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Hidden in the shadows of the Covid-19 pandemic is the U.S.’s drug epidemic, which is getting worse. One group that is paying the price for it, but shouldn’t be, are people who live with chronic pain conditions.

The opioid epidemic was initially fueled by the misuse of prescription opioids that were often obtained illegally. In recent years, though, the majority of overdose deaths have been caused by illegal or “street” drugs such as illicit fentanyl and its analogs, heroin, cocaine, and methamphetamines.

About a decade ago, in an effort to address the increase in opioid-related overdose deaths, government agencies at both the state and federal levels clamped down on prescription opioids in a misguided effort to tackle the crisis. The result? Numerous pain patients who were legitimate users of opioids were forced to stop taking these effective painkillers and left to fend for themselves. As a result, some of them turned to the black market, leading to far more overdose deaths.


Data from the Centers for Disease Control and Prevention depict a disheartening trend. Overdose deaths have been rising steadily since 1999. Although there was an encouraging decline in 2018, in 2019 a record number of deaths were recorded.

Patrick Skerrett / STAT Source: CDC Wonder/National Center for Health Statistics

Worse still, the Covid-19 pandemic has increased social isolation causing widespread mental health issues, especially anxiety and depression. Not surprisingly, this has led to an increase in illegal drug consumption. Indeed, preliminary data from the CDC indicate that 2020 will see a record number of overdose deaths.


Chronic pain can result from a multitude of conditions that cause severe neurologic symptoms leaving patients suffering and threatening their ability to function. This can lead to job loss, financial devastation, social isolation, chronic anxiety and depression, and suicide. In the U.S., approximately 50 million patients live with chronic pain caused by conditions such as injury, neck and back issues, multiple sclerosis, Parkinson’s disease, arthritis, autoimmune diseases, and more. Of these, 19.6 million live with what’s known as high-impact chronic pain, which affects their ability to work.

When I was the chief medical officer at the Department of Health and Human Services, I had the opportunity to chair the national Pain Management Best Practices Inter-Agency Task Force, a joint effort by HHS, the Department of Veterans Affairs, and the Department of Defense. The task force included pain experts, primary care doctors, surgeons, mental health experts, pharmacists, patients, veterans, and many others.

The seminal report from the task force, published in 2019, recommended a multimodal approach for patients in pain after an injury or operation, as well as for those with chronic pain and various underlying pain conditions. Recommended treatments include medications — non-opioid as well as opioid medications (while emphasizing safe opioid stewardship), interventional approaches, restorative therapies, behavioral health interventions, and complementary and integrative approaches. An underlying theme was that treatment must be individualized, and one size does not fit all.

The publication of best practices and the development of sound policies can ensure that health care providers have the knowledge and tools they need to help manage and provide treatment for those living daily with painful conditions.

But policymakers have lately been erecting roadblocks to treatment, such as prior authorization, that threaten some of these innovative approaches. If we do not act quickly to counter these actions, people who are already suffering from pain will suffer even more. By limiting access to these treatments, it affects their ability to perform activities of daily living including work, sleep, and other routines. Some will require additional medical care and hospital admissions, both of which will worsen their quality of life. Furthermore, these counterproductive actions will have a negative economic impact on our health care system, already severely strained by the pandemic.

Many pain specialists, including me, are concerned that recent announcements from the Centers for Medicare and Medicaid Services aimed at slowing the “overutilization” of safe and effective pain treatments will prevent Medicare patients from being able to access these non-pharmacologic treatments.

For example, CMS recently required prior authorization for therapies like Botox injections for people with chronic migraine who are being treated in outpatient settings. Even more concerning is CMS’s proposal to require prior authorization for neuromodulation treatments such as spinal cord stimulators in the outpatient setting. The effectiveness of neuromodulation — the electrical or pharmaceutical alteration of nerve activity — is backed by strong clinical evidence. It can reduce nerve-related pain and improve function among people with high impact chronic pain.

Prior authorization is a bureaucratic hurdle that delays access to safe and effective treatments for patients living with chronic pain, such as physical therapy, movement therapy, medications that help patients maintain functionality, and others. This is exactly what pain patients don’t need.

