Top Officials at CDC Resign After Director Fired in Dispute Over Vaccines

By Pat Anson

CDC Director Susan Monarez has been fired by President Trump, capping a week-long drama that began with Monarez refusing to make changes in vaccine policy ordered by Health and Human Services Secretary Robert F. Kennedy Jr.  At least four top CDC officials resigned in protest after Monarez was ousted, creating further chaos at the country’s top public health agency.   

“The agency is in trouble, and we need to fix it, and we are fixing it, and it may be that some people should not be working there anymore,” Kennedy told Fox News.

Kennedy, a longtime critic of vaccines, demanded that Monarez resign or be fired, and she refused. Monarez had been acting CDC director since President Trump took office and was confirmed by the US Senate only a month ago.

Attorneys for Monarez say she could only be fired by the president and accused Kennedy of “weaponizing public health for political gain” by dismissing CDC scientists and appointing vaccine skeptics to CDC advisory committees.

“When CDC Director Susan Monarez refused to rubber-stamp unscientific, reckless directives and fire dedicated health experts, she chose protecting the public over serving a political agenda. For that, she has been targeted,” attorneys Mark Zaid and Abbe Lowell said in a statement. “The attack on Dr. Monarez is a warning to every American: Our evidence-based systems are being undermined from within.”

Tensions have been rising at the CDC for months after steep cuts in its staff and budget, followed by the overhaul of advisory panels ordered by Kennedy.

Recently, a gunman angry about Covid vaccines fire hundreds of shots at CDC headquarters in Atlanta, killing a policeman and traumatizing employees. Both President Trump and Kennedy were notably silent after the attack, which only made morale worse.  

More than 750 HHS staffers signed a letter saying the Trump administration “failed to adequately respond” to the attack and that Kennedy was “endangering the nation’s health by repeatedly spreading inaccurate health information.”

‘This Is a Heartbreaking Decision’

The four high-ranking CDC officials who resigned are Dr. Debra Houry, the CDC’s deputy director and chief medical officer; Dr. Demetre Daskalakis, who headed the center that makes vaccine recommendations; Dr. Daniel Jernigan, who oversaw vaccine safety; and Dr. Jennifer Layden, who was in charge of the CDC’s public health data. Kennedy recently pressured the agency to share health data for a study to confirm his beliefs that vaccines cause autism.

“This is a heartbreaking decision that I make with a heavy heart,” Houry said in an email to colleagues.

When she started at CDC over a decade ago, Houry was director of the CDC’s National Center for Injury Prevention and Control, which oversaw the secretive drafting of the agency’s controversial 2016 opioid guideline. Critics say anti-opioid activists had too much influence on the guideline and accused then-CDC Director Thomas Frieden of “blatant violations” of federal advisory committee laws.

Although the guideline was voluntary, it was so widely implemented by doctors that it caused “serious harm” to pain patients who were tapered to lower doses or no longer able to get opioid medication. Many suffered through withdrawal, uncontrolled pain, psychological distress and, in some cases, suicide.

Things got so bad, the CDC revised its guideline in 2022 to give doctors more flexibility in prescribing opioids. By then, Houry had left the Injury Center and been promoted to chief medical officer.

“From a very narrow viewpoint, some might take comfort in the resignation of Debra Houry as chief medical officer of CDC. Prior to holding that position, she had been Tom Frieden's action arm for implementing the original opioid guidelines. However, like Frieden, she also had a history of positive accomplishments and her current resignation appears to be a laudable matter of principle,” said Dr. Charles LeBaron, a retired CDC epidemiologist.

LeBaron wrote a book critical of the agency’s guideline and its leadership: “Greed to Do Good: The Untold Story of CDC’s Disastrous War on Opioids.” He says the current turmoil at CDC and HHS is likely to disrupt other public health efforts besides vaccines.  

“This is a developing situation in which efforts to address both pain and addiction treatment matters are really suffering collateral damage in a war over vaccines and related matters of public health,“ LeBaron told PNN in an email. “Whatever happens, it's hard to imagine that RFK Jr, with his ‘healing farms’ approach to eliminating opioid use, is ever going to make matters better in this area. 

“Until we get a sane person in charge of HHS, it's hard to see how anything useful in any area, including pain treatment, is going to happen. If you want my opinion, the more that the pain treatment community (along with everybody else) can successfully urge for RFK Jr's replacement, the more likely we are to see some progress at some point, rather than the current headline-de-jour chaos.”

The most immediate impact of the turmoil at CDC is a continued delay in release of the updated 2025-2026 Covid vaccines. Earlier this week, the FDA approved the use of new vaccines made by Pfizer, Moderna and Novavax, but limited who can get them to older Americans or those with a high-risk health condition.

Final approval for the vaccines’ release must still come from the CDC and its new advisory panel, which now includes doctors and researchers who have publicly questioned the safety of vaccines.

The Advisory Committee on Immunization Practices is scheduled to meet September 18-19. According to the agenda, the panel will discuss many common vaccines, including those for COVID-19, hepatitis, measles, mumps, and rubella. The panel will consider whether to “revise the list of vaccines for administration to vaccine-eligible children.”

Meanwhile, several states are reporting a surge in Covid infections caused by a new Omicron variant. And people seeking boosters or their first Covid vaccinations are unable to get them.

Back Pain Will Cost Australia Billions, but Rx Opioids Dismissed as a Remedy

By Crystal Lindell

A new study is sounding the alarm about lost worker productivity in Australia caused by chronic back pain, but an inexpensive remedy is being dismissed as “low-value or harmful.” 

Published in JAMA and led by researchers at Monash University, the study projects massive losses in productivity in Australia caused by long-term back pain. In 2024, nearly 3 million Australians had chronic back problems. That’s projected to grow to nearly 3.3 million by 2033.

The researchers estimate that back problems will result in an estimated loss of 3.4 million productivity-adjusted life-years over a 10-year period. That equates to a loss of more than $638 billion in Australian dollars in the country’s gross domestic product. That’s about $414 billion in US dollars.

That’s a lot of lost productivity and money. Just a 10% reduction in the number of workers with long-term back problems would save over $41 billion Australian dollars 

“Substantial economic gains could be achieved from reducing the prevalence and impact of the condition,” wrote lead author Sean Docking, PhD, a health economist at Monash University. “Action is needed to reduce the prevalence and burden of long-term back problems, with a focus on better-quality care and supporting people of working age to remain in the workforce and working productively.”

Indeed, there is a need to reduce the “impact of the condition.” I completely agree. However, while the authors call for interventions, they ignore an obvious tool that used to be widely available in Australia until 2018: codeine. 

That’s when Australia made codeine available by prescription only. Until then, the opioid was sold over-the-counter, and no doubt was often used to help people with back pain get out of bed, go to work, and be more productive.

While pop culture has often crafted a view that opioid medications are sleep inducing and that people who take them are lazy, the reality is that millions of people take them so that they can work and be productive. That’s especially true for mild, low-risk opioids like codeine.

The Monash researchers also point out that calling in sick and working less creates “considerable financial stress and may disproportionally impact already disadvantaged communities.”

Again, I agree. Not being able to work because of chronic pain can definitely result in a huge financial burden. And effectively treating that pain can literally make it possible for people to continue working and not rely on public assistance programs.

Unfortunately, rather than addressing this or offering practical solutions, the researchers dismiss all opioids as a “low-value” care option. Instead, they recommend “high-value” care, which basically consists of vague advice to “stay active” and get back to work as soon as possible. 

