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ALO ALTO, Calif. — For Thomas P. Yacoe, the word is “terrifying.”

Leah Hemberry describes it as “constant fear.”

For Michael Tausig Jr., the terror is “beyond description.”

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All three are patients struggling with chronic pain, but what they are describing is not physical agony but a war inside the medical community that is threatening their access to painkillers — and, by extension, their work, their relationships, and their sanity.

Two years after the United States saw a record 27,000 deaths involving prescription opioid medications and heroin, doctors and regulators are sharply restricting access to drugs like Oxycontin and Vicodin. But as the pendulum swings in the other direction, many patients who genuinely need drugs to manage their pain say they are being left behind.

Doctors can’t agree on how to help them.

“There’s a civil war in the pain community,” said Dr. Daniel B. Carr, president of the American Academy of Pain Medicine. “One group believes the primary goal of pain treatment is curtailing opioid prescribing. The other group looks at the disability, the human suffering, the expense of chronic pain.”

Pain specialists say there is little civil about this war.

“There’s almost a McCarthyism on this, that’s silencing so many people who are simply scared,” said Dr. Sean Mackey, who oversees Stanford University’s pain management program.

“The thing is, we all want black and white. We don’t do well with nuance. And this is an incredibly nuanced issue.”

Nuance does not matter to people like Tausig, 43, who has been unable to work or socialize since 2008, when the last of his five spinal reconstruction surgeries left him in constant pain.

He last got a taste of life without opioids a few years ago, when his pharmacy’s corporate parent imposed opioid-distribution limits, forcing him to find a new one.

“Those three days were among the worst of my life,” he said. “I wandered the house at night, legs shaking like a whirling mass of putty, sleepless and without respite from the pain.”

Now, with regulators and health industry leaders continuing to bear down on opioids, and the arrival of a new president whose statements indicate that he might further restrict opioid distribution, Tausig’s worries have deepened.

“It’s put the fear of God in me.”

Michael Tausig has been unable to work or socialize since 2008, when the last of his five spinal reconstruction surgeries left him in constant pain. Elizabeth D. Herman for STAT

The medical community’s battle over painkillers burst out into the open in late 2015, when the New England Journal of Medicine published a commentary in which two doctors argued that chronic pain patients should focus not on reducing the intensity of their pain, but on their emotional reactions to it.

The authors, Dr. Jane C. Ballantyne, the president of Physicians for Responsible Opioid Prescribing, and Dr. Mark D. Sullivan, argued patients should pursue “coping and acceptance strategies that primarily reduce the suffering associated with pain and only secondarily reduce pain intensity.”

The pair argued that patients who mainly focus on pain intensity tend to escalate their doses of opioids and worsen their quality of life.

On NEJM’s website, the comments section devolved to a flame war more suited to YouTube than the staid pages of the nation’s top medical journal, with some accusing the authors of a lack of compassion, and others lauding them for a sane approach to public health and addiction prevention.

But the comments also laid bare a fundamental problem in the debate over opioid treatments: Neither side has much evidence about the benefits or consequences of long-term use because almost no such studies exist.

A few studies have identified a litany of side effects beyond addiction. One survey, by palliative care doctors Mellar P. Davis and Zankhana Mehta, pointed to symptoms including increased risk of depression, anxiety, cognitive impairment, and sleep apnea, among other issues. Patients with lung disease were also more likely to die when their treatment included opioids, according to the survey’s authors, who practice at Geisinger Health System.

Stanford’s Mackey said those risks are important to recognize. But, he said, nearly 15,000 people die a year from anti-inflammatory medications like ibuprofen. “People aren’t talking about that,” he said.

Mackey says doctors being trained at Stanford’s pain center have grown increasingly fearful about prescribing opioids. Elizabeth D. Herman for STAT

On a Monday morning last month, Mackey entered an exam room to greet one of his patients who uses opioids: an 81-year-old physician with a bad back.

The doctor, who agreed to be interviewed on condition of anonymity, said he’d routinely cycled to work until relatively recently, when a degenerative spinal condition worsened. Surgery in October failed to help, and now, he told Mackey, he can only get out of bed if he takes five opioid pills at dawn and sleeps another half-hour before rising.

The doctor wanted to find a way to address his back problem without the painkillers, which, he said, cloud his thinking.

Mackey spent nearly 30 minutes with him, talking about scans, symptoms, and previous treatments. He planned a follow-up consult in January, when another set of test results would arrive.

Over lunch, Mackey reviewed the case.

“Do you get any sense from him of drug-seeking behavior?” he asked. “Is he selling this stuff on the street or trying to score some synthetic fentanyl or heroin? No. All he wants to do is be more functional so he can see patients and be relevant and have a life.”