One of the many consequences of our nation’s response to Covid-19 has been the cancellation of nonessential procedures, which has limited access to non-Covid-19-related medical care. It has affected millions of Americans, and made matters worse for patients with painful debilitating conditions leading to worsening of pain, increased suffering, and poorer outcomes. Many of my patients who had been getting better have suffered severe setbacks. As recent data show, the improvement in the care of patients with Covid-19 has been countered by the negative impact of the pandemic on mental health, which has been caused by the unprecedented isolation that affected more than 310 million Americans at the height of lockdown restrictions.

Worse still, people who has been taking opioids safely for years to treat chronic pain continue to be subjected to forced tapering, meaning they are weaned off of opioids against their will, depriving them of a medication that can be lifesaving for those with complex neurological pain. Forced tapering can worsen medical conditions and some patients who legitimately and safely use opioids have been abandoned by their physicians. Add on the proposed CMS restrictions and we will inevitably see more suffering and more preventable deaths.

CMS must put a stop to this dangerous practice of limiting patient and provider access to therapies that they need and deserve.

Congress and several presidential administrations have made it clear that the health care community must use all of its resources to confront the opioid epidemic. To do so, clinicians need access to all of the safe and effective therapies that have been created by our nation’s innovators. Federal policies must not take us backward at this critical junction.

Instead, science and compassion are needed to address dueling public health crises: millions of people living with chronic pain and overdose deaths from the use of illicit drugs. This can be addressed by solutions that are right in front of us — if patients and their doctors can access them.

Vanila M. Singh is an anesthesiologist and pain management specialist at Stanford University School of Medicine, clinical associate professor of anesthesiology, pain, and peri-operative medicine at Stanford University, former chief medical officer at the Department of Health and Human Services Office of the Assistant Secretary of Health, and chair of the Pain Management Best Practices Inter-Agency Task Force.

  • What the chart doesn’t tell you is that the majority of the deaths are due to street drugs. Typically drugs laced with Fentanyl and Fentanyl in it’s multiple forms.

  • People who have never abused a prescription or have never used street drugs must stop being punished because of those that do. Opioids also decrase inflammation & without them people are becoming debilitated. Cancer patients, incl. terminal patients, are being denied pain meds. Suicides are escalating because people can’t take the pain. Causing horrific suffering in those with chronic pain will not stop one single addiction or overdose by those who insist on abusing drugs.

    • Well they don’t care if you or I are in pain. No meds without represrntations. Doctors are way to scared of Trump and the DEA. Majority of people in true pain don’t abuse the pain meds they WERE getting. The Hippocratic oath means nothing any more. Pathetic AND disgusting now. Wish we had help from someone with more power than what we have. For example, if Mrs Clinton is having issues with pain, I’m almost certain she would have no problem at all getting proper pain relief and politicians would say nothing about it. Sad state this country has become now. God help us please.

  • It has been shown time and again that underhanded and flawed “studies” were used to declare an “Opioid epidemic” so a certain group could benefit financially and politically from their findings. Add in the reluctance of our ‘representatives’ to acknowledge that problem, and that because of the forced tapering and downright denial of pain meds the suicide rate has skyrocketed (22 Veterans a day is shameful – and due to pain) when they should be passing laws protecting us innocent compliant pain patients rather than being afraid of looking like they aren’t doing something about the overdose problem. They would look better and get more votes if they did the right thing and went after the TRUE problem which is illegal drugs. There have been addiction issues since time began. We just happen to be easy pickings since we are unable to fight enmasse as other groups who’ve gotten changes made have been able to do. Picture having open heart surgery and getting 3 days of pain meds, or watching a loved one suffer through their end of life journey in agony because they ‘might get addicted’ if given the pain meds that would ease their passing and more people will understand that there are those who need pain meds to have a life, maybe even a productive one, and stop blaming us for the people who are continuing the problem by using ILLEGAL drugs. All we want is to feel like we are not being used as pawns in a game we want no part of, just to be treated as human beings with the right to live somewhat of a pain eased life, to think others aren’t blaming us for something we didn’t start not perpetuate, and could stop having our lives meddled with from our dr’s being terrified out of practice, to denial of needed meds (they wouldn’t do that to someone on insulin or heart meds), to having our med records being open to everyone and I do mean everyone, to predictor progs deciding you might become an addict so no meds, to pharmacists changing your scripts to being treated like dirt under others feet and I could go on. It just isn’t right or moral what is being allowed to happen to us.