“A major way of addressing the burden of long-term back problems is to reduce the proportion of individuals who receive low-value or harmful care,” researchers said. “However, contrary to evidence-based guidelines, low-value care is prevalent. Examples of low-value care have been associated with longer absences from work. By contrast, high-value care could prevent chronicity, improve patient health outcomes, and result in productivity gains that benefit society.”

Perhaps the use of opioids is associated with “longer absences” because the pain medications are only given out when patients have severe back pain and really should stay at home.

It’s frustrating that, like many pain studies these days, the Monash researchers found a way to work in a negative view of opioids and suggest that they don’t “benefit society” or improve patient health.  

The fact that they left out how the crackdown on opioid prescribing contributes to lost productivity is also disheartening, especially when opioids are an inexpensive remedy.

When people have adequate pain relief, they can be productive. When they don’t, they can’t. Chronic pain patients understand this. Now we just need medical professionals to understand it too.

The Strange Denial of Complications Caused by Poorly Treated Pain

By Drs. Forest Tennant and Scott Guess

There has been no shortage of controversy, scandal and fraud regarding the opioid and pain crises of the past decade. One standout in the debate over opioids and pain treatment has been a lack of an honest, objective discussion of the benefits of pain care.

A basic tenet in medical practice and therapeutics is what is called the “risk-benefit” ratio. This is a simple analysis of whether a specific drug or therapeutic measure has more benefit than risk.

For example, the risk-benefit of drugs taken during pregnancy is well-known and established. But strangely, the debate over whether opioids have more benefit than risk in the treatment of pain has never been broached.

None of the parties involved, especially the anti-opioid zealots, will discuss any benefit that opioids may bring. In fact, essentially their only discussion is that opioids are a risk for overdose and addiction, so they have no benefit and shouldn’t be used.  

This risk is overrated and overstated in relation to opioids prescribed and monitored by a physician. According to the CDC, total opioid overdose deaths in the US (including deaths from illicit opioids) were 24 deaths per 100,000 population in 2023.

That compares to the overdose death rate for prescribed opioids, which was 4 per 100,000 population. That is a raw number for prescribed opioids.  Some data reports opioid deaths among physician monitored chronic pain patients to be as low at 0.1 per 100,000 population. 

In other words, the overdose risk of evidence with prescription opioid is minuscule.

Pain has a number of pathological complications that benefit from opioid therapy. In addition to physical relief, there are humanitarian benefits, such as a reduction in suffering, and the ability to mentally and physically function as a productive person.

When poorly treated or left untreated, chronic pain has profound negative and deleterious effects on the cardiovascular and endocrine (hormonal) systems. Pain puts the cardiovascular system into overdrive, which raises blood pressure and pulse rates. Coronary artery spasm may also result from severe chronic pain.

We can personally attest to prescribing blood pressure medication and nitroglycerin to many pain patients at risk of cardiac arrest or heart failure.

Hormonal suppression and deficiency of cortisol, testosterone, estradiol and other hormones are also common in undertreated chronic pain patients. Cortisol levels can drop below levels that sustain life. We have administered emergency cortisone to pain patients who were severely ill, debilitated, and near collapse because they had inadequate cortisol levels.

Among Dr. Thomas Addison’s eleven reported original cases of Addison’s Disease in 1855, about half had serious intractable pain conditions such as adhesive arachnoiditis.

Chronic pain has also been found to alter blood glucose and lipids (cholesterol). Sleep deprivation is another major problem in pain patients.  And anorexia with malnutrition is common.

Given the medical complications induced by pain, one would logically think that there would always be a discussion of risk-benefit when discussing opioid therapy. But we’ve never heard or seen such a discussion in medical literature or in political circles.

As if denial of benefits over risks weren’t bad enough, an even stranger denial has occurred. We have searched the major medical textbooks used in medical schools today, and couldn’t find a single word that chronic pain is a risk for hypertension and cardiac disease, much less hormonal deficiencies.

Isn’t it time we quit denying that chronic pain has medical complications that can be easily treated with opioids and other medicinals? The risks of opioid therapy simply don’t outweigh the benefits. 

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis. Readers interested in learning more about his research should visit the Tennant Foundation’s website, Arachnoiditis Hope. You can subscribe to its research bulletins here.   

Scott Guess, PharmD, operates an independent pharmacy and clinic in Atascadero, CA that specializes in pain management and arachnoiditis.

The Tennant Foundation gives financial support to Pain News Network and sponsors PNN’s Patient Resources section.  

Hydromorphone Injections Can Quickly Relieve Intractable Pain

By Dr. Forest Tennant

I recall the time over a decade ago when Anazao Laboratory in Tampa, Florida informed me they had developed ultra-high potency (50 mg/ml) hydromorphone for palliative pain care. Anazao Labs was well aware of my patients’ needs, since they formulated my endocrine medicinals. 

In contrast to the other injectable opioids, Anazao’s hydromorphone formulation could be injected subcutaneously under the skin rather than intramuscularly.  The injection required a very small amount of fluid (.1 to .2 ml) that was administered with an allergy or insulin syringe.

My patients’ pain was called “intractable” to meet California’s Medical Board guideline and legal definitions.  The criteria for patients to enter my clinic was a determination that there was a high risk of death within one year unless opioid treatment could be administered. The top causes of intractable pain were adhesive arachnoiditis, traumatic brain injury, severe neuropathies (CRPS), autoimmune disease, and post-cancer care.

I recall the first patient to whom I prescribed ultra-high potency hydromorphone.  She was not receiving adequate pain relief with long-acting and breakthrough opioids, so she was referred for an intrathecal implanted device (pain pump) for opioid administration.  Due primarily to its cost and insurance reasons, she could not obtain this expensive treatment, so I chose to experiment with the new ultra-high potency hydromorphone. 

It worked remarkably well.  In fact, she soon found she didn’t require a long-acting or breakthrough opioid. Using the new hydromorphone formulation, she dropped her daily morphine milligram equivalent (MME) dosage from over 500 to less than 100 MME per day.

After success with this patient, I prescribed the hydromorphone formulation to other patients on high dose oral opioids, who could not obtain intrathecal opioids or an implanted electrical stimulator.  All the patients tolerated and adjusted well to it.  Ultra-high dose hydromorphone became an alternative to intrathecal opioids at my pain clinic.

When I later prescribed the hydromorphone formulation to other patients with intractable pain, I found that I could eliminate or reduce their use of high dose opioids through oral, patch or sublingual administration, and obtain equal or superior pain relief.

I have since retired from clinical practice, but still believe this is a major reason for using ultra-high potency hydromorphone for patients in severe pain.  My initial experience told me that the hydromorphone formulation could be an alternative to standard intractable pain care, which is the combined use of a long-acting opioid with a short-acting opioid for breakthrough pain. That therapy has shortcomings, because long-acting opioids suppress endocrine levels, which can lead to a wide range of health problems.

My procedure in prescribing hydromorphone was to instruct both the patient and a live-in family member on proper injection technique, secure storage, and maintaining sterility.  At the time I closed my clinic, I probably had about 2 dozen patients who successfully used this innovative formulation.

I have come to some conclusions that go against common beliefs about opioid therapy.  First and foremost, high potency hydromorphone can usually substitute in most cases for long-acting opioids such as OxyContin, transdermal fentanyl, and methadone.  Effective pain relief occurs within minutes after the injection, so the patient doesn’t have a proclivity to follow the opioid dose with a sedative or neuropathic drug such as a benzodiazepine. 

