The FDA’s new restrictions on hydrocodone are unlikely to solve any problem.

America consumes 80% of the world opioid supply (99% of the world hydrocodone supply), but has about 5% of the world’s population. If you don’t think America has some kind of opioid problem, then move along because this rational, evidence-based, experience-laden way in which I’m going to discuss opioid use and misuse will not interest you.

To combat our opioidification the Food and Drug Administration has recommended prescribing restrictions on hydrocodone (remember, we consume 99% of the global hydrocodone supply). These obstacles do not appear derived from evidence-based guidelines and probably won’t do much to reduce the vast majority of inappropriate prescribing, although they may slightly curtail physicians that run pill mills and may also help with diversion (lying to get opioids to sell them on the street).

But I want you to consider these following pain scenarios, because this is how the majority of opioids are prescribed in the United States. In each scenario there is a patient with chronic low back pain who started taking a Norco (acetaminophen and hydrocodone) every day or two for her pain, but now four years later is taking 8 Norco a day.

  • Patient A was never referred to physical therapy, never prescribed an adjuvant medication for chronic pain (adjuvant medications treat the way chronic pain is produced in the nervous system), never given a graduated exercise program, never had her anxiety or depression discussed never mind treated, and never given the option of a long-acting opioid. In short, she was only ever offered one therapy, the wrong one. Over time, her pain worsened (a natural consequence of untreated depression, anxiety, and immobility) and she needed more Norco a day.
  • Patient B was offered all the above therapies and they were well-covered by her insurance, but she found reasons to cancel physical therapy at the last minute, was intolerant of every medication except the Norco, and refused to speak with a pain psychologist despite being profoundly depressed (PHQ-9 of 24) and suffering from an anxiety disorder. Over time her pain worsened and she needed more Norco a day.
  • Patient C wants to go to physical therapy, but the co-pay is $80 so even twice a month isn’t possible (a month of Norco costs $5). She is dutifully doing her home exercises, but often does too much and pays for it in pain the next day because learning pacing from a pain psychologist isn’t a covered benefit. She is open to addressing her depression and anxiety, but don’t have mental health coverage. She tried nortriptyline (the only truly low-cost adjuvant medication for chronic pain, $4 a month via WalMart), but it was ineffective. Generic gabapentin, the next generic that is offered (because brand name drugs are prohibitively expensive under her health plan) is $1 a pill and that will be about $180 a month. She would love to do Tai-Chi or restorative Yoga to get moving, but can’t afford it. Over time her pain worsened and she now needs 8 Norco a day.
  • Patient D had an MRI when she complained of back pain. A bulged disc was identified. After 2 epidurals that didn’t work (no PT or other multidisciplinary approach was offered), she had back surgery. When, after a brief 4 month post surgery respite, the pain worsened she had more epidurals and another surgery with a multi level fusion. And then another one. Over time her pain worsened (she now has failed back syndrome) and she takes 8 Norco a day

Despite the fact that opioid monotherapy is sub-optimal care, it happens all the time. I’m not sure how the FDA restrictions will help a doctor, who has less than 15 minutes and may not fully understand the multidisciplinary approach required to address chronic pain, delve into anxiety, depression, physical therapy, cognitive behavioral therapy, weight loss, pacing, adjuvant medications, nerve blocks, dietary modifications, and the appropriate use of opioids (just to name a few therapies).

Non compliance is a challenge in all aspects of medicine, and chronic pain is no different. However, the availability of opioids as a potential therapy certainly confuses things. A beta-blocker for high blood pressure has no component of secondary gain. How do we approach non compliance in chronic pain when opioids are on the table? We know that exercise and physical therapy reduces both pain and work disability for many patients with back pain and are the standard of care, but what if a patient is less than compliant with physical therapy or flat-out refuses yet shows up on time for her opioid prescriptions? Non compliance isn’t limited to physical therapy or exercise either. How will the FDA restrictions guide clinicians in these scenarios?

In almost every single health plan in the United States it is easier to get an MRI and back surgery than it is to get physical therapy. FDA restrictions will not solve this problem.

In the United States there is a reluctance to accept that the mind-body connection is a huge part of the pain equation. The neurochemical changes of depression and anxiety increase pain, because the same chemicals released by an anxious or depressed nervous system are the very same chemicals that produce pain. Basically, depression and anxiety fuel the fire of pain. How will the FDA regulations fix this mind-body disconnect (among both patients and providers ), solve mental health parity, and break down the stigma of mental health?

What if the patient actually has access to and wants to go to a cognitive behavioral therapy program, but she works two jobs and can’t afford to take the time off to go? After all, most of these programs are offered during the day. How will the FDA restrictions help in this scenario?

There are only a few generics for the medications that can actually treat chronic pain, so most of these drugs are very expensive. Many opioids are as cheap as M & Ms. A few extra hoops for hydrocodone won’t solve this issue.

Some docs have admitted to essentially giving Vicodin goody bags to improve Press Ganey scores. Yes, you read that correctly. Check out that link at the peril of your sanity. There is a push to give the patient what they want, which may not always be the standard of care. And yes, many people want opioids. How will the FDA restrictions put the brakes on this trend?

And finally, we practice medicine in a world where some chronic pain conditions respond suboptimally to evidence-based therapies and appropriate, responsible opioid prescribing may be a necessary component.

I practice in chronic pain Nirvana. Everyone of my patients has access to skilled physical therapy, adjuvant medications, a pain psychologist, and a psychiatrist, although rising co-payments are eroding away at the way people can practically access these services. We have intensive cognitive behavioral therapy programs designed to get the immobile moving (immobility is the nemesis of chronic pain, a self-fulfilling prophecy). We even have Tai Chi and Feldenkrais. And yet, sometimes even when we harness all these treatments we still need opioids (although almost always we are able to lower the dose). And sometimes, patients decline all these therapies and only want opioids.

Proposing restrictions helps us think about opioid misuse and abuse, which is good. New York City’s decision to limit opioids prescriptions from the emergency room to a three-day supply is a more thoughtful approach, although not perfect. Chronic pain shouldn’t be managed in the emergency department, although what happens to the patient without insurance who goes to the emergency room for her pain because she knows she won’t be turned away? Should this patient be treated differently than the patient who is going to the emergency room to get Dilaudid (hydromorphone) hoping that her doctor, with whom she has a pain contract, won’t find out?