Mackey also wasn’t sure the opioids were causing the cloudiness. The patient’s cognitive issues could be the result of non-opioid medications he takes before sleeping, so dialing down the opioids without first exploring other options might harm him more. Without them, his pain would be so severe he would be relegated to bed.

“If you’re 81 and you stop getting out of bed, it’s a slippery slope,” he said.

Mackey, a past president of the American Academy of Pain Medicine, has built Stanford’s pain center into one of the nation’s most comprehensive and well-funded pain research operations. But he said doctors being trained there have grown increasingly fearful about prescribing opioids.

“In many cases that can be healthy, but I’d like to see a thoughtful, balanced approach,” he said. “Opioids are a tool — they’re more often a fourth- or fifth-line option for me.”

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Mackey recalled the case of a patient who had crushed his foot in an accident and undergone 10 surgeries that failed to diminish his “burning, terrible pain.” The patient now relies on opioids.

“People will say, ‘This guy’s on way, way too much opioid medication, you have to take him off,’” Mackey said. “But guess what: He gets up every morning and goes to work and does his job, and he’s been on the same regimen for years and years and tried everything else first.”

Even some of Mackey’s colleagues have issues with that kind of thinking.

Dr. Anna Lembke, who practices alongside Mackey at Stanford’s pain clinic and is chief of the Stanford Addiction Medicine Dual Diagnosis Clinic, published a book about the opioid crisis last year. It was titled: “Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop.

Lembke believes that long-term opioid use can cause patients to perceive pain even after the original cause of pain has cleared. Some patients, she said, find themselves free of pain only once they have endured the often agonizing effects of opioid withdrawal.

“That’s what we’re seeing again and again,” she said.

Lembke believes people with chronic pain who have taken opioids daily for long periods may never be able to break their dependence on the drugs, and may need permanent doses of medications like Suboxone, which is commonly given to people with opioid addictions.

But chronic pain patients who have not yet started on opioids, she said, should only take them intermittently — “like every three days or so” — to avoid addiction.

The American culture has grown too intolerant of pain, Lembke said.

“Whether it’s surgery or women going into childbirth, there’s an alarmist reaction to pain, and it’s contagious and makes more people anxious, which makes the pain worse,” she said. “We’re terrified to experience pain.”

Mackey has built Stanford’s pain center into one of the nation’s most comprehensive and well-funded pain research operations. Elizabeth D. Herman for STAT

Those who experience chronic pain say these views embolden clinicians, pharmacists, and others to treat them like addicts and criminals.

Hemberry, a 36-year-old multimedia specialist in Leavenworth, Wash., suffers from a connective-tissue disorder called Ehlers-Danlos syndrome and trigeminal neuralgia, an often-excruciating nerve condition for which she occasionally takes opioids.

She heard Lembke interviewed on NPR recently and was bereft. “Every pain patient is now an addict and a failure,” Hemberry said.

Last March, the Centers for Disease Control and Prevention issued guidelines for opioid prescriptions. Those guidelines focused on addiction prevention, opioid trafficking, and medication diversion, and included stern cautions against using the drugs for chronic pain.

To Hemberry, the guidelines seemed reasonable. “But many doctors and administrators have taken a hard-line ‘no opiate’ stance,” she said, and go to absurd lengths to enforce it.

“What people forget is, those who end up on opioid pain management have usually tried everything else unsuccessfully.”

Thomas P. Yacoe, who suffers from chronic migraines

Earlier this winter, Hemberry recalled, she went to the emergency room with a migraine headache, a frequent symptom of her medical conditions. She was seeking a saline drip — one of the few treatments that has helped her pain — and said she wasn’t seeking opioids.

The nursing staff nonetheless grilled her on her medications and chided her for taking too many pills, even though her daily medications are non-narcotic. She turned her head at one point and started sobbing.

Others report a similar lack of empathy.

“What people forget is, those who end up on opioid pain management have usually tried everything else unsuccessfully,” said Yacoe, 61, who suffers from chronic migraines. “I stayed away from opioids for decades. It was really and truly a last resort.”

A patient room at the Stanford University Center for Back Pain. Elizabeth D. Herman for STAT

Some clinicians trace the early roots of the opioid crisis not to the pharmaceutical industry’s marketing of controlled-release morphine pills, but to a 1986 study of 38 non-cancer patients performed by palliative care doctors at Memorial Sloan Kettering Cancer Center.

Most were treated with oxycodone, methadone, or levorphanol in small daily doses — less than half the surgeon general’s current recommended starting dose — and 24 reported acceptable or adequate pain relief, while two patients developed “management” problems with the drugs. (Both had histories of substance abuse.)

According to Carr, of the American Academy of Pain Medicine, the conservative opioid treatment approach used in the study, and the modest benefits reported, reflect the current practices and expectations of many doctors.

But a growing number, he said, are being pressured into a zero-tolerance policy.