Seldom did my patients use over 3 to 4 injections a day.  To date, I know of no overdoses occurring.  I attribute this to hydromorphone’s rapid, potent, short-acting activity, which doesn’t invite the use of other drugs (including alcohol), to help the patient achieve pain relief.  Blood levels of the hydromorphone don’t stay elevated longer than about two hours, which protects against overdose. Pain relief remains much longer, however, likely because it is hydrophilic in neurologic tissues.

In summary, I have found ultra-high potency hydromorphone to be a significant advance in palliative pain care for intractable pain patients.  It has proven to be a bonafide alternative to intrathecal opioid delivery and to high opioid dosages necessary when combining the use of long and short acting opioids.  Its unique properties seem to reduce the risk of overdose. 

Families and patients can be trained to safely and effectively use this medicinal to relieve suffering from the most severe forms of intractable pain.  Unfortunately, it is an under-recognized and underused treatment for the palliative care of intractable pain patients.

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis. Readers interested in learning more about his research should visit the Tennant Foundation’s website, Arachnoiditis Hope. You can subscribe to its research bulletins here.   

The Tennant Foundation gives financial support to Pain News Network and sponsors PNN’s Patient Resources section. 

Limits on Rx Opioids Led to Unintended Consequences in Australia

By Pat Anson

An Australian study highlights some of the benefits and unintended consequences of efforts to limit the prescribing of opioid pain medication.

Like the United States, there’s been a fair amount of controversy in Australia about opioid medication and the role it played in the so-called opioid crisis. In response, Australian regulator took two steps in 2020 to limit prescribing: creating prescription drug monitoring programs (PDMPs), and limiting the amount of opioids and repeat prescriptions subsidized by the government.

To see how well the changes worked, researchers analyzed emergency department (ED) visits by patients prescribed opioids by primary care doctors in Victoria, the second most-populated state in Australia with over seven million people. Victoria was the first state to adopt a mandatory PDMP, which doesn’t stop a doctor from prescribing opioids but alerts them to possible misuse by a patient.

The research findings, published in the Medical Journal of Australia, show that ED visits by patients on prescription opioids fell by 11.8 visits per 100,000 people after opioids restrictions were implemented. At the same time, however, researchers identified a short-term but statistically significant increase of 7.3 ED visits per 100,000 people that were linked to non‐opioid substances.

The study didn’t identify what those non-opioid substances were, but researchers suspect that some were uncontrolled medications, such as pregabalin and antidepressants, which are often prescribed as alternatives to opioids for pain relief.

“As we expected, the new policies were associated with reduced opioid‐related harm; the reduced availability of prescription opioids presumably explains this change. We also expected that the changes would have unintended effects, and found an immediate increase in the non‐opioid substance‐related ED presentation rate that was greater among people prescribed opioids than in the control group,” researchers reported.

“One possible mechanism underlying the increase in non‐opioid substance‐related harms could be related to increased prescribing of unmonitored pain medicines, such as pregabalin and tricyclic antidepressants, following the introduction of the prescription drug monitoring program.”

PDMPs have also had unintended consequences in the United States. In a 2021 study, the Reason Foundation found that opioid prescribing declined in states that adopted PDMPs, but that overdoses involving heroin, illicit fentanyl and cocaine significantly increased – suggesting that some patients were substituting illicit drugs for prescription opioids.

The focus on prescription opioids may have been misplaced in Victoria. According to a 2023 report by the state’s coroner, the anti-anxiety medication diazepam was the lead drug involved in fatal overdoses (213 deaths) in Victoria, followed by heroin (204 deaths), methamphetamine (164 deaths), alcohol (153 deaths) and pregabalin (78 deaths). In contrast, oxycodone was involved in 41 deaths and codeine in 24 deaths.

Bad News Continues for Non-Opioid Analgesics

By Pat Anson

The bad news keeps piling up for non-opioid analgesics, which are often touted as safer and more effective alternatives to opioid pain medication.

A large new study found that pregabalin (Lyrica) raises the risk of heart failure in older patients, while Vertex Pharmaceuticals said it was stopping development of an experimental drug for post-operative pain because it was less effective than a low dose of hydrocodone.   

The pregabalin study, recently published in JAMA Network Open, compared the drug to gabapentin (Neurontin) among Medicare patients with chronic non-cancer pain. Both pregabalin and gabapentin are gabapentinoids, a class of nerve medication that was originally developed to prevent seizures in epileptic patients.

Because they are not opioids and perceived as safer, both drugs are now widely being prescribed for a variety of pain conditions, usually off-label.  

In a subset of patients with cardiovascular disease, researchers found that hospitalizations and emergency department visits for heart failure were more common in pregabalin users compared to patients on gabapentin. The difference wasn’t significant (18.2 visits vs 12.5 per 1,000 person-years), but it was enough for researchers to recommend caution when prescribing pregabalin.

“Practicing clinicians should undertake a careful assessment of ongoing cardiovascular risk factors and perform adequate risk-benefit counseling for older patients before prescribing pregabalin for chronic pain,” wrote lead author Elizabeth Park, MD, Columbia University Irving Medical Center.

Pregabalin is believe to be riskier because it binds to calcium channels associated with heart failure and arrhythmias. Both the American Heart Association and European Medicines Agency already list pregabalin as a drug that increases the risk of heart failure.

"The study serves as an important reminder that not all gabapentinoids are created equal and that in the pursuit of safer pain control, vigilance for unintended harms remains paramount," said Robert Zhang, MD, and Edo Birati, MD, in an accompanying editorial.

"For older adults with chronic pain, particularly those with cardiovascular disease, clinicians should weigh the potential cardiovascular risks associated with pregabalin against its analgesic benefits. This is particularly relevant given the growing use of gabapentinoids in older populations and ongoing polypharmacy issues in this age group."

The research doesn’t give gabapentin a clean bill of health, since it also raises the risk of heart failure in older patients – just not as much as pregabalin. Last month another study found that gabapentin increases the risk of dementia and cognitive impairment.

Researchers have long been concerned about the effects of gabapentinoids on the brain, while many patients have complained the drugs cause brain fog, dizziness, weight gain and mood changes. Despite warnings that they are overprescribed for conditions they were never intended to treat, the use of gabapentinoids continues to grow in the United States. 

New Analgesic No Better Than Vicodin

The new analgesic being developed by Vertex Pharmaceuticals – called VX-993 -- will apparently never reach patients, after the company announced disappointing results from a Phase Two clinical trial.  VX-993 is a non-opioid that blocks pain signals in peripheral nerves before they reach the brain, which means it doesn’t have the same “liking” effects of opioids, which can lead to addiction.  

When given to patients recovering from bunionectomy surgery, VX-993 was slightly more effective than a placebo in reducing post-operative pain, but provided less pain relief than a low dose of a hydrocodone/acetaminophen combination (Vicodin).  

“Based on these results, as well as the totality of preclinical data and results from our previous bunionectomy clinical studies, VX-993 is not expected to be superior to our existing NaV1.8 inhibitors and therefore we will not be advancing it as monotherapy in acute pain,” Carmen Bozic, MD, Executive Vice President and Chief Medical Officer at Vertex, said in a statement.

VX-993 acts similarly to Journavx (suzetrigine), a non-opioid developed by Vertex that acts on peripheral nerves. Journavx was recently approved by the FDA to treat moderate to severe acute pain, despite lackluster results in clinical trials that also showed it was no more effective than Vicodin.

The FDA’s approval of Journavx coincides with implementation of the NOPAIN Act, which makes non-opioid analgesics in outpatient surgical settings eligible for higher Medicare reimbursement rates. Journavx costs about three times as much as Vicodin.