Requiring a new written prescription for hydrocodone every 30 days probably won’t change too much. Some doctors, to avoid the hassle, might refer a little sooner to pain programs (which will be good, if such a program is available) or to a surgeon (in general less good for chronic pain, but always available). Some doctors may refuse to start opioids (good for some patients and bad for others), but many doctors will probably just leave written prescriptions with their receptionists for their patients to pick up. In summary, the American problem with opioids and chronic pain will remain unchanged.

Join the Conversation


  1. Just wanted to let you up here in Calgary I follow your blog. Love that you take the time to educate anyone that is interested in learning what is really going on. You make so much sense. Please keep it up I am sure there are many others that read your work.

  2. I have chronic pain/sciatica from a herniated disk. I suffered horribly for 9 months. I was told to take NSAIDS, (horrible for the liver), which gave me an ulcer, went to PT, used ice, heat and TENS. It was sheer agony that made it difficult to sleep, commute to work and work because I couldn’t sit. Trying to use the toilet, get dressed or retrieve things from the ground only increased the pain. Finally the insurance company authorized me to go to a pain mgmt specialist and counseling. We continued trying different things like TCA’s and Cymbalta. The problem is that they left me so foggy all day that I couldn’t function at work. As a hospital RN, I need to use critical thinking skills and as a single parent, I need to work. The MD finally tried giving me oxycodone and it has made an amazing difference. Taken at home and continuing the PT, ice, heat, exercise and counseling has saved my life.

  3. Your analysis of many back pain problems is direct and appropriate. From the point of view of a back patient, I can echo your assertion that it’s sometimes very complicated. There are also doctors and insurance companies relying on statistics (like “90% of back pain will resolve itself with or without intervention within 1 year”) to limit medical costs. I believe that those statistics are wrong in many cases like, when a patient doesn’t receive meaningful help for back pain, they often quit going to the doctor and the doctor chalks it up to not needing any help. The statistics are also wrong for people with back pain that need more aggressive intervention. In my case, I wasn’t given time off work or other intervention and, instead of healing, became permanently disabled. We need more analysis of the problems and solutions and insistence on medical insurance compliance with identified best practices.

    1. That’s what happened to me, but the attitude of the medical professionals toward the complaint of ‘pain’ is a problem in and of itself.

      I went to the doctor every few months of complaints of severe back pain. Over and over, it was the same story. “Muscle spasms”. I was given prescription ibuprofen and sometimes a muscle relaxant.

      I spent over ten thousands dollars on chiropractors and massage over the years and gave up on doctors for that particular issue. Oh, I’d bring it up, but nobody was interested in checking into it.

      A case of bronchitis was severe enough to warrant an x-ray to check for pneumonia.

      The doctor ‘freaked out’ when he saw my spine. He called me and told me to come in immediately.

      I had five compression fractures – three severe – and four completely destroyed discs. He said that this was the kind of injury that he’d only seen in people who’d taken severe falls or had hang-gliding accidents. I told him that it probably happened from a fall that I’d taken (30 feet – landed in a sitting position) when I was young.

      He didn’t know how I was still walking and functioning.

      I asked him, “Why are you only looking into this now? You’ve been my doctor for five years.”

      He said, “You complained of back pain. I assumed you were a drug seeker.”

      The horror of that moment, of knowing that I’d suffered for two decades without help because the medical profession assumed that back pain=drug seeker… Oh, you have no idea how… insulted, frustrated, angry, disgusted… Nobody would even LOOK at my spine because of that assumption. I’d never done a drug in my LIFE.

      That day led to a three year saga of steroids, anti-depressants, pain meds, physical therapy, hell and, eventually, to a 12-level spinal fusion.

      Now I’m totally disabled and in unrelenting chronic pain.

      My life is, effectively, over. All I do is ‘endure’.

  4. Never, ever has limiting supply of drugs of abuse done anything to stem drug abuse. Generally, it just causes an increase in the use of more dangerous and impure compounds to take their place (like methanol for ethanol during prohibition). It will however lead to treating pain patients who are not at all prone to drug abuse like potential criminals. It will also lead to increased prescribing of expensive patent medications like buprenorphine/ntx and tramadol that have their own problems- pharma will like that as hydrocodone is inexpensive and does not make them money any more. This legislation is simple minded pap spearheaded by the DEA (using lots of resources and doing nothing to really get at drug abuse issues) and entertained by folks who think you can wipe out drug abuse by passing laws. You can not wipe out drug abuse and addiction by passing increased laws anymore than you can wipe out old age or cancer by passing laws. Give someone alcohol, cigarettes, or naproxen or ibuprofen at moderate dosages for ten years and you will cause much more damage than by giving them hydrocodone or related narcotics in a similar manner. These people making this recommendation have watched too many episodes of HOUSE. Hydrocodone is prescribed a lot because it is safe and effective when used responsibly and carries less restrictions than other effective narcotic medication. Yes, there are a lot of problems with only using them for pain relief and not using the full arsenal of pain control techniques. But for many older patients of mine they are God’s own medicine, allowing mobility and useful life styles and avoiding costly and dangerous surgeries. I have a 90 year old patient who takes 2-3 Vicodin daily for pain in his knees who is active and still does his own shopping- and is healthy and as sharp as a tack. Making his life harder with these rules will not reduce drug abuse. Moreover, those that are playing the system will not be deterred by red tape- they will work a little harder to get the pills and then get more money for them when they sell them. That is the way of the black market. Again, this is not to say that there are patients who are at danger when getting narcotics due to medical co-morbidities like untreated sleep apnea who die due to poor medical care or their own poor health habits. But increasing red tape will not prevent that either. Educate the public and providers about better pain treatment and the risks of all the treatment options and their alternatives is a better way to go. But it looks a lot more cool for the FDA and DEA to add more restrictions- plus they do not have to do anything real or hard to improve the treatment of pain. And a balanced article would mention how on the biggest cause of increased morbidity in health care to this day is poorly treated pain.