  • I am one of the patients you portray in the article. For a decade or more I have suffered from two spinal fusions for hip replacements and neck problems that need pain medication. I was at a pain clinic for over 20 years. My doctors reacted to the governments warnings about over prescribing pain medication and I was cut off in weeks. I went through horrible withdrawals and my pain increased substantially.

  • This well written article needs action, not words. My “story” is absolutely in it. The CDC, etc. costs me big $$, friendships, and jobs. I am 79. I barely can care for my wife, but can not afford to have assistance. I had to go on disability in 1990 due to O/A in my hands & back. After reaching retirement age, I got work in areas that could accommodate my disability. I was taking opioids by prescription and anti anxiety and muscle relaxers plus access to individual psycho therapy using EMDR. I was diagnosed with PTSD from childhood abuse.
    All in all, the government has been an enemy with its one cure fixes all legislation.
    No wonder so much death from illegal usages of opioids & other “unlawful “ devices. Things need to change for us as today’s policies are highly discriminatory to legitimate patients that benefit from proven therapeutic applications involving any & all medically sound practices.

  • Dr. Singh this article along with the comments you make on twitter sound like everything pain pts need to hear and what needs to be demanded by the professional community. Unfortunately the “best practices” like CMS don’t allow for all modalities and resources because you know as well as I do the end game is to put anyone that has pain on Bupe. NHS along with a host of other underhanded, self aggrandizing “researchers” have studied pain pts against their will and without their knowledge and best practices summed up says put the patient through all the “other” modalities and if they still hurt put them on Bupe. Researchers fail to realize chronic pain patients have mostly already tried all the “options” before they sought out a Dr for pain medication and now the medical community is literally throwing Bupe at pain patients and addicts alike. Bupe is an addiction med and now there are pain patients willing to lie and say they are addicted when they aren’t so they can get some kind of relief even if they have to be labeled addict. Sadly Bupe has several issues that make it not optimal for pain pts and you know that too. What you need to be doing is demanding the government get the DEA out of medical practice and allow Drs to treat patients without fear and with use of the full formulary in this nation and without interference from CMS, HHS, DEA. I realize your move to Pacira was profitable but Buprenorphine and Exparel are not the blanket answers and pushing these products in place of other medications that have been widely available for years has done nothing but bring further harm. Here is one for you. A doctor attempted to do a hip replacement with a local which put the woman in ICU for days and all she was given for pain was Tylenol. This has become government sanctioned torture and while your article sounds very aware and caring all it really means is jumping through more hoops to eventually be told your only option is Bupe which is very good for you. When you were in the position to make real change for pts you did not. Now we so called “experts” raking in massive tax dollars for research only to turn around and tell people in excruciating pain to meditate and do goat yoga. Way to go Vanila

  • Hello, I’m a forgotten chronic pain patient due to unintended consequences of the 2016 CDC guidelines left suffering and I want to let anyone reading this article know that this is a very real situation. In March 2018 my neurologist of 13 years at the time force tapered me at home alone to a dosage so low it was completely ineffective and I was forced to stop all medications due to this. I was denied switching to anything else at all that might have worked and haven’t been able to see or work with my dr. since this. I never abused my medication, never diverted my medication and yet like so many others needlessly suffering now was forced to the point of no help now for the actions of others. Using legitimate legacy chronic pain patients to achieve the goal we all want to see achieved making us innocent casualties in the war on opioids is inhumane and will never achieve the goal at hand. Taking the little help one can offer people like myself, taking away someone in my situations ability to have a small quality of life and leaving us lying around suffering desperately searching “chronic pain” only to find very true reminder articles like this is also inhumane and simply doesn’t have to be this way but until the county wakes up and gets on the right track with the opioid crisis innocent pain patients like myself will continue to be demonized by those running the show.

    • @Sue….BUPE IS buphrenorphine a class 3 “narcotic” used to treat opioid addiction. The doctor has to be approved by DEA to prescribe this med as some people divert and abuse it also. It blocks the opioid from giving you the side effects like euphoria that pain meds give a lot of patients. If you take it while taking pains meds you will get sick…..much like an alcoholic that takes the drug called antebuse to help them cope with withdrawal symptoms. Hope this info helps you.