Canada Facing Nationwide Shortages of Opioid Pain Medication

By Pat Anson

Pain patients in the United States have been dealing with persistent shortages of opioid pain medication for years. Now their counterparts in Canada face a similar issue.

Health Canada has issued a warning about nationwide shortages of oxycodone and acetaminophen combinations, along with medications that combine codeine with acetaminophen. Acetaminophen and oxycodone are sold under the brand names Percocet and Endocet, while acetaminophen-codeine combinations are often sold as Tylenol #3.

While the opioid shortages in the U.S. appear to be largely driven by a national opioid settlement that rations pain medication at the pharmacy level, the Canadian shortages are being blamed on manufacturing disruptions and increased demand.

“We recognize the importance of having acetaminophen with codeine or oxycodone products available for patients. Addressing this shortage is a top priority,” Health Canada said in a statement.

“We're communicating with health care providers, provincial and territorial governments, and distributors to coordinate the sharing of information about this shortage. We're also working with manufacturers and stakeholders to monitor the supply of acetaminophen with codeine or oxycodone and looking at options for increasing access to these products.”

The Canadian Pharmacists Association (CPA) expects the shortages to last a few more weeks, when a “significant resupply” is expected.

“The shortage is the result of manufacturing issues affecting one major supplier, which has increased pressure on other manufacturers. While the supply situation is expected to improve by mid-August, supply constraints are expected to continue until the end of September,” the CPA said in a statement.

A patient advocate says the opioid shortages don’t appear to be causing many problems for patients, at least not yet.

“As far as the shortages go, at least for those I was able to speak with, they are coping with it,” Barry Ulmer of the Chronic Pain Association of Canada told PNN.

“The real problem is the lack of actual doctors who will prescribe (opioids) and in doses needed. Even though Health Canada and the provincial regulators say opioids are O.K. to use, they still warn doctors about overprescribing and tapering is still a very real reality. Almost every doctor that I have known over the years have now retired or just plain quit because of this ongoing problem.”

Smaller Doses and Tapering Recommended

Until the shortages ease, the CPA is advising pharmacists to suggest non-opioid pain relievers for patients suffering from acute short-term pain, such as headaches and muscle strains.

For long-term pain patients already using oxycodone and codeine combinations, the CPA recommends limiting doses to 90 morphine milligram equivalents (MME) a day. Switching to another opioid and/or tapering is another alternative.

“If the current dose is high, give 50% or less of the new opioid converted to morphine equivalents. Otherwise, start with 60–75% of the previous dose converted to morphine equivalents,” the CPA said.

In the United States, either scenario would be considered a rapid taper, which can raise the risk of an overdose or mental health crisis. The CDC recommends more cautious tapering of patients, with a dose reduction of just 10% a month.

The American Society of Health-System Pharmacists (ASHP) first reported U.S. shortages of oxycodone-acetaminophen combinations in the summer of 2023. Not much has changed in the last two years.

In its June report, the ASHP said several drug manufacturers have oxycodone-acetaminophen combinations on back order, with no estimated resupply date. Only one drug maker, Major Pharmaceuticals, anticipates having new supplies in early August.

Some companies are phasing out the production of opioid medication. Endo Pharmaceutical stopped making Percocet in 2024, while Teva Pharmaceuticals discontinued production of immediate release oxycodone in 2023 and Transmucosal Immediate-Release Fentanyl Medicine (TIRF) in 2024. Opioid litigation has been very costly to Teva and other drug makers. In 2022, Teva paid $4.25 billion to settle thousands of opioid liability lawsuits.

Continued Blaming of Purdue Pharma Won’t Solve the Opioid Crisis

By Lynn R. Webster, MD

On July 15, The Washington Post published an editorial urging states to use opioid settlement funds to expand naloxone access and addiction treatment programs.

These are sound public health goals. But the editorial’s framing — tying these investments to reparations for damage attributed to Purdue Pharma — rests on an oversimplified and misleading narrative that has shaped policy and public opinion for over a decade.

Purdue Pharma aggressively market OxyContin and contributed to early overprescribing. However, it was never the dominant supplier of prescription opioids. Analyses of pill counts, morphine milligram equivalents, and regional variation show that Purdue’s market share was often far less than one-third. While its actions were consequential, the disproportionate focus on Purdue distracts from the broader, ongoing drivers of the crisis.

Addiction is not caused by the availability of opioids alone, but also by the conditions that make people vulnerable: poverty, trauma, housing instability, and untreated mental illness. By fixating on corporate actors, we risk mistaking the spark for the fire — and neglecting the deeper issues that sustain the epidemic.

The editorial also perpetuates confusion between physical dependence and addiction. The former is a predictable response to long-term opioid use; the latter involves compulsive behavior and impairment. Blurring the two has led to harmful policies, including forced opioid tapers and abandonment of stable pain patients.

These policies have not reduced deaths. As prescription opioids became harder to obtain — often due to regulatory pressure — some patients turned to illicit alternatives; not to get high, but to avoid withdrawal or manage pain. This shift laid the groundwork for the explosion of heroin and illicit fentanyl use. Today, illicit synthetic opioids are involved in more than 70% of overdose deaths.

Framing settlement spending as payback reinforces a punitive narrative rather than advancing evidence-based solutions. Naloxone, youth prevention, and addiction treatment should be pursued because they work — not because they symbolize restitution.

The real challenge lies in addressing the conditions that lead to substance use in the first place. Reforming housing policy, expanding mental health care, and ensuring access to meaningful employment are more difficult— but are far more essential — than litigating against a defunct company.

We should also be asking why the healthcare system permitted aggressive opioid marketing, why insurers incentivized pill volume over outcomes, and why evidence-based addiction care and harm reduction remain chronically underfunded.

Managing the crisis requires more than blame. It requires accurate explanations, structural change, and sustained investment in public health — rather than narratives that feel satisfying but obscure the truth.

Lynn R. Webster, MD, is a pain and addiction medicine specialist, and serves as Executive Vice President of scientific affairs at Dr. Vince Clinical Research, where he consults with pharmaceutical companies.

Dr. Webster is the author of the forthcoming book, “Deconstructing Toxic Narratives – Data, Disparities, and a New Path Forward in the Opioid Crisis,” to be published by Springer Nature.

‘This Is Blood Money’: Who Is Policing How Opioid Settlement Funds Are Spent?

By Aneri Pattani, KFF Health News

After years of legal battles, state attorneys general won billions of dollars in opioid settlements from drug companies accused of fueling the addiction crisis. They declared victory at press conferences, and some touted the deals during their gubernatorial campaigns.

But now that the windfall is being spent, are attorneys general doing enough to ensure it’s used for the intended purposes?

No, say many families affected by the overdose crisis, recovery and harm reduction advocates, policy experts, and researchers following the cash.

“This is blood money,” said Toni Torsch, a Maryland resident whose son Dan died of an overdose at age 24. It can’t make up for the lives lost, but “we do want to make sure that it’s going to count.”

Torsch and others affected by the crisis are increasingly worried that no one seems to be guarding the opioid settlement cash while elected officials eye it hungrily. With the Trump administration slashing federal funding for addiction and Congress approving massive reductions to Medicaid — the largest payer for addiction care nationwide — people fear state legislators will use the settlements as a grab bag to fill budget shortfalls.

In the face of these concerns, two research and advocacy organizations are proposing a solution: a crowdsourced database to identify potential examples of misuse and prompt attorneys general to investigate.