    1. you are so very correct in all that you say. i am a chronic pain patient with no insurance, so i have to go to the free clinic, and they cant prescribe narcotics here in va, so i get ultram 50. when i did have insurance and was working, i went to a dr. she had me on four hydrocone 10/500 a day. so i lost my job because i couldnt do the work and was missing days and i was the manager of a store, so it was vital for me to be there. i was very honest with the free clinic when i went there and they told me that if i wanted to stay on hydrocone, i would still have to go to the primary care physician every four months but they could treat my other problems. so when i went to primary care dr. and gave her a list of the meds i was taking from the clinic, i was very honest with her also. but she didnt pay much attention to me cause i got five minutes maybe less every four months. then she had me sign a opioid contract. i did this for three years. then she said i needed to take a drug test and asked me what narcotics i was taking, i told her only one that was her prescription, then she ask me what else meds i was taking. i told her i had gave her nurse the list from the free clinic. she then wrote them down again. i took the test thinking i had no reason to not pass it. it came back with the codiene and ultram. four months and three prescriptions later, went to regular appt, she said tramadol is a narcotic. i said i dont think so it is a controlled med but not narcotic. because the free clinic was not allowed to write narcotics. she then gave me another drug test. those were at my expense at 350.00 a test. it came back same thing. she continued seven more months then all of a sudden she said i cant give you your prescription today, i have to do a med check. then she called and had me bring the tramadol script in so she could see it. so i did. she sent her nurse out a hour later into the waiting room and she told me in front of all these people that dr couldnt see me no more, she was not going to be my dr anymore because she felt i was a deceptive person. i ask if i could talk to her and the nurse said no, she is not your dr. you will have to continue somewhere else and we will send your records. i was so embarrassed to be told this in front of all these people looking at me. the nurse was talking to me and backing up at the same time, prob because maybe some patient they also did this to did not take that news so well. i just up and left, no need to argue. if she was going to be like that, then i didnt need a dr who could do that to you. she wrote on my record narcotic dependence. i feel like this should not have been put on my record. i had worked fourteen hours a day six days a week when i first came to her, i was 143 pounds an depressed and scared. but with the correction of the pain, i began to look and feel better and gained weight. that last time i saw her she had commented on how well i looked so healthy but that i needed to lose my weight. she had filled out a functional reprort for ssdi a couple of months before saying i could not work, and there at the door for the last time, she ask are you going to be back at work now? ?????? i look healthy but am obese. i was a product of her medication and i was looking good and healthy, except for my wieght. so therefore i dont think if i was dependent on narcotices i wouldnt be looking too good. if anyone has any advice on this i would love to hear it. also the ones that dont need it and get it to sell and make money, they get it and the ones that need it cannot, so the ones that cant get meds they need, they go buy it from the ones who dont need it. that is what should be stopped. i have knowledge of a lot of people and know they dont need it, they just get it to make extra money and it makes me mad that the dr that dumped me is supplying them with no problem. i dont guess there is nothing i can do. i am too embarrassed to take my records to another dr. i just cant do it. how would i explain this. they may not beleive me if i told them the truth. and i will not lie. not even if i get no help at all, anyways these government people who walk around with no pain at all, hats off to you, but your turn may come round, and then you will have to deal like the rest of us, and deal with the fact they are your rules. they should put dr up there to make decisons who actually have chromic pain, someone who understands and precieves correctly. i hope everyone is doing good. thanks for reading my post.

      1. I understand completely, I saw a pain Dr. Who started me on two a day. He didn’t really care, lookin back now, I thought he did. But as I was going worse in pain and asked for MRI. As I had already had shots,mepidural from him also. But he set me up, told me if I need more there were places I could go. I looked a him and said that wrong. It when I was in too much pain, I went for a consult. Y doin this he said I broke our contract, which was not true I never signed it. It was something he had made up after I sarted seeing him. As he could not produce where I signed one. But I think this past summer man pain Dr.s tried to get rid of patients they profiled into dependant. Because of new laws coming out. He actually left the room and said I don’t need any meds. Ha, I was in shock, as I knew my pain was getting worse for some reason.
        I decided to go to a neuro surgeon, I needed surgery right away, I had three blown discs, and the worse part two bone spurs were growing in the opposite direction and pulling my sciatic nerve like a rubber band. If I would not of had the surgery in about a year it would have snapped my sciatic nerve and I would be in a wheelchair. So much for a pain medicine Dr. They are drug dealers, that jus get you hooked, and then let you fend for your self, if he thought I was just dependant why didn’t he offer a rehab place.
        Unfortunately, after the surgery, I had to see a wound care, and they got strep B in my blood and I went septic, now that is pain, you can’t walk, and your bones are never the same, so as I am better from the surgery. I have hip pain from the sepsis. And slightly loss of feeling in left leg, from the nerve being messed with in surgery. And now the new rules. Wow had to go to four different pharmacies. Because they say, the company is not delivering the medication. Why, bc now people like the ones selling it. Can get like 1500 at once now. Which leaves them empty for the people with real problems. dEA needs to get their act together. There was a shooting at a pharmacy today. They say it was from a couple.mi bet it was more, of a patient getting told no we don’t have that medicine. I mean fine they changed the rules. I told my Dr. Fine lower me to codeine. He said no, you can’t do that until your total healed. I had open wound from surgery. And if I’m in pain he said it would slow m healing. So chane the rules. But wh are they NOT sending the medicine to the pharmacies. If I had to go off today, my BP would go sky high, and I would have a stroke. So they are not helping at all. They make decisions by statistics. Well they should talk to real people in pain. And how well this medicine helps ou function and be a human being. Without it. I hae no life, I already hae a bad walk. Without medicine, I am in bed. Squirmin in pain, or trying to e so still to not hurt. Our society has created us. Too much sports in younger years, that other countries don’t push. Girls jogging ruining knees, football players in pain forever jus for the money. The change has to start way back. With simple times, and no Victoria Secret magazines, so girls don’t kill themselves tryin to be skinny. It’s going to get worse before they realize this new law is a mistake. How many people are going to die, from not being able to get the medicine they have taken for years. The Stars tha they started all this, we’re on hydrocodone,mouth they were also mis usin it. And taking meth, pot, heroine. But they don’t focus on that. Why are they on all that. For plastic surgery. Or jus screwed up from Hollywood rules. DEA talk to real people who need the medicine to live. There was more control before than now. Admit you screwed up!! For me, and a lot of others sake.

  5. Thank you for this thought-provoking post Dr. Gunter! This fact is one that is completely unacceptable:

    “In almost every single health plan in the United States it is easier to get an MRI and back surgery than it is to get physical therapy. FDA restrictions will not solve this problem.”