“Because if one isn’t anti-opioid enough, there’ll be protests,” said Carr, who is also founding director of Tufts University’s Pain Research, Education, and Policy Program.

Other experts note that, as opioid restrictions tighten, the medical system and insurance industry have done little to support opioid-withdrawal efforts, help more physicians learn how to help patients manage pain, or enable access to alternative therapies.

In some cases, patients seeking to treat their pain have turned to street drugs like heroin or synthetic fentanyl, while others have instead chosen suicide. (In one high-profile case recently, a man who committed suicide left behind notes saying he could find no help for his chronic pain; at least two of the roughly 20 patients interviewed for this article said they had considered suicide because of their pain.)

Everyone wants the number of opioid overdoses to fall. But patients like Tausig don’t want to be made to suffer.

Tausig, a single father of two teens, said that every month he needs to fill a prescription, he’s fearful it will be denied.

Whenever he thinks he might meet with a new pharmacist or clinician, he dresses neatly to hide his tattoos. He said he thinks they can cause people to rush to judgment or even stigmatize him as an addict.

“You’ve got the wars on the medical side, but then you’ve got the governmental people stepping in, who have no idea,” Tausig said. “All they know is drugs: bad.

“They don’t see a struggling single dad in the most expensive place in the US who’s just trying to get through the day.”

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  • Mr.Craig,,,I can not speak of the ,”how” so-called non-whites get treated,,,but I can speak to how ALLL CPP’S ARE BEING TREATED,,,,HELL,,ANYONE IN PHYSICAL PAIN DUE TO ANY MEDICAL CONDITION,,, are being denied access to effective medical care for physical pain due to a medical condition,,ALLL our doctors are being viewed by this government,,the dea,,, as criminals,,,just like US,, chronic pain human beings,,thus why the suicides have sky rocketed,.,,,,jmo,,It is torture and genocide of the medically ill for $$$$$$$$$,,,,,,maryw

  • What goes around, comes around
    When non white patients begged for pain meds ( for legitimate pain), they were branded as criminals
    no response from the medical community, no flame wars, no media coverage
    Now when white patients clamor for pain meds ( for legitimate pain) it is a nationwide crisis…
    Do not ask for whom the bell tolls, it tolls for thee..

  • Hello fellow CCP,
    I’ve been reading and occasionally commenting on here ever since this wonderful journalist wrote the article that pulled us all together to talk, scream, try to figure out what to do. I’m in the same situation as most of you and I want to fight this political insanity that is “killing” us. I only put that in quotes because all of us on hear are still alive and I’m not sure how long we all will be if nothing changes this insanity. I was reading about a petition, could someone direct me to it and any other things that can help me start fighting this atrocity being done to us. It’s incredible that those of us who can barely get out of bed need to fight this immense political witch hunt for our lives. Id appreciate any ideas, forms, petitions that anyone has. Thank you

    • Hello Mara,
      I can relate to your comment about barely being able to get out of bed. Without adequate pain relief, the pain is so bad I freeze, and it seems like forever before it subsides. I fear a heart attack because the pain makes my heart beat too fast when I’m trying to get up. All my Doctor could do was offer an apology. I already know it’s not his fault. For those of us who are not ready for a nursing home, here are 2 petitions to please sign and share:
      CDC
      https://www.change.org/p/centers-for-disease-control-and-prevention-make-opioids-available-to-chronic-pain-patients-again?recruiter=750479203&utm_source=share_petition&utm_medium=copylink&utm_campaign=share_petition

      House of Reps
      https://www.change.org/p/u-s-house-of-representatives-make-chronic-pain-patients-exempt-from-cdc-guidelines

      change.org has more related petitions as well. As I was signing and perusing them, I came across one addressed to Pres. Trump with a long list of strongly worded demands for more heavy-handed restrictions from govt agencies. Nowhere did it ask for exemptions for us. All the more reason to make our voices heard. Addiction is a legitimate issue, but stomping on legitimate pain mgmt patients is not going to help addicts, and it’s already made life tougher for us. Please also consider writing or calling NJ Gov. Chris Christie. He is head of the “Presidents Commission on Combating Addiction and the Opiod Crisis”, a position he has only held since March 2017 and already he’s an expert. In June 2017, his approval rating was 15%, the lowest recorded for any NJ Governor. That doesn’t give me much confidence in him. Here is his address:
      Governor Chris Christie
      Office of the Governor
      P.O. Box 001
      Trenton, NJ 08625
      609-292-6000
      It also doesn’t give me much confidence that by the commission’s own admission, they only have 1 medical person, Bertha Madras, who is listed as a “Professor of Psychobiology” which I’m guessing is their substitute for a true addiction specialist. I hope we all join together and make our voices heard on this matter. Stay strong and much love to all.