The Opioid Policy Institute and Popular Democracy launched a website that allows members of the public to submit alleged cases of waste, fraud, abuse, and mismanagement of opioid settlement funds. Submissions are reviewed by Jonathan Stoltman, director of the Opioid Policy Institute, and then posted with details such as how much money was spent, what was purchased, who made the decision, and links to relevant news articles or budget documents.

The database, shared first with KFF Health News, includes about 150 examples to start, including $2,362 awarded by a Missouri county to its roads and bridge department and $375,600 spent on a body scanner for a Michigan county jail. The initial examples were sourced from people in recovery, advocates, and others Stoltman and his team asked to test the project. Stoltman acknowledged he’ll face criticism as the primary arbiter of what qualifies as misuse for the database, but said he’ll use research studies to defend his decisions.

The website also shows people how to file complaints with their state attorney general and ask the office to develop a formal process for receiving and investigating such complaints.

“I hope this is a wake-up call for state AGs that their work on this project is not done,” said Frank Kearl, who co-led the effort with Stoltman and is working as an attorney at Popular Democracy until July 14. “We still have time” to make changes to ensure we “spend this money in a way that actually responds to the harm that was caused.”

The website’s launch comes just over a week after New Jersey lawmakers passed a budget that gave health systems $45 million in settlement funds despite the state attorney general’s opposition. Legislators said it would shield hospitals from the blow of federal Medicaid cuts, but harm-reduction advocates said it gives short shrift to people with substance use disorders, whom the money was meant to serve.

Lawmakers in North Carolina and Washington, D.C., are also considering using settlement funds to plug gaps, and Connecticut and Nevada have discussed it too.

“That’s not what it’s there for,” said Torsch, who runs a nonprofit dedicated to addiction recovery in her son’s honor. “We want to make sure that money is being spent in the most responsible and effective way to help people that are still struggling.”

Last year, when Torsch heard that a western Maryland county spent some of its settlement money on guns, she reached out to her state attorney general to complain. The office said it wasn’t its responsibility, Torsch said, and told her to contact the health department.

She was confused.

The attorney general’s office is supposed to represent “the top cops,” Torsch told KFF Health News.

The Maryland attorney general’s office declined to answer KFF Health News’ questions about how it handles opioid settlement complaints.

Few States Monitor Spending

About a dozen companies are expected to pay state and local governments more than $50 billion in opioid settlements over nearly two decades. Purdue Pharma’s case, the most well known, is still wending its way through court. But other companies, including Johnson & Johnson, CVS Health, and Walgreens, have begun paying.

Although the specifics of each settlement deal vary, most require states to use at least 85% of the money on efforts related to the opioid crisis. But enforcement is left to the companies that paid out the money. And legal experts are skeptical that the companies are monitoring state spending.

Attorneys general should be enforcing that standard too, said Stoltman, of the Opioid Policy Institute. “If you’re going to bang your chest about how much money you got for your state for opioids,” he said, “what are you doing to make sure that it’s actually being spent well?”

Stoltman’s and Kearl’s teams surveyed attorneys general offices in 56 states and territories to see if each office had a complaint form specific to this pot of money, explained the details needed to report misuse, and allowed submitters to track their complaints. They also searched websites of state auditors, comptrollers, and similar entities for complaint forms or procedures.

Their findings? Only three states mentioned specific processes for reporting misuse of opioid settlement money.

South Carolina and New Jersey had links on settlement-related websites that directed people to general complaint forms. Oklahoma was the only state to have an opioid settlement-specific form.

Jill Nichols, opioid response and grant coordinator in the Oklahoma Office of Attorney General, said it was created in April in response to the researchers’ inquiry. As of late June, she’d received one complaint, which was found to be without merit.

Stoltman and Kearl said they hope the crowdsourced database will encourage more attorneys general to take an active oversight role by illustrating how much potential misuse is occurring.

The Michigan attorney general’s office said it plans to publish a settlement-specific complaint form this year.

But some attorneys general told KFF Health News it wasn’t their job to track how the money is spent.

Brett Hambright, a spokesperson for Pennsylvania Attorney General David Sunday, said the state created an opioid settlement council to take on that responsibility.

In North Carolina, Attorney General Jeff Jackson’s office said, settlement funds are controlled by the state legislature and local governments. “Our office does not administer the funds nor do we have the power to withhold them,” spokesperson Ben Conroy said.

Even when attorneys general watch the money closely, their power may be limited. For example, Arizona Attorney General Kris Mayes went to court last year to stop the state legislature from giving $115 million in settlement funds to the Department of Corrections. But a judge ruled against her.

Maryland Attorney General Anthony Brown’s office directed KFF Health News’ questions to other state agencies.

Michael Coury, a spokesperson for Maryland’s Office of Overdose Response, said members of the public can email the office with complaints. If the office agrees misuse has occurred, it will bring the complaint to the attorney general, who — per the state’s agreement with local governments — “may” take action.

As of this year, the attorney general’s office will receive $1.5 million of Maryland’s opioid settlement funds annually to cover personnel and administration costs related to opioid-related lawsuits. This may involve suing more companies for future settlement deals.

Torsch, the Maryland mom, said she wishes the focus wasn’t just on winning more money but also ensuring that existing settlement dollars are spent well.

“We owe it to all the families that have been destroyed and suffered great losses,” she said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — an independent source of health policy research, polling, and journalism. Learn more about KFF.

Study Links Gabapentin to Increased Dementia Risk

By Crystal Lindell

Gabapentin (Neurontin) may significantly increase the risk of dementia and cognitive impairment, even for middle-aged patients who only took the nerve medication for six months.

That’s according to a new study, published in the Regional Anesthesia & Pain Medicine journal, which looked at health records for over 26,000 U.S. patients with chronic low back pain.

Researchers found that patients with six months or more of gabapentin use had a 29% higher risk of developing dementia and an 85% higher risk of developing mild cognitive impairment (MCI). 

Gabapentin was originally developed to prevent epileptic seizures, but is now commonly prescribed off-label as an alternative to opioids for pain management.

Researchers have long been concerned about gabapentin’s effects on neurotransmitters in the brain, while patients have complained the drug causes brain fog, dizziness, weight gain and worsens mood. 

Perhaps the most startling aspect of the study is that gabapentin increases the risk of dementia and cognitive decline in middle aged adults.

Dementia risk more than doubled and MCI risk tripled among 35–49 year olds. A similar pattern was observed among 50–64 year olds.

Risks also rose the more often patients use gabapentin. Those with 12 or more prescriptions were 40% more likely to develop dementia and 65% more likely to develop MCI than those with fewer prescriptions.. 

“Our findings indicate an association between gabapentin prescription and dementia or cognitive impairment within 10 years. Moreover, increased gabapentin prescription frequency correlated with dementia incidence,” wrote lead author Nafis Eghrari, a medical student at Case Western Reserve University School of Medicine.

“Our results support the need for close monitoring of adult patients prescribed gabapentin to assess for potential cognitive decline.”

As a patient who has taken gabapentin for chronic pain, these results are alarming to say the least. And I wonder if the findings would also apply to pregabalin (Lyrica) and other gabapentinoids in the same class of medications. I have also been prescribed Lyrica. 

I don’t believe I was ever warned that gabapentin could increase my risk of cognitive decline, despite the fact that was a known concern. I don’t know if such a warning would have deterred me from taking it, but that’s still a choice that should have been given to me. 

I am also concerned that the information about these very real risks associated with even relatively short-term gabapentin use will reach patients and prescribers. Sales of gabapentin and pregabalin have tripled from a decade ago, when they were first touted as safer alternatives to opioids. 