    Stephanie Prendergast
    International Pelvic Pain Society

  6. A little clarification- I do find this article to be balanced and thoughtful. I would like to add that I am responding more to the deluge of articles talking about how the changing of hydrocodone products from CIII to CII will solve the problem of drug abuse or poorly treated pain. And tramadol, while it has become less costly in the last few years, has many dangerous drug interactions, is addicting itself, and works poorly- but due to its new found cheapness and perceived safety is becoming the new panacea of chronic pain. In five years after the increased hydrocodone restrictions they will be talking about how tramadol is being abused, is over prescribed, and causing all sorts of health problems. I am sure they will pass a law restricting it as the solution to these many problems.

  7. Jen, I’m a former family doctor, tutor in palliative medicine and recovering morphine addict, so I guess I’ve looked at clouds from both sides now. When I was a tutor in Ireland in the mid-90s, my definite impression was that opiates were being under-used due to the stigma attached. So your blog is a big surprise to me. One thing I used to emphasis was keeping the pharmacological options simple, the 3-step approach; paracetamol, then codiene, then morphine. The advantages of analogues like buprenorpine and tramadol were minimal. Why is hydrocodone used rather than morphine?

    1. If morphine was available combined with APAP, I suspect it would be used similarly to hydrocodone/APAP if it were a schedule III drug. But of course morphine is more toxic than hydrocodone due to the M6G metabolite. I don;t believe that tramadol has any particular advanatge unless one is especially trying to blunt the opioid affect, as the receptor binding of tramadol is 6000x less that of morphine (similar to dextromethorphan). Burprenorphine on the other hand is a whole different animal in that it is 95% mu-1 specific has only partial agonist activity and also antagonist activity with a plateau on efficacy as an analgesic. You folks may also want to see and

  8. This is a wonderful, thoughtful article, Dr. Gunter. I’m a family nurse practitioner, with 15 years previous experience as a hospital RN, 4 of which were med-surg. My co-workers used to comment on how much pain medication I would give in the immediate post-op period, but I also got my patients up and walking and moving around – adequate pain medication in that first 24 hours decreased their need for pain medication after that. Now. as an FNP, I see patients for pain probably more often than any other single problem, except possible URI’s during this time of year. Just as we have to educate people that they really don’t need a Z-pack, or any other antibiotic, for the vast majority of URI’s, and we have to educate them how to manage those symptoms, we have to educate people on the multi-faceted nature of appropriate pain management. I do prescribe narcotics, but never as monotherapy, and I do require patient contact for their refills – no automatic refills, no more than one month at a time, and any acceleration in a refill request means they need to come in and see me immediately to discuss what’s going on.

    I see a fair amount of drug abuse and diversion, everything from the drug screen that came back negative for oxycodone but positive for cocaine, to the son stealing his father’s MS Contin (the father was in hospice for prostate cancer, and there is a special level of hell for that young man), to the mother who “shopped” her developmentally delayed son around to every urgent care in town to get Vicodin, to the man who ate his Fentanyl patch (that did not end well); but I do not see how this regulation will fix these problems. Patients will ask prescribers to write for TID instead of QDay so they don’t have to keep running back and forth asking for written prescriptions, and prescribers who are compassionate to this additional roadblock (such as J Sheridan’s 90 year old with arthritic knees), or over-burdened with frequent refill requests, will do so. So now, patients will have 90 or 120 VIcodin sitting in a bottle in their cabinet, or in their purse (and it’s amazing how purses are stolen so often when there’s a bottle of Vicodin or Percocet or Adderall in it!)

  9. There really does need to be a better control of narcotic prescriptions such as this one. Not only for patients, but prescribers, too. When I was in the hospital after my c section, the staff got me addicted to oxycodone before I was discharged. When I had to go to the emergency room for withdrawals, I had the choice of more oxycodone or methadone or the likes.. But I had only had a c section a week prior, so I still needed pain mess to deal with the pain. Every time I have gone to the drs about my pelvic pain or my nerve pain, they have just handed me a script for oxycodone or some other narcotic.. It’s disgusting. Why take the time to get to know your patient and figure out what’s wrong when you can just throw a prescription at them??

    1. I only have 1 kidney, so I had medication restrictions. Instead of giving me Percocet and offsetting it with ibuprofen, they offset it with more oxycodone. When they tried to stretch the time between doses, I would get violent shakes, pain, and have a panic attack, so they would just give me a shot of anxiety medication and more perks or oxycodone. When I went to the emergency room, They were just going to give me more Percocet. Which is RIDICULOUS since I couldn’t take anything but MORE Percocet if I was in pain. I had to be the one to suggest that they give me straight oxycodone so I could take more Tylenol than oxycodone. Any time I would go to the emergency room for pain in the future, even though I would TELL them about this, I would still get written a prescription for oxycodone. And I would STILL get violent shakes 4 hours after taking the medication. I find it to be ridiculous.

  10. I find that threatening to drink an entire bottle of alcohol in one sitting when being denied appropriate pain relief reminds the physician that the MDs do not have a monopoly on pain-alleviating substances.

    I suffered from retained objects after surgery, and carried them around in my belly for over a year before the problem was finally addressed with a second surgery. It’s very hard to cope psychologically when the ED dept. staff labels the patient as a frequent-flying hypochondriac before trying to address the anatomical issues first. I am all better now, except for a few lingering digestive issues, and thank my lucky stars for the surgeon who took the surgical clips out.

