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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.

  • Thanks. I’m a retired construction laborer and survived a pancoast lung tumor. I know pain. I have a great pain management Dr. Many of my retired friends are suffering needlessly in a misguided war on opioids. Many turn to the alternative market.

  • Very good article, I told my Drs almost word for work of what you have written about and at the time 2-3 yrs ago our government had our drs so screwed up about the policys that they basically told there patient’s the their drs license was more important than a person’s pain and then just cut them off of meds they have been taking for yrs and let us suffer .

  • I want to thank you putting your voice out there. I truly appreciate it. My mother has suffered chronic pain for most of her life. She is one of those that is being forced to taper. Sadly, my very talented wood craftsman mother is bedridden and I feel she is being taken from me because of misplaced power.

  • I want to thank you with every once of me !!! Thank u thank u for bringing this crucial information to light , in today’s society where addiction is still looked with so much stigma and misinformation that if that if ur suffering with addiction you have no will power instead of looking at the science of addiction and how there brains are not wired correctly people are so quick to judge others and then in our chronic pain community we are loosing so many lives to suicide because we are also looked at like criminals and addicts that we get no compassion relief respect and we are treated so poorly and accused of horrendous acts just for trying to be treated for pain relief that we have science to prove our many debilitating diseases that cause such horrible pain and yet we are denied any type of relief we are judge harshly accused of faking our pain and then let’s talk about if your fortunate enough to get a dr to take you on as a patient and the tower of hoops we have to jump through to get the smallest increment of pain medication that drs are now being accused of over prescribing and then the dea is prosecuting these drs and shutting down there offices and abandoning patients and loosing their licenses so is it any wonder why drs are now not prescribing any type of pain relief even after surgeries where patients are loosing limbs and breast or worse and how is all of this not a human right violation, and please what about all of our wonderful military people that sacrificed their lives and privileges for our country only to be denied any type of pain relief, when will this nightmare be over ? When will suffering be seen heard or taken seriously?? Thank you for starting this conversation!!!

  • Refreshing to hear from someone who knows what they’re talking about . I’ve been on methadone low dose for years . Very strict pain doctor . Never a problem . I tapered myself knowing of this insane , inaccurate report that was coming out . I felt like I should not acknowledge pain . Get over it !! You’re a druggie . You’ll kill yourself . You can’t be trusted . You’re a liar . Don’t call me if you’re in pain . My hands are tied . Right now I’ll stay at home and die because I refuse to go to ER and put up with that insanity, hours of being treated by robots , not humans . Denying treatment really . Treat everyone the same . You are just here for drugs the government tells me . Anyway I know you’ll become addicted and die .
    I believe this is criminal!!!
    Quality of life ? Ha !!! Who cares ?
    It is what it is . I don’t know who should be responsible for changing this ? But it needs to change !
    If you want to punish someone, punish China for the fentanyl.
    Chronic pain patients don’t like to complain and draw attention to themselves. It’s silence.
    More physicians need to speak out and change these crazy laws with the DEA .

    • Yes as I lay here this moment I’m in so much pain I’ve been on opioid since 2002. Went to a new doctor today he prescribed something has no pain medication in it at all feel all my pain none stop legs hip and back is burning. So I will keep looking until I find a doctor who gives real pain medication Sharp pain shooting my lower back. I believe government trying send us to the crazy house or overdosing.

  • Since Biden has left some small comment about reversing a lot of Trump policies, I was really praying that he would reverse his policy on this so called opioid crisis and allow QUALIFIED patients to resume getting pain meds from legitimate doctors. Please Joe rescue us from the BS policy of a opioid pandemic.

  • Iam in constant pain from being a guinea pig for harrington rod in the 60’s. Iam glad to have helped but now denied any pain relief after over 50 yrs of getting some. I understand that there is a drug problem in U.S. but dont take it out on the elderly and cancer patient who need pain relief. Times I wish someone would cut my legs off they hurt so bad. If you think anyone wants to be living a life where you can’t make plans or have a life because you don’t know if you will be pain free to move that day. 80% of your day looking for pain relief. Now they moved medicine to Tier 4 and the cost sky rocketed, and insurance won’t cover. When seniors have no money now. Don’t penalize us!!

  • You people have NO Idea how we suffer hourly in pain!! Why don’t you do something about the millions of people dying from cigarettes and those who die from COPD who NEVER SMOKE!! You are so greedy getting your dirty money from kick backs you don’t address the facts that underage kids are smoking. Living with chronic pain is beyond words, yet you have the “AUDACITY” to put conditions on are medications, let me see you put limits on our PAIN!! NO ONE enjoys being in pain, I for DON’T!! I have days my pain is so bad I just want to remove my skin.. I am sure YOU & YOUR FAMILY ARE NOT REFUSED PAIN MEDICATIONS! No just us poor individuals who have No Representation or compassion dealing with people like myself! You NEVER need to decide pain medications or food or rent DO YOU?? Want to know why some people commit suicide, PAIN!!! you get tried of living with the pain, and the “No Compassion, No Caring who have No HEARTED Politician that has never Wanted for Anything! Try going for shoes all day then maybe you

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