Gabapentin is FDA-approved for epilepsy and neuropathic pain caused by shingles, but is also prescribed off-label for depression, ADHD, migraine, fibromyalgia, bipolar disorder and postoperative pain.  

Anyone prescribed gabapentin for pain should be told that using the medication for just six months greatly increases their risk of developing dementia. However, I doubt that will happen. In my experience, while medical professionals are quick to point out the supposed risk of opioids like hydrocodone, they often push alternatives like gabapentin onto patients without much discussion. 

The assumption is always that anything must be safer than opioids. Unfortunately, that doesn’t always seem to be the case. 

New Jersey Town ‘Wasted’ Opioid Settlement Money on Concerts

By Crystal Lindell

A town in New Jersey used its opioid settlement money for two concerts costing more than $632,000 – and a large sum of that money was used for six-figure contracts for a town employee's family businesses. 

That’s according to a scathing report by New Jersey’s Office of State Comptroller (OSC), which details the ways the township of Irvington misused the money, 

According to the OSC report, Irvington “wasted and misspent” opioid settlement money on two “Opioid Awareness Day” concerts in 2023 and 2024. A substantial portion of the money – $368,500 – was paid to Irvington employee Antoine “DJ Qua” Richardson and his wife, who were hired to book musical performers and deejay the event. 

However, the state said Irvington officials do not know — and never asked — how Richardson actually spent the hundreds of thousands of dollars he received.

“In interviews with OSC, Richardson’s wife refused to account for the money, while Richardson claimed not to know or recall how the money was spent,” the OSC said.

State investigators determined that Irvington spent more than $200,000 on billboards and other promotional materials advertising the concerts, including $34,445 on t-shirts and $16,000 for mobile billboards, which prominently featured Irvington Mayor Tony Vauss. 

Irvington also used settlement money to pay nearly $13,000 to rent luxury trailers for the performers, and $29,000 to purchase power generators and food supplies like popcorn machines, cotton candy, and shaved ice.

Irvington police officers were paid over $17,000 in overtime to provide security at the two concerts.

State investigators say “none of the billboards, promotional materials, or t-shirts that Irvington provided to OSC included information about obtaining treatment or avoiding abuse of opioids — they simply promoted the concerts.” 

The organizers made only a “superficial effort” to raise awareness about opioid abuse in the town of 61,000 people, according to the report. Most of the concert material promoted the performers, the mayor, and the concerts themselves.

The stage display also made no mention of opioids. In fact, the only message displayed on stage was an ad for a “Yacht Party Cruise Around Manhattan” hosted by Richardson.

The township also didn’t allocate any of the settlement money to pay for the overdose reversal drug Narcan that was handed out at one concert.

IRVINGTON TOWNSHIP IMAGE

Instead, concert organizers requested donations for Narcan, “even though this life-saving drug was the only clearly effective measure at one of the concerts that could directly address the crisis and potentially save lives,” the OSC said.

“These funds are meant to address an ongoing public health emergency that continues to claim lives. When municipalities like Irvington fail to meet that duty, they not only waste resources but erode public trust and betray the communities most in need of support.”

Irvington officials dispute many details in the OSC report, and even went to court to block the report’s release. Mayor Vauss released a lengthy response to the report and said the township would proceed with a defamation lawsuit against acting State Comptroller Kevin Walsh and the OSC.

Walsh’s investigation wasn’t fair, according to attorney Christopher Kinum, who represents Irvington. He said state guidance on how to spend opioid settlement money was vague.

“Every municipality is using the funds for a different reason. These funds were disbursed before there was guidance. All there was, was some term — ‘evidence-based methods to combat the opioid crisis,’” Kinum told the New Jersey Monitor.

‘A Grave Misuse of Funds’

The use of billions of dollars in opioid settlement money is an issue around the country. Over $10 billion has been handed to state and local governments in recent years, and billions more are expected over the next decade. New Jersey alone has been provided over $120 million in opioid funding, with another $520 million in future payouts.

New Jersey recently diverted $45 million in settlement money to four cash-strapped hospitals to offset federal cuts in Medicaid funding. Harm reduction advocates called that a “raid of opioid settlement funds” and want the money returned.

Nevada and Connecticut also want to use settlement money to shore up social service programs hurt by federal funding cuts; while Arizona transferred $115 million in settlement money to the state prison system to help close a budget deficit.

“I have a very high level of fear that states are going to be tapping into these settlement dollars in every creative way they can to fill some of these budget shortfalls,” national recovery advocate Ryan Hampton told KFF Health News. “It’s a grave misuse of funds and one that is going to have dire consequences.”

If you want to see how your state and local government is spending opioid settlement money, you can visit a KFF Health News database or the Opioid Settlement Tracker.

Descending Pain: A New Way to Control Severe Chronic Pain

By Dr. Forest Tennant and Ingrid Hollis

The control of severe chronic pain in medical practice today is almost exclusively based on “ascending” or “neuropathic” pain:

Ascending pain occurs when a pain signal is transmitted from the site of injury or disease up the spinal cord to the brain. Neuropathic pain is the pain that results when there is damage or dysfunction of nerve tissue in the brain, spinal cord or peripheral nerves. 

In recent years, researchers discovered that when chronic pain centralizes, it creates a third type of pain called “descending” pain. This is a critical issue for persons with adhesive arachnoiditis and other diseases that cause severe chronic pain, because descending pain requires different medications than those used for ascending and neuropathic pain.

A person with constant pain will produce excess bioelectricity (central sensitization or centralized pain) in the glial cell matrix of the brain. This bioelectricity “descends” or travels down the spinal cord and vagus nerve. It not only produces pain, but over-stimulates the cardiovascular system. 

Descending pain is controlled by the noradrenergic receptor.  The neurotransmitter to this receptor is called noradrenalin or norepinephrine. 

Symptoms of Descending Pain

Descending pain will be present in persons who have constant, unremitting pain. Here are the symptoms:

• Pulse rate elevates

• Periodic hot flashes

• Cold hands/feet

• Excess sweating

• Allodynia (pain upon light touch) 

Over-Reliance on Opioids and Neuropathic Agents

The lack of awareness about descending pain is one reason why high doses of opioids and neuropathic agents (i.e., gabapentin, diazepam) may be over-prescribed. Physicians may simply raise the opioid or gabapentin dosage if they are not aware that the cause is descending pain.  What’s more, the increase in dosage may be ineffective or even harmful.

This also applies to opioids in implanted pumps.  Countless persons have been treated with an implanted device or “pain pump” with the erroneous belief that no medication, except intrathecal opioids, are needed.  Patients with these devices soon learn that their pain is poorly controlled by opioids alone. 

Opioids and neuropathic agents have little effect on descending pain.  It must be treated separately.

Pain treatment and relief are based on a medicinal that activates or stimulates a specific receptor (think “action point”) that is present in nerve cells in the brain, spinal cord or peripheral nervous system. Here is how the three types of pain and their receptors can be treated:

1. Ascending pain needs to be treated with medications that activate the endorphin or opioid receptor. 

2. Neuropathic pain control depends on activation of a receptor called gamma amino butyric acid (GABA). 

3. Descending pain control must activate the norepinephrine (noradrenalin) receptor.

To achieve good control of severe, chronic or intractable pain, all three of these receptors must be simultaneously activated.  Severe chronic pain is commonly undertreated, because all three receptors are not simultaneously activated.

Medication Classes for Descending Pain

Three medication classes are used to treat descending pain.  Medical practitioners and patients have choices, and can experiment to help decide which medications and supplements bring the most comfort.