  11. Here is a comment left on my blog ( about addictions.. which I found exceptional.. BTW.. I don’t think that opiates are addictive… some people have additive personalities and opiates seems to bring those out
    Any substance or activity that has a short term feeling of euphoria/fullfilment by the user can have a tendency towards causing full fledged addiction. There are the common ones we are taught to identify such as nicotine, alcohol, opiates, benzodiazepines (particularly short acting ones, ie Xanax), other sedatives, methamphetamine, cocaine , etc. As easily as a person can be addicted to a substance, they can also be addicted to an activity that brings them pleasure. There are shopaholics, workaholics, chronic masturbators, sex addicts, greed addicts, power addicts, internet addicts, food addicts, etc. The difference is not in the underlying causal mechanism, which I liken to being primarily in a state of unhappiness or dissatisfaction with your current state of being and wanting to escape; but instead it is defined as addiction based on society’s belief structure. To illustrate this point lets loosely define addiction as an act/substance which the addict compulsively engages in to the exclusion of other normal activities even though the addict is aware that their relationship with the act/substance is causing physical/emotional/mental harm to himself or others and they have an unwillingness or inability to stop. So lets say Steve is addicted to methamphetamine. Steve will eventually get caught using by the authorities and get sent to treatment (or god forbid prison), or overdose and die. On the other hand Tom is addicted to work and power, he works day and night for the corporation to the exclusion of everything else in his life. Tom eventually becomes CEO of the corporation and impresses his addiction upon his employees expecting total obiediance of his underlings to maximize profits even though his actions and expectations are destroying personal relationships, harming the environment, destroying mental/physical health of his employees, etc. the difference between Steve and Tom is that society acknowledges Steve’s addiction while denying that Tom has any problem at all. In fact it is likely that Tom will be given several rewards, huge compensation, and praise from most people even as he systematically destroys his life and his workers lives through his addiction. Addiction is a MENTAL state of being compounded by a physical craving for a substance. Modern medicine focuses almost exclusively on the physical aspects of addiction while focusing solely on abstinence as the only form of mental treatment. Well it’s no wonder why almost all addicts “use” again! The causal mechanism of unhappiness, unfulfillment, dissatisfaction and disequalibrium have not been addressed! What I believe we need to address is either:
    1) Acknowledging the blocked/negative emotions, feelings, and diet of the addict that have lead to the disequalibrium and tendency toward addiction.


    2) Provide/teach another healthy activity (like yoga, meditation, etc.) that causes more long lasting fulfillment or joy than the destructive relationship with the act or substance so the addict chooses the less destructive activity by default.

    In conclusion, no substance or activity in itself is “addictive” to everybody. It depends upon how your brain is wired and the state of your mental/emotional well being. Also we need to broaden our scope of what we call addiction. I would think that most people have an addictive relationship with at least 1 activity or substance. Treatment should not focus solely on abstinence but should include psychotherapy to identify and come to terms with the negative thoughts/emotions that promote addiction. Also addicts should be given the tools to find a new pursuit that brings them even greater pleasure/joy!
    Thanks for reading
    Young Gun

    1. Wow thank you so much. I humbley request the knowledge addiction and having the surroundings of all things positive!

  12. I so appreciate your comments! From those of us on the dispensing side….We are constantly at a crossroads, having to make split second decisions between legitimate and abuse. We never want to deny anyone with appropriate pain relief… but how many rx’s for #180, 240, 360 oxycodone 30mg tablets can we see in one day? There needs to be better communication between the physicians and pharmacists, we get no advice or help from the BOP or management. So to all those in need of pain medication, this is my best advice. Establish a relationship with your pharmacist, let them know your diagnosis. DO NOT go to multiple pharmacies, do not get your pain meds at one pharmacy and all other meds at another. Do Not lie to us for any reason, believe me We have heard it all! Take your medication at the prescribed dosage. I do not care if your dog ate it, it fell down the toilet/sink. your boyfriend stole it, you left it on the plane. If you are a legitimate pain medication patient, beleive me that we will do all we can to make sure that we help you, if not… get the hell out of my pharmacy!

  13. As much as restricting certain ways opioid analgesics are prescribed might sound good to some physicians, I think they are missing a huge piece of the pain management puzzle. First of all, being treated like a drug fiend each time I see a doctor is not only degrading, but it exacerbates my already high levels of pain. I have a combination of autoimmune and neurological disorders, and believe me, the pain is constant and can be absolutely excruciating at times. I have done years of PT, chiropractic treatment, acupuncture, diet/exercise, and various other types of medications and supplements, counseling, and psychiatric care. I have had very little success in managing the pain. I can manage day-to-day, but for those times where the pain is extreme, opioid analgesics are really the only thing that helps. And I have had a hell of a time getting a prescription for them. The pain management doctor I saw required regular drug tests, pill counts, etc., and did not listen to any of my concerns. I was told that if I were a 60 year old patient, and not a 30 year old one, he would have no problem giving me “any drug I wanted.” I do not have a history of drug abuse, and I don’t feel that I should have to be subjected to any of this bs to ease my pain. What many doctors don’t realize, however, is that by consistently denying effective pain treatment to patients, they can actually drive them into seeking relief in other, less legitimate ways. People do become desperate when the pain is bad enough. When patients are denied, again and again, medication for their pain, some of them reach out to the very people these restrictions are meant to guard against: the drug dealers/abusers. I have regular contact with other chronic pain patients, and we’ve all had our own stories, or have had stories shared with us, about desperation driving patients to buy drugs like Norco or Oxycontin on the street. And when these drugs are bought that way, and not under the supervision of a caring and competent physician, they can lead to other extreme measures. I’ve come across patients who began habitually using heroin because they had no access to legitimate pain relief (and at times it was less costly than buying a supply of pills). I know it might sound extreme to some people, but it happens a lot more than people realize. Guarding against drug abuse can actually backfire quite a bit, and push people who would have never considered it before, into illegal and dangerous activity. Doctors need to think a little more about protecting the well-being of the patient beyond simply thinking that they “might” have potential to abuse painkillers.

    1. You are amazing. I felt because I was so young that I was called a drug seeker. Also I have sever menstrual cycles and a doc Actually said I’m not giving you opioids for a period. Geez if only he were a woman. Finally I got an MRI and eventhough I am young I have a hereditary disease, degenerative disc disease, early arthritis, and bulging disc. My boyfriend thought it was all in my mind as well as my doctors. I kept on trucking though! Only bad part is I am a new mother of twins and moving. I’m doing PT starting soon, and I was wondering do you know of any other pain relievers? Thank you for listening.

  14. Why are all the patients referred to as she .
    I was dismissed by my pcp’s pain clinic because I refused injections and don’t have cancer .
    This was after pt surgery and I was already seeing a therapist and psychiatrist for anxiety and depression
    So my pcp tried to treat my pain the best he knew how (i guess ) wasn’t good enough for me . So I went to a privately owned pain clinic . Now with injections and opiates I am back to doing the things I love

  15. Why do I have to wait one day before my prescription refill when I have been on pain medications for 20 yrs? Is it the pharmacist’s decision? Or the government or the Doctor?? What if there is a storm or hurricane? Then I go into detox. I can’t seem to get a straight answer.

