numbers don’t lie. If the opioid crisis were really about prescriptions, the lines on the chart would look very different.

So why didn’t the narrative charge?

Because blaming illicit fentanyl means:

• Confronting illicit drug supply chains

• Admitting policy failure

• Acknowledging complexity

Blaming prescriptions is easier. It creates easy villains to target:

• Doctors

• Patients

• Pain medication

And it opens the door to:

• Restrictions

• Guidelines

• “Education programs”

• Entire industries built on fear

Who paid the price?

Pain patients. People with cancer, autoimmune disease, neurological damage, and severe structural pathology.

People who were stable. Functioning. Living.

Until they were cut off.

This was never about prescriptions. The chart makes one thing brutally clear: The U.S. overdose crisis is a fentanyl crisis.

Everything else is a false narrative. A fairy story. One designed to vilify people who are already among the most vulnerable people in our communities – the ill, the disabled, people living with severe pain.

It’s important to note that by the time Physicians for Responsible Opioid Prescribing (PROP) was created in 2012, prescription opioid deaths had already stabilised and were falling.

PROP was instrumental in creating the CDC’s infamous 2016 opioid prescribing guidelines. But there was no need to restrict opioid prescribing. There was no need for forced tapers that lead to suicides and overdose deaths. There was no need for dose ceilings that meant people’s pain was no longer treated adequately.

There was also no need for the fabrication of “evidence” that does not stand up to even a little scrutiny. Just read the studies that the CDC guidelines are based on. They do not show what you have been told they show.

But no one actually reads the studies. No one examines the data. No one questions. Doctors just blindly follow the guidelines. It’s hard to blame them when they face prison time if they don’t.

It has been ten years since the forced tapers started in the U.S. Six years since Australia blindly copied this failed policy. No one in Australia bothered to read the research. Australia just copied the U.S. guideline and allowed politicians to decide who gets pain relief and who does not.

Australia could see the policy going horribly wrong in the U.S. Yet it implemented those same policies and tortured Australian chronic pain patients the same way. The same is true for Canada and the UK as well.

This should never have happened.

Patients on three continents have been abandoned, left to suffer in agony day after day. Given psychological therapies for physical disease and injury. And no one says a word. 

I have contacted many politicians, journalists, and senior public servants in Australia.  No one will take this on. No one will right this wrong.

And the media continues to push a false narrative about an opioid crisis that does not exist. But it gets clicks.

It may be futile, but my life and those of many others depend on access to safe and effective opioid therapy.

And so, I will continue to fight.

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.”

CYP2D6: The Enzyme That Determines How Effective an Opioid Is

By Dipa Kamdar

For a medicine so commonly found in bathroom cabinets and high street pharmacies, codeine has a surprisingly complicated story. It sits at the intersection of pain relief, genetics, public health and regulation. 

As the UK and other countries continue to tighten rules around opioid use, codeine offers a useful case study in how a drug can be both helpful and potentially harmful, depending on who takes it and how it is used.

Codeine is an opioid used to treat mild to moderate pain. In some formulations, it is also used to suppress coughing. Over-the-counter products typically combine it with paracetamol, as in co-codamol, or ibuprofen, while stronger doses are available only on prescription.

Codeine itself is a weak opioid. Its analgesic effect is about one tenth that of morphine. Once swallowed, it is metabolised by enzymes in the liver, with some of it converted into morphine. That morphine then produces pain relief by acting on opioid receptors in the brain. 

For most people, the body makes enough morphine to ease symptoms. For others, the same dose can be ineffective or unexpectedly strong.

Fast vs Poor Metabolisers

One of the most striking features of codeine is how differently people process it. The enzyme mainly responsible for converting codeine into morphine, CYP2D6, varies significantly between people. Most metabolise codeine at an expected rate, but some carry genetic variants that alter the process.

A small proportion of the population are ultra-rapid metabolisers, thought to make up around 1% to 2% of people. They convert codeine into morphine much faster than average. 

This trait is more common among people of North African and Middle Eastern backgrounds, for whom even standard doses can produce unexpectedly high morphine levels, increasing the risk of severe drowsiness, breathing difficulties and other serious side effects.

Around 2% to 11% of people are intermediate metabolisers. Their CYP2D6 enzyme works more slowly or less effectively, so codeine may provide only limited benefit.

At the other end of the spectrum are poor metabolisers, estimated to make up 5% to 10% of the population. They convert very little codeine into morphine, so the drug may offer little or no pain relief. 

Poor metabolism is more common in people of white European descent. In these cases, it may make more sense to prescribe a different painkiller rather than rely on a drug the body cannot use efficiently. This wide variation makes codeine far less predictable than many people assume.

The Trouble With Codeine

That unpredictability matters because low-dose codeine does not always offer much in return. Research suggests that many over-the-counter codeine products provide little proven benefit for pain relief, particularly at doses below 10mg, while still carrying the risk of side effects. 

A review found that low-dose codeine combinations gave only modest relief for short-term pain, such as dental pain, episiotomy pain or pain after minor surgery, and many of the underlying trials were small.

By contrast, combinations such as ibuprofen 400mg with higher-dose codeine, between 25mg and 60mg, appear to provide more reliable relief. Even so, studies suggest that simple combinations such as paracetamol plus ibuprofen can match or outperform low-dose codeine products without the risks associated with opioids.

Common side effects include constipation, nausea, dizziness and drowsiness. At higher doses, codeine can slow breathing and impair coordination. It can also interact with other medicines that cause sedation, including some antiepileptic drugs. Certain antidepressants can block the enzyme that converts codeine into morphine, making it less effective.

Like other opioids, codeine can also become less effective with repeated use. This process, known as tolerance, happens when the brain’s opioid receptors adapt to the drug. People may then need higher doses to achieve the same effect. Even when taken as directed, tolerance can develop within days, and as doses rise, so does the risk of physical dependence.

Stopping suddenly after regular use can trigger withdrawal symptoms such as restlessness, sweating, anxiety and poor sleep. This is why health professionals advise using codeine for the shortest possible time and tapering the dose if it has been taken for longer periods.

Concerns about misuse, addiction and accidental harm have prompted tighter regulation in the UK. The Medicines and Healthcare products Regulatory Agency has introduced clearer warnings on packaging about addiction risk and limited over-the-counter pack sizes to a maximum of 32 tablets or capsules. Non-prescription codeine-containing products are now intended for use for no more than three days. Stronger codeine tablets, including 30mg formulations, have long been prescription-only.

Some products have faced even stricter controls. Codeine linctus, once widely used as a cough suppressant, was reclassified as prescription-only in 2023 because of growing concerns about misuse and diversion. 

It has been used in “purple drank”, a recreational mixture of codeine cough syrup with soft drinks and sometimes alcohol. Its opioid effects can lead to dependence, breathing difficulties and overdose, especially when combined with other sedatives.

Codeine remains a useful option for short-term pain when other medicines are unsuitable or insufficient. But its effectiveness, safety and potential for dependence vary far more than many people realise.

In a landscape where medicines are often judged by how familiar they feel, codeine is a reminder that common does not always mean simple. Used carefully, it can help. Used carelessly, it can cause problems that last long after the pain itself has passed.

Dipa Kamdar is a Senior Lecturer in Pharmacy Practice at Kingston University.

This article originally appeared in The Conversation and is republished with permission.