1. Bioelectric Blockers: Tizanidine, propanolol, clonidine, tapentadol (Nucynta).

2. Receptor Activators: Modafanil (Provigil), methylphenidate (Ritalin), dextroamphetamine, amphetamine salts (Adderall), phentermine, lisdexamfetamine (Vynanse). Non-prescription activators: lion’s mane, mushroom extract, St. John’s wort, rhodiola, mucuna, whole adrenal gland.

3. Precursor (Amino Acids) of Noradrenaline: Phenylalanine at 1,000 to 2,000mg a day. Tyrosine at 1,000 to 2,000mg a day.

When not controlled, chronic pain, inflammation and autoimmunity will deplete a number of neurotransmitters and hormones.  When that happens, noradenaline (norepinephrine) will often be depleted. 

Supplements of either amino acids (phenylalanine or tyrosine) and daily protein intake may help reduce both background and flare pains. Phenylalanine and/or tyrosine need not be taken every day, but they are highly recommended at least two days a week. They can and should be taken with a bioelectric blocker or receptor activator.

Noradrenergic receptor activators do not raise pulse rate or blood pressure in a constant pain patient like they do in a normal person.  They may actually lower blood pressure and pulse rate.  That’s because chronic pain, inflammation and autoimmunity deplete noradrenalin.

One medication, tapentadol (Nucynta), is both an opioid and norandrenergic blocker. It is highly recommended.

Descending pain is a new discovery that must be recognized and controlled to achieve relief from severe chronic pain.  A sole reliance on opioid and neuropathic agents may often provide inadequate pain relief.

To learn more about descending, ascending and neuropathic pain, you can watch a recent episode of DocToks with Dr. Forest Tennant and Friends.

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis. Readers interested in learning more about his research should visit the Tennant Foundation’s website, Arachnoiditis Hope. You can subscribe to its bulletins here.

Ingrid Hollis is a person in pain, patient advocate, and advisor to the Tennant Foundation.

The Tennant Foundation gives financial support to Pain News Network and sponsors PNN’s Patient Resources section.   

Poor Pain Treatment in ER Raises Risk of Opioid Misuse Later

By Pat Anson

Patients with acute pain who are dissatisfied with their pain treatment in emergency departments are more likely to misuse opioids three months later, according to a new study. The findings are particularly true for black patients, who are more likely to be unhappy with their treatment and to be sent home without an opioid prescription.

“While a great deal of studies on opioid misuse focus on overprescribing, this study flips the script by showing that under-prescribing—or more precisely, ignoring a patient’s pain treatment preferences—can also lead to harmful outcomes, especially when patients are dissatisfied with their care,” said Max Jordan Nguemeni Tiako, MD, an assistant professor at the David Geffen School of Medicine at UCLA and lead author of the study in the Journal of General Internal Medicine.

Previous studies have found disparities in pain treatment between white and black patients in emergency rooms, with white patients 26% more likely to get opioid medication. This new study has similar findings, but went a step further to see what the long-term consequences of poor treatment could be.

Nguemeni Tiako and his colleagues analyzed data for 735 ER patients treated for acute back or kidney stone pain, and surveyed them about their experiences 90 days later. The survey asked a series of questions about their medication use, appointment problems, emotional/psychiatric issues, and drug misuse --- and then assigned a current opioid misuse (COMM score) based on their answers.

Researchers found that black patients (21.8%) were more likely than white patients (15%) to have an “unmet opioid preference” when they were discharged from the ER. They were also more likely to be dissatisfied with their pain treatment overall.

Black patients with poor satisfaction and unmet opioid preferences had higher COMM scores compared to white patients. Both blacks and whites who were highly satisfied with their pain treatment had low risk of opioid misuse.

“The finding that unmet opioid preference had a unique effect on opioid misuse risk among Black participants is consistent with our prior analyses of this cohort, in which we found that receiving a prescription for opioids at discharge was associated with lower odds of reported non-prescribed opioid use,” researchers reported.

“Similarly novel to our study is the finding that satisfaction with pain treatment significantly mediates the impact of unmet preference on opioid misuse, especially among Black participants.”    

While an unmet preference for opioids may lead some patients to seek relief through nonprescribed opioids, researchers think other factors in the ER could mitigate such risks, such as more empathy by providers, more patient-centered communication, and patient education about effective therapies and opioid risks.

Scientific Review Dismantles Myths Behind ‘Opiophobia’

By Crystal Lindell

“There is little evidence that physicians and surgeons prescribing opioids for short-term pain relief leads to substantial levels of opioid use disorder (OUD), addiction, or death.”

That one sentence, found in a new scientific review, cuts straight to the heart of America’s irrational fear of opioids — also known as opiophobia.

Published in ACS Pharmacology & Translational Science and authored by John Bumpus, PhD, the paper looks at the irrational fear that prescribing opioids in any capacity is harmful – and how little evidence there is to back up such claims. 

Bumpus opens his report by saying that there is a false narrative that “even short-term (seven days or less) use of opioids under medical supervision to treat acute pain will often lead to opioid use disorder (OUD) and/or addiction.”

As a result of that narrative, many healthcare professionals and policy makers believe that the best way to address this problem is to “avoid using opioids altogether or to severely limit the use of prescription opioids, especially after surgery.” 

Bumpus says many providers also assume that limiting prescriptions will significantly reduce overdose deaths. Then he adds the line that cuts to the heart of opiophobia: 

“There is, however, substantial evidence that this is not the case.”

In that one sentence, Bumpus dismantles the main argument that’s often used to claim that opioid restrictions are necessary: the idea that such restrictions are “evidence-based.” 

His report lays out how opioid-related misconceptions have led to policy decisions that are not only unsupported by evidence — but are often harmful. Anyone who has had trouble accessing needed opioid medications over the last few years will find the article both cathartic and affirming.  

Bumpus, who’s a Professor of Chemistry and Biochemistry at the University of Northern Iowa, starts the paper by defining "'opiophobia'" based on the definition shared in a 2023 paper, “Opiophobia and the tragedy of needless pain”

Opiophobia led many patients and providers to “fear, avoid or condemn the use of these compounds,” which Bumpus calls ‘the most effective family of analgesics known.”

While large chunks of the report focuses on surgical patients in post-operative pain, Bumpus says that many chronic pain patients use opioids “successfully and appropriately,” but have been “adversely affected by the catastrophization of issues and misinformation surrounding the use of opioids and the opiophobia it has generated."

Bumpus asserts that anti-opioid zealots have gone too far. 

“Although opioid-free protocols and policies may have their benefits and role, for some physicians, researchers, administrators, and politicians, the elimination of opioids appears to have become a goal in and of itself,” he warns. 

Bumpus says there's an underlying assumption "that physicians and surgeons are currently overprescribing opioids." He then adds, "Nationally, this does not appear to be the case."

While the number of opioid prescriptions decreased by about 50% from 2010 to 2022, Bumpus says deaths involving prescription opioids have remained constant. Meanwhile, fatal overdoses from illicit fentanyl and other synthetic opioids have skyrocketed.

“It does not appear that prescription opioids are the major problem here,” Bumpus concludes

He says those advocating for severe opioid limitation often ignore the adverse effects of alternatives like acetaminophen.

"For example, annually in the U.S., acetaminophen overdose is responsible for over 56,000 emergency department visits, 2600 hospitalizations and 500 deaths,” he writes. “Acetaminophen overdose is also the most common cause of acute liver failure and the most common reason for liver transplants in the U.S."

He says that "the narrative that the opioid crisis is caused by the prescribing habits of ethical, conscientious, and caring physicians is patently untrue."