  16. People that have never suffered from back pain with sciatica don’t have a clue as to what pain is.
    I have been taking Norco for ten years now. I never know when the Sciatic nerve is going to be hit.
    I am in constant pain to a more or lesser degree everyday and live with it.
    I have had approx. thirty epidurals over these past ten years.
    They work for me to large degree.
    However,when the Sciatica flares up I can’t walk,sleep,go to the bathroom unless I’m crawling on my hands and knees. I have considered suicide.
    I am sixty seven years old. NEVER has the drug interfered with my life. I don’t abuse it and I take 100 Mgs a day.
    I have a blood workup every six months. My liver is fine.
    Everyone metabolizes drugs differently. I take two 10 Mg tablets every four hours.
    I DO NOT GET HIGH ! Hydrocodone does NOTHING when you are dealing with Sciatica. The pain is so severe.
    The fact that so many idiots are using opiates to get high is the problem.
    What is going to happen to people that need pain relief ?
    You won,t be able to take care of yourself and as with any chronic disease,you will be at a loss. If the FDA does what they are implying,your going to see a spike in suicides from people with chronic pain.
    It was about three years ago when I had a terrible bout of sciatica. I could not get in to see the doctor or have an epidural for six weeks. I had the rope out and was ready to hang myself. The pain had ruined my life. Norco is not a strong analgesic by any any stretch. I finally found someone to take me to the Emergency room and they gave me a shot of Dilaudid and a Fentinal patch. It did wonders for about three days,then the pain was back.
    The point being. Had I not had that treatment in the ER ,I would be dead now.
    This is a Catch 22

  17. Dearest dr. I read your lasso of truth it is interesting and very acurate however very very perspective based .though you do adress the honest client at little length you mostly sell your very perspective truth as you see it. I usually don’t dabble in thses type of relative truth issues as I am a baptist minister yet I have learned from many years of being humbled the hard way that while I may know the forensic aspect of one side of the mountain I can not know the other without experience. This arrogance I learned and continue to learn very well. My point is simply that you failed to point out that epiderals are 50 percent on average failure to do anything except cause the patient greater pain and expose them to drugs much more dangerous than hydrocodone. Pain psychology is also mostly a failed practice for people with physical mechanical problems and majority for patients with emotio al pain. Psych. In general is a failing practic in healing. Herbs vegitable and other alternative meds are s ake oils of yesteryear and chiropractic is only a treatment proper for about ten percent and then o ly certain types of chiropractic is not ongoing and seffective as some are very dangerous considering they school for less time than a vet. In short anyone who has and has treated patients with real varifiable medical issues that put them into the class of severe chronic intractable pain patient knows what does and doesn’t work for them and as all good science shows every bady reacts differently to any given situation and therapy thus as has been done by the best drs. In the world for for over fifty years each case must be adressed and evaluated individually without predjudice to treat that patient to the spirit and letter of the oath and the patient bill of rights. Thanks

  18. I have chronic pain at 70 years old with little time left on the world. Now I must put up with the FDA’s new rule that will not change a thing. Those that want them to sell will get them,the only ones who will be affected are those that need the medicine. why doesn’t the FDA approve some new cancer drugs or diabetes drugs..Another stupid rule change.

  19. I am a pain patient who has been on hydrocodone for 4 years due several issues. I had chronic hip pain in both hips due to severe hip dysplasia. It was nothing but bone on bone. I had both replaced but I also have a compression fracture in my lumber spine and continue to feel the ill effects of my fall 2 years ago. Hydrocodone is the only medication which helps me because I cannot take NSAIDs due my Barrett’s syndrome. This medication has given me the added benefit of lessening effects of my Barrett’s. Every morning I wake up gagging and at times vomitting and when I take it the pain and gagging sensations begin to subside. I take 3 a day and I do not abuse it. I do not understand our government for this action. It will push patients underground like in the the previous period of prohibition in our country’s history (wasn’t that a good idea). It has the potential of increasing criminal activity for patients that are in real need of pain killers by going to pushers or even the mob. I seem to recall that is how the mob got its foot hold in this country during prohibition. If it was not for hydrocodone, I would not have made it. I think the FDA should keep out of decision making process between patients and their doctors. Does that not restrict our individual freedoms to make our own minds as to what is best for us? Cigarettes kills more people every year than pain killers and is more dangerous as well. The FDA has more important things to accomplish than to restrict things like hydrocodone. I wish they would stop being our nanny.

  20. Ok Dr. Jen. Gunter. You just profiled everyone together. Bc even if IT started with low back pain. Why the crap. Look at that’s the way it stayed for the person. It did not in my. Case. I almost lost my life. Due to having to have back surgery and then. Stupid wound care place. Wanted people coming back and put a metal type needle. Which put step B in my blood. Have you ever known that kind of pain. I don’t think so. Nothing can touch it. You hurt soo bad you cannot walk. Fever 103. I did not ask for that. But if I would not if agreed to a laminectomy finally. After years if just suffering. With constant pain to very immediate sharp fall to your knees pain. Because two bone spurs pulling my sciatic nerve apart. My neuro surgeon found thank God. As I do have relief now. And I am finally able to cut back. But from the sepsis u am left with aching hips. And cannot sleep at night from hip pain unless I do take the hydrocodone. I think, the ones that DEA were trying to get should have been left to the police. And answer me why are they not sending the medication out to pharmacies now. Bc now some of these frauds can get their “friend Dr. To writ for like 1000. So they can sell. And when I go I hear oh we don’t have those anymore. I told my Dr. I’m already cutting down. But from months if a picc line. I have C-difficle now. And he says NO. You cannot go off your med. until that is gone. Well I’m pretty sure me and many others who are really ill and need this med. to just be half way normal. Will die or be in ER rooms. Is the FDA going to pay for all that. NO! This is wrong kind if control. It points and profiles the real sick. Leave the bad people up to the right people the Police. And stay out of my life!!!!

    1. I’m not really sure what your point is or how it relates to my post. I wrote about how we don’t treat pain correctly in the United States and how changing FDA regulations is unlikely to help much. How exactly does that put me in your life?

  21. Dr. Jen,
    I think you are right on the mark. I am a nurse with 18+ years of experience. I see the real people scenarios you give almost every day. I don’t think the new ruling will change OD’s much, although I have seen the change in the real response to the new DEA ruling. People will turn to illegal drugs in greater numbers I fear(not that it is anything new), even people with legitimate reasons for asking for narcotics will turn to this desperation. Only time will tell, of course. I am just agreeing with others who have predicted this phenomenon. I think your final sentence sums up the direction of the whole article….”the American problem with opioids and chronic pain will remain unchanged”.