  • This is an interesting opinion piece on a subject for which I have great sympathy, but as with many of these articles published recently here there are plenty of anecdotal comments and a gross misuse of statistics. 50mm Americans with chronic pain is 1/6 of the US population including children. Given much chronic pain is experienced in adults that would suggest chronic pain afflicts much more than 25% of the adult population and further that that population requires medication for their pain with opioids. Further, it begs questions about the definition of chronic pain. Is it a multi year or multi day definition. Opioids are an important part of relief for chronic sufferers but plenty of bad data has infiltrated the science. Potential for addiction and it’s associated travails must be considered before proscribing these potentially helpful but still dangerous medications and doctors did themselves no favor handing them out like candy, regardless of what the distributors and manufacturers said.

    • If you would like to read about gross misuse of statistics I would highly suggest you do the research into the statistics that were used in order to come up with the guidelines that all drs are now forced to obey by in prescribing these potentially helpful but still dangerous medications that you better pray you may never need even if your dying from multiple cancers including urethral bladder prostate that has now spread to the bones and let’s not forget thyroid cancer then have your drs limit your pain relief to getting more rounds of radiation to help aid you for pain since one does not want you to suffer from addiction even though your 81 , & this is protocol from one of the highest cancer treatment hospitals that guidelines have now dictated they follow!!!!

  • It so great to hear that people are finally starting to talk about pain care with clear logical responses! People with painful diseases should not have to suffer because of what another person or group of people think about their medical treatment. People with painful diseases are adults that are able to make decisions for themselves regarding the benefits and risks of their medical treatment. Nobody should be subjected to intolerable suffering because of what those that don’t suffer this horrible disability think. Thank you for this. I hope to see many more medical and public articles like this.

    • Clearly you are not in medical field. This doctor is manages chronic pain pts and opioids are imp tool in the box . Other doctors were forced to prescribe ‘strong’ pain meds for a simple cut or dental pain in the guise of customer satisfaction. Bottom kind is There’s too meddling by people who have no clue but love to practice medicine without a license

  • Closing the loop on the absurd relationship between these two medical crises, many doctors are terrified of DEA action if they prescribe safe opiate cough remedies that have hundreds of years of proven safety and effectiveness. Some physicians have signed contracts with malpractice carriers, agreeing never to prescribe an opiate nor opioid, in exchange for a reduced malpractice premium. Conventional decongestants and dextromethorphan-based cough medicines, whether sold OTC or given at higher dosages by prescription, elevate the blood pressure. Italy’s experience in the first weeks of the COVID-19 Crisis clearly indicated that pre-existing hypertension was present in 85% of COVID-19 deaths, clearly making it medically unwise to attempt to treat a COVID-19 cough with a cough medicine that worsens hypertension. For many Americans this meant self-medicating for a COVID cough with the wrong medicine, making more difficult the task of keeping the airway open. For too many it meant hospitalization for the consequences of bad opioid policies leading to failure to prescribe the correct drug, and use of the wrong drug, to treat a COVID cough. The Kingdom of Sweden avoided these problems by never adopting US opiophobia seriously, even in the early 1900s when everyone from Harvard to the Ku Klux Klan had bad things to say about opiates. Sweden left opiate cough medicine on formulary and doctors prescribed it for COVID bronchitis. Apparently this resulted in lower rates of COVID pneumonia, because Sweden’s hospitals never became overcrowded, social distancing remained voluntary, and immunocompromised or frail individuals were advised to shelter from COVID exposure but healthy blood donors were allowed to catch the infection, recover, and donate plasma antibodies to help the immunocompromised and the frail.

    There will be another novel virus someday, that attacks our respiratory tracts and poses a challenge exactly like COVID-19. Will our country lock itself down in utter paranoia because we’re terrified to take safe cough medication, while we wait a year or more for a vaccine to be invented? Or will we learn from Sweden’s example, that opiophobia did during COVID, what homophobia did on a smaller scale, with AIDS. Fear interfered with rational decision making and harm reduction. San Francisco shut down the bath houses, permanently, as responsible members of it’s gay community took the responsibility to limit the spread of HIV infection by such harm reduction strategies as were available. Anti-gay outsiders who tried to use HIV fears to terrorize the gayness out of gay people, simply failed to do anything to stop the spread of AIDS. Anti-opioid outsiders, who are trying to terrorize the pain patient population into accepting permanent disability, are just as irrational as the anti-gay forces that obstructed sensible harm reduction strategies from. being employed to stop the spread of AIDS. The problem is that the anti-opioid outsiders have now created a medical disaster with improper treatment of COVID, and have crippled most of the population from being able to earn a living while we cower in basements and collect our own sneezes in surgical masks when out in public.

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