Rather, what is true is that the “undertreatment of postoperative pain is a serious ongoing concern.”

Misleading Data Used to Justify Opioid Restrictions

While opioid-restricting polices may be well-intentioned, Bumpus says there is little evidence that physicians prescribing opioids for short-term pain leads to substantial levels of misuse.

For example, some of the claims used to justify opioid restrictions rely on a study that found 30% of Medicaid patients prescribed an opioid for the first time developed opioid dependency.

That is claim is misleading. The researcher was simply citing the fact that 30% of patients who filled a single opioid prescription needed a refill 3 to 9 months later. Getting a refill alone hardly meets the criteria for opioid dependency, much less addiction.

Bumpus says opioid restrictive policies have had the unintended effect of encouraging patients to store leftover opioids at home, which only makes them more likely to be misused by someone else. 

"Ironically, programs aimed at reducing access to opioids and their long-term storage may actually incentivize the hoarding of these medications," he says. 

People storing leftover opioids is understandable though, when patients fear their future pain will be untreated or they won’t be able to see a doctor.

"Long-term storage of opioid medications and self-medication may not be behaviors endorsed by the medical profession,” Bumpus says. “However, such behaviors are understandable human reactions, and they undoubtedly occur." 

Bumpus argues that while it’s illegal and medically unsupervised, using leftover prescription opioids is safer than turning to street drugs:

“These drugs serve as a relatively safe supply of opioids for people who use them,” he writes.

Ultimately, Bumpus says the public “should have access to information that accurately portrays the benefits as well as the risks associated with the medicinal use of opioids.” 

His paper is heavily researched and includes over 200 footnotes, including several PNN articles that debunk the narrative about opioid misuse being common. 

Bumpus says his paper is important for administrators, policymakers, and lawmakers to read, “so that mistakes of the past are not repeated, making sure that ill-conceived laws and policies are not put in place that do more harm than good.”

Bumpus is correct, of course, and his message is urgent. Now the medical community and policymakers just need to actually listen to him. 

OxyContin Fueled the Opioid Crisis, But Not How You Might Think

By Crystal Lindell

Attorneys General from 55 U.S. states and territories recently accepted a $7.4 billion settlement with Purdue Pharma and the Sackler family, potentially ending over a decade of legal wrangling over the company’s role in the opioid crisis.  

But much of the media coverage still doesn’t seem to grasp what Purdue Pharma actually did wrong with its marketing of OxyContin. Purdue Pharma’s original sin was not flooding the market with too many OxyContin pills – it was too few.

OxyContin’s share of the opioid market was never more than 4 percent. That small share, however, was magnified by higher dose pills, which made OxyContin more likely to be misused. 

The company drove misuse by claiming that OxyContin pills lasted for 12 hours. In reality, they only lasted 4-6 hours. I know, because I’ve been on them myself for chronic pain.

This is how the Los Angeles Times described Purdue’s marketing campaign in 2016: 

“Purdue tells doctors to prescribe stronger doses, not more frequent ones, when patients complain that OxyContin doesn’t last 12 hours. That approach creates risks of its own. Research shows that the more potent the dose of an opioid such as OxyContin, the greater the possibility of overdose and death."

So if a patient wasn’t getting steady relief from two 10mg OxyContin a day, the doctors would be encouraged to up it to two 20mg OxyContin pills a day. In reality, it would have been better to keep the dose at 10 mg and increase the frequency to four pills a day.

Purdue was well aware of the problem. They knew the pills did not last the full 12 hours. But it was OxyContin’s 12-hour dosing regimen that was its main selling point. It was supposed to set it apart from much cheaper opioid options like hydrocodone, morphine and oxycodone. 

Here’s what happened when doctors prescribed more OxyContin pills to give patients relief, according to the LA Times:

“When many doctors began prescribing OxyContin at shorter intervals in the late 1990s, Purdue executives mobilized hundreds of sales reps to ‘refocus’ physicians on 12-hour dosing. Anything shorter ‘needs to be nipped in the bud. NOW!!’ one manager wrote to her staff.”

Purdue then encouraged doctors to prescribe higher dose 80mg pills, because the higher the dose, the more Purdue made off the pills. While the company charged wholesalers about $97 for a bottle of 10mg pills, a bottle of the 80mg version went for $630. 

The company also based the commissions and performance evaluations for its sales team on the proportion of high-dose pills they sold. 

‘The Dose Makes the Poison’

Over 500 years ago, Swiss physician Paracelsus coined the phrase, “The dose makes the poison.” For Purdue Pharma, that was especially true. It was the high doses at long intervals that made OxyContin so dangerous.

Patients would go through cycles of withdrawal as their high doses wore off early, or they would just take a few extra pills each day. That meant they would run out of their prescription early, leaving them to go through days or even weeks of withdrawal. 

And make no mistake, even short intervals of withdrawal from 80mg OxyContin would make anyone feel like hell. God forbid you run out early and have to go through that. It’s the perfect recipe for driving patients to seek other sources of relief, whether that means buying pills from someone else or buying street opioids. 

Understanding that the root cause of OxyContin’s danger was not that doctors were prescribing too many pills, but prescribing too few of them challenges the popular narrative of how the opioid crisis started.  

The actual problem was not that doctors were treating pain with opioids. They were treating pain with opioids at the wrong intervals. 

Media coverage of Purdue still often frames OxyContin as the same as every other opioid though. But OxyContin isn’t fentanyl and it’s not hydrocodone, either.

Low and frequent doses of hydrocodone are relatively safe for the vast majority of patients. Which makes sense, since the reason OxyContin led some patients to misuse was because it was literally the opposite: High doses taken infrequently. 

That message seems to get lost in current opioid-phobia coverage. Just last week, the LA Times ran a column headlined, “Surgeons give patients too many opioids. A few simple steps could curb excess prescribing”

The column is authored by Zachary Wagner, PhD, a health economist at USC, and Craig Fox, PhD, a psychology professor at UCLA who specializes in studying behavioral risk. Neither of them are medical doctors.

In their op/ed, Wagner and Fox spread the misinformation that it’s leftover post-op pills that are driving opioid deaths. They think surgeons should be encouraged to prescribe fewer opioids. 

“If we could get surgeons to prescribe only the number of pills patients need for their own use, this could greatly reduce the number of excess pills available for diversion and misuse,” they wrote. 

This is dangerous and misleading. Opioids are so difficult to get today that pain patients are far more likely to hoard their “excess pills” than to sell or divert them. Opioid diversion rates are quite low, according to the DEA, which estimates less than half of one percent of oxycodone (0.493%) and hydrocodone (0.379%) are used by someone they are not intended for. 

Do surgeons really need lectures from economists and psychology professors about what they should prescribe?

I have seen first-hand how many surgeons already give post-op patients a regimen of only ibuprofen or acetaminophen due to opioid-phobia laws and regulations. Providing adequate post-op pain relief isn’t just the ethical thing to do, it’s also important for the healing process and to prevent acute pain from becoming chronic.. 

The bottom line is that pain refuses to be ignored. People will find ways to treat it, regardless of whether or not their doctor helps them. Simply refusing to give people opioids won’t solve anything. It will, however, drive people to street drugs or to self-medicate with alcohol and other substances. 

If doctors actually want to help patients, they should still be prescribing low-dose opioids, which are relatively safe. And they should prescribe high-dose opioids to people who really need them, just at realistic intervals.

Purdue Pharma’s sins were real – but letting that justify complete bans on pain treatment only results in more suffering, not less.