    • Hi Mara,
      I sent you a couple of links to petitions I know of, but my reply didn’t show up 😕. I’m wondering if they don’t want links on here. I didn’t exactly read through the terms. Please go to change. org (put link together) and type key words such as DEA OPIOID OPIATES MEDICATION CDC TRUMP MCCAIN PAIN DOCTORS, etc. There are at least 4 related open petitions, and they really need signatures. Also, here is contact info for Pres. Trump’s Head of Drug Abuse Commission:
      Governor Chris Christie
      Office of the Governor
      P.O. Box 001
      Trenton, N.J. 08625
      609-292-6000
      Thanx in advance if you can sign and share the petitions. Take care

    • Hi Paulette,

      Thank you so very much for this information! I will look for the petitions and see if I can get people to sign them and write letters to Christie and anyone else that there is. I just can’t believe what they are doing, going after the legal users rather then the harder route of dealing with the illegal users. Once again, thank you for responding to me and for the information. I wish us all the best of luck in this fight☺

    • Mara, you are very welcome. I got an idea to post part of the link name hoping to make it easier to find the 2 main ones:

      centers-for-disease-control-and-prevention-make-opioids-available-to-chronic-pain-patients

      u-s-house-of-representatives-make-chronic-pain-patients-exempt-from-cdc-guidelines

      I hope this will help narrow down the search. These petitions need all the help they can get, as do pain management patients and our Doctors. Take care ☺

    • Hi Paulette,
      Thank you for the links and the expanded information. Reading what you said you found, the demand of Trump to get an even heavier hand on this, scared the hell out of me, even more than I already am. I will do all I can think of, I will do all your suggestions and hopefully I can get others to join in. Anyone in our position or who knows someone in this position please sign the petitions and write letters to Gov. Christie and your representatives. We need our side well represented since the “committees ” don’t have us represented at all, by CP Drs or patients.

      Ok, thanks again Paulette for your help. Please try to hang in there, take care of yourself 😊

  • I am a pain patient who was able to be a functioning person who was able to work with opioids Have gone through monthly urine and pill counts as my doctor oversaw my how this helped my quality of life Now I’m in a situation where I can not work enough to pay my monthly obligation Ps my doctor told me 26 years ago you are going on disability I told him no I have a family to raise i have been able to do so only with meds It’s not a great life but at least I could live NOW WHAT DO I DO ITS GETTING CRITICAL I HAVE MY BILLS TO TO PAY AND I DO PHYSICAL WORK PLEASE LET. ME KNOW HOW CAN I EXIST NOW

    • Hi Hayden, I’m sorry you’re going through this. I am too. There’s probably nothing I can say to help. I can only tell you thing’s that kinda help me. I research everything I can think of…try n stay focused….exercise through the pain…try and sleep enough…meditate focusing on anything but the pain…
      Hopefully your doctor will give something…stay strong.

    • To Stevei,,,,here lies the problem,AND ITS NOT JUST U,,, it is the government,klondike,harvard all those who sit in these little meeting w.there ignorance as big as there arrogance,,”in theory crap”’,,,in your reply,,Do u know Mr.Haydens medical history??Do u know what causes his physical pain from a medical condition????my medical condition is chronic neuralgia of the thoracic spine,,due to a lamectomy to remove a spinal cord tumor caused by a ,”MISSED,” pancreatits,gallstones ,,”missed,” cardiac artifact,,blamed on me,,,when it was not my fault,,but my internal organs swelling all the time from blockages of ducts via calcium stones ,,which do not show on x-rays,,but hey they burnt my heart muscle 17 x’s,,ie cardia ablation,,and my lamectomy never healed proper due to swollen internal organs pressing against the thorcic spine,,ohh and a few left lung collaspe’s,,My issue it hurts to breath,,eat,laying on my side,cough,laugh,,etc,what ,”exercise thru the pain do u recommend??I’m being a wise ass,,,point being NO-ONE,,NO-ONE,,, has the right to decide/force anyone to endure treatable physical pain due to medical conditions,,,NOT EVEN the government by denial of access to effective medical care,,via lessening physical pain w/opiate MEDICINE..u LUMP ,”CHRONIC PAIN,” into 1 size fits all,,which is inhumane cruel and ignorant,,,Everyone has different medical reasons for their pain,,no-one can ever physically feel that physical pain,,thus,,,it is between u and your doctor how to effectively treat it,,,NOT,,ANYONE WHO KNOWS NOTHING ABOUT YOUR PHYSICAL PAIN,,YOUR MEDICAL HISTORY,,,,,,OPINIONS,,,WILL NEVER STOP PHYSICAL PAIN,,,BECAUSE ,”THOUGHT,” WILL NEVER STOP PHYSICAL PAIN,,,THATS JUST BASIC COMMON KNOWLEDGE,,COMMON SENSE,,,WHICH THERE IS A HUGE LACK OF LATELY,, not to mention the word,,,,,HUMANE TREATMENT,,,,maryw

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