  22. The only problem I’m having is my insurance company quit paying for one of my meds and now I have to pay specialty co pay every month plus full price for Rx.
    I’m on Disability. It’s really putting me in a terrible bind since new every month policy. I was struggling before this.

    BTW: one MUST exercise in some manner to fight pain. Never let anyone get out of this condition when taking meds for pain. If you don’t use it, you lose it.

    Really enjoyed your article Dr. Gunter. Thank You.

  23. Just one thing that I don’t think that you’ve considered, Dr. Gunter.

    Half of the planet wouldn’t survive what the American medical system allows us to survive. We had people working longer – older – than the European countries. As the FDA cracks down on pain management, the disability rolls are rising at a stunning rate. We were able to work harder and longer than others in the Western world because we had better pain relief. Now our disability rates are rising faster than our population is aging because pain will stop a person from functioning.

    I also want you to consider countries like Singapore what routinely deny people pain relief for things like terminal bone cancer. Do we really want to be like that?

    The World Health Organization has decried the *lack* of pain relief around the world as a human rights issue.

    We were better, but now we’re inflicting unnecessary suffering on our population – right as the Boomer Bubble enters their senior years. This is a humanitarian disaster.

    Our veterans are killing themselves at an unprecedented rate right now and it doesn’t occur to people that the VA cracking down on pain relief *might* have something to do with it? (All of those Vietnam ‘kids’ and now in their 60’s and 70’s and many of them are carrying decades of chronic injuries into their senior years.)

    Instead of looking at other nations’ lack of opioid use and seeing a model, perhaps it would be better to take a moment to let in the shocked horror at how terribly other countries allow their citizens to suffer and how poor their citizens’ quality of life really is.

    1. Perhaps you might want to read the post again. My comments were about how the American Medical System doesn’t approach chronic pain correctly and how rescheduling a drug will not fix our issue with opioids.

      If you don’t think the US has an issue with opioid prescriptions, then you are wrong. That doesn’t mean an individual person is wrong to use them, that means that how they are prescribed by most doctors for chornic malignant pian doesn’t fall within guidelines or is not done in a safe or evidence based manner.

      Opioids are not the only option for pain relief, so while treating pain is essential assuming that opiods are the only way to do it is incorrect medically and ethically.

      1. I am a patient of the same doctor for over 20 years, for 17 years after trying all different medications we found that opioid therapy was the safest and effective way to treat my pain, I have every spinal condition in my lumbar and cervical areas , I have had three operations and have done years of physical therapy. This med allowed me to work with a pain scale of 4 for 15 years with over time increasing the 10mg 6 pills as needed daily thats every 4 hrs and at times i could go longer and maybe get away with taking less then the recommended dose.I also had 12 or more epadorial shots along with steroids and many MRI and nerve tests. My doctor informed me that I am not a surgical candidate due to the level of degeneration along with most every other condition that effects the spine. You cannot replace your spine and its a trade off having surgery after surgery to correct every level ,not to mention the hundred thousand plus cost incurred. I also was a victim of the restraints that were placed on opioid use and my doctor said lets try pain management again as they can do more . Well that was a joke. not even knowing every thing I have done and been through i was prescribed lyrica witch I told him my insurance would not cover and the intense phys therapy he also prescribed,. after being told to also see a psychiatrist on there team who was located over 50 miles away in order to be covered by my insurance i could not see him at that location were the clinic was . My experience was a waste of time and copay. My family doctor and another Mri said no to the intense therapy and has always recommended aqua therapy. Tramadol 50 mg four times a a day 2 tablets was no doing any thing to help.1200 mg of tylenol 6 times daily did not help much at all over that 6 month period, I was able to do less at home and for my family. My doctor after seeing him has now prescribed my normal depression and sleep meds is also trying Oxycontin extended release 10 mg. and I am hoping to at least get my pain level down a few points and be able to do more activity. I may ad that I never became addicted or misused my meds . The agency’s that are restricting opioid use need to stop the misuse but not cause harm to those who need the meds to get there lives back. Doctors who just give in and say no to long term patients due to restrictions that are in place should consider one of the other pain meds . I am still waiting to get the
        Oxy supply and hope I do not have problems finding a pharmacy that will have this med and fill my much needed superscription and get some relief. from the agony I was put through due to these restrictions. FYI ,I am now permanently disabled at 56. That alone is depressing . I hope this helps people who need relief.

  24. I am wondering why, since most opioids were manufactured to be taken every four hours, unless opiate naive or intolerant, why do doctors continue to prescribe them at the rate of one every six hours? Patients are deemed noncompliant when its the doctors who are prescribing them incorrectly.

  25. I’m beginning to think..after reading all these comments from so many people with legitimate pain that there must be some other reason for physicians not treating pain appropriately …could it be that they are getting some kind of monetary rewards???? to erradicate what they consider flawed individuals….To allow people to experience so much pain and not LISTEN ..but to assume every behaviour is drug-seeking is such an insult…especially when it comes from your family physician….I am 63 yrs old…I have had numerous sugeries on my legs…they can’t figure out why that is but they …it appears the medical higher ups can now tell me …after taking percocet and hydromorphin for ten years that this is an addiction and cut my dosage down so severly stating my body would be able to manage after a year!!!A year of hell..It’s been a yr. and a half…every time I try to address this he smiles and says his hands are tied….that this is the highest dose he can give me. Most days it just takes the edge off…the remaining 4 days every two weeks I often run out….I am in hell…I go for a right knee replacement hopefully soon…I can no longer walk…spend most of the day sitting because even when I feel o.k. if I do more…like make a meal….I pay for it the next few days…I have worked 30 years as an r.n. I would still be working if I could…but this apparently is linked in drug seeking behavior…there is no-where to go…no-one to talk to….no-one cares …and family doctors are obviously not educated enough in this field…you wouldn’t go get you hip replaced by a family physician…!!!..What’s really going on…if I could…financially I’d take this whole issue to a lawyer and the media…but I’m just another peon suffering every day of my life…Where is there some-one…anyone…to help me???

    1. I am an RN and have worked for almost 20 years as a staff nurse in an acute care hospital. I have had three spine surgeries and one shoulder surgery and a hernia surgery since getting into nursing. Thankfully, I am now transitioning into teaching nursing half to full time. It does not pay as much, but the rewards are better and the impact on my body will not be as great. I understand your predicament! I have had chronic issues with my back since I was a teenager(I turn 53 this fall), but since entering nursing, I have seen my back issues getting worse. I have been on Hydrocodone for 15 years, low doses mind you, but all handled by my primary physician. I am not an addict and am damn lucky that I have not had issues with my body demanding more of the drug to get the same relief. What can I tell you? I am not going to tell you to try pot or go to illegal sources for your medication, but a person has to do what he/she feels is right, DEA be cursed! This is what it has come to in this country. We are so backwards, here in America, that it borders on stupid! Progressive minds would have either done away with the DEA a long time ago, or changed its mission and focus. Our drug and pharmaceutical laws are outdated and antiquated to say the least. There is bias, collusion, racism, and unfounded paranioa at work in the halls of our government. I can’t afford a lawyer for a class action suit against the DEA/FDA collusion, nor can most of us who are affected by the latest changes in the scheduling of narcotics. Do you really think our congressmen and senators care about this issue? You are naive to think so, if you do. It is every person for themselves and maybe that is what the DEA wants. Gives them a reason to exist and justify/ grow their budget.

  26. I have Tourette syndrome severely for over 30 years it’s slowly going away I’m so much god damn my doctor from Brooklyn retired few months ago at 67 years I’m trying to find Dr around jerseys around here but for some reason the doctors around here are of frayed to do their damn people like does the really need are God damn medication I having a hard time getting from the scumbag drug addicts and the DEA scumbags I like one of them to come to my f****** door I’ve had severe threats for over 30 years then laugh. Really cute old stared beat up now it’s it’s going away and now I have all of this f****** paying and you Dr in Jersey are a bunch of pussies so you’re the doctor that drive us to go up the f****** New York where real doctors are. If there are any real Dr that was supposed to help people like us contact me now you DEA people are like every other wanna be here oh stop drugs in America stop weapons you guys are just lining your pockets you’re pushing people that really need medicine away to start shooting f****** heroin you people are so f***** up I hope that your family members have chronic pain I know yet hooked on f****** heroin. So get off your lazy fa go after the bad doctors and the people that don’t need this s*** and others people that need it leave us the f*** alone and another thing I’ve seen and I’ve heard that doctors are charging more to Medicare to yup for all patience that they’ve been losing and you know what I’m happy for them the doctors go to the school for a lot of years and scumbag like you think that you know what the hell you’re doing basically all you’re doing is ruining the doctors Family lives and you’re putting people that needed that can’t get it with needles in they’re f****** arms and yes I’m sorry for all the cursing but you people you people are f****** rotten wait till your family members get pain when they are older or whatever happens to them there’s no pain doctors left the we going to same goddamn thing as normal people like us getting heroin because it’s cheaper

    1. Hello People, I have the same problem, I have been treated by the same doctor for 20 years, had 5 operations back and neck, I have all wrong that can be wrong, shots to the spine and neck are no help, My spine is so arthritic that I pay with pain for doing what life requires , Loratab was my god send after trying many different drugs, I am now getting oxycodone 10mg twice daily and still in a lot of pain, I was taking hydrcodine hlc and it made my life livable and now since I cannot afford Butrans patch at 500 dollars a month . I became disabled from my printing career after 37 years, I now every ones body is different. I hate what is going on , I need what works best for me and gives me a decent Quality of life. The life I am living is pure hell, Doctors have to do what is best for them and it appears they will be punished if they don,t follow the rules, If you travel to Ber-lies you can buy these over the counter 500 at a time, if you move to Florida your more likely to be givin what you need,
      I am pea’d off about this situation, I can only due whats needed and recover for a few days and redo the same thing, a trip to the supermarket leaves me in anguish , making love to my wife of 35 years also is painful but I love her , I will just deal with the pain , I pray for life to be over soon as I refuse so far to go with herion to ease my a pain , that is something I will not due, If you need this medicine you do not become addicted, you are depended on having it to help you lift a gallon of milk, and so it will be what it will be, I am trying to relocate to florida . maybe then I can regain my life through pharmacological means.

  27. I have been on 6 norco per day for about seven years. My doctor does not feel that surgery will improve my situation, and is likely to worsen it. I did all the shots in the spine and physical therapy that was a joke and next to impossible as a mom living alone with an autistic child five days a week. I have reduced my dosage occasionally so I didn’t get immune, but I suddenly have found that I cannot sleep. The pain wakes me up after a few hours and I can’t go back. I used to be able to take more meds and try again, but nothing works anymore. Mind you, I have been tested poked and prodded. I have been more than willing to try anything. I asked my doc if I could cycle another drug temporarily and see if I respond to norco again. He said he cannot change the opioid agreement, even to another drug on the same level… I am so confused because its his contract. I have given them no reason to distrust me. The only thing i wouldnt try is prednisone pills, because i have seen how bad it was on my mom who had MS for 25 years. Now I go back for another MRI on Monday. I said I would do more shots. I’m getting pain and numbness in my feet now, and shooting pain down my leg has started to flare now. I feel hopeless and so bad about myself, but I pass the depression tests just fine. But it doesn’t ask you questions like, “is inactivity due to pain ruining your relationship?” And it doesn’t ask, “can you imagine being alive in ten years considering the progression of your current pain?” Or “Are you able to be a productive member of society at your current pain level?” (Answers: yes, no and no) I do understand the need to get rid of junkies, I understand that. I never even smoked pot or a cigarette in my whole life!!!. But this war on pain sufferers is like not just throwing the baby out with the bathwater, but then taking a baseball bat to the tub as well. The junkies will now just use heroin and die that way…I have heard of a few already. And the saddest thing is that if someone can’t trust you after 7 years….its a very disturbing thing. Very. If this is such a huge problem, why aren’t opioid pills banned altogether? I can tell you why…because people would be killing themselves right and left, or drinking themselves to death. It’s a sad world when people without the curse of chronic pain have all the answers, no empathy, and make the laws for people who do.

  28. I agree my mother started taking vicodin 30+ years ago.. She is taking handfuls a day… She takes 120 vicodin in 5 days then the rest of the month goes through withdraws.. It’s sickening too me.. She just gave up… She also takes 90 Zanex with them.. She Shits all over herself and does this every month… But my dad who is 70 just let’s her do it

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