Chronic pain

Chronic pain sits at the center of a consequential contradiction: patients had long been undertreated, yet the new drive to measure and relieve pain helped expand opioid prescribing before clinicians could adequately assess its risks or define what successful treatment meant. The book follows how a humane call to take pain seriously became entangled with commercial promotion, institutional incentives, and disputed clinical evidence—leaving both people in pain and people vulnerable to addiction caught in the consequences.

From neglected symptom to measurable vital sign

For years, concern about pain treatment focused on patients whose suffering was dismissed or inadequately relieved. A widely discussed example was an older nursing-home resident with severe osteoporosis and pulmonary disease who received only Tylenol. The account captured a growing belief among health care experts that outdated fears of addiction had contributed to needless suffering. That corrective impulse mattered: pain was not an abstract policy issue to patients living with it, and the book does not treat the prior neglect as imaginary.

In the 1990s, however, medicine began to formalize pain as a measure of care. The idea of pain as the fifth vital sign placed it alongside blood pressure, heart rate, respiratory rate, and temperature. In 1999, the Joint Commission on Accreditation of Healthcare Organizations approved mandatory standards for pain assessment and treatment. At the same time, patient surveys, including those administered by Press Ganey, made reported experience a competitive measure for doctors and hospitals. When ratings could affect reimbursement, clinicians had institutional reasons to respond quickly and generously to reported pain.

The new standards did not settle the question at their center: what counted as adequate pain relief? Pain could be rated, but a number did not make the experience objectively comparable. A person in labor and a person with a stubbed toe might each give their pain the highest rating, depending on individual tolerance. The appearance of precision made a subjective measure easier to standardize, while leaving the meaning of the score unresolved. The book notes that pain scales did not correlate with improved patient outcomes and were associated with increased opioid prescribing and abuse.

Commercial promotion and clinical incentives

Purdue Pharma entered this changing environment with OxyContin and a broad claim about its safety. The company promoted the idea that addiction was exceptionally rare when the medication was taken as prescribed; its pain specialist David Haddox gave a figure of one-half of one percent. The claim became part of the message carried by pharmaceutical sales representatives, who promoted OxyContin for chronic pain as well as for cancer pain and presented prescribing it as responsible and compassionate care.

The commercial effort intersected with a much wider expansion of drug marketing. After the U.S. Food and Drug Administration loosened rules for television advertisements making detailed claims about nonnarcotic drugs, pharmaceutical advertising grew from $360 million in 1995 to $1.3 billion in 1998. Companies also increasingly used gifts to influence doctors, at a time when industry and federal rules governing prescription-drug promotion were sparse. The broader sales culture encouraged the idea that a pill could remedy every ill and sometimes prompted patients to seek medicines they did not need.

Purdue’s own plans reveal how closely the company aligned its promotion with the new pain-assessment standards. It anticipated presenting itself as an expert that could help hospitals meet the requirements, and budgeted $300,000 for OxyContin-branded scroll pens, $225,000 for resource binders, and $290,000 for wall charts and clipboards bearing the fifth-vital-sign message. Such materials brought the brand into clinical spaces where nurses and doctors were learning to make pain assessment routine. The institutional push to acknowledge pain and the manufacturer’s sales strategy reinforced each other, even though their purposes were not the same.

The risks behind the numbers

The gap between confidence and evidence became visible in clinicians’ retrospective accounts. John Burton, head of emergency medicine at Carilion Clinic, recalled that physicians had been told to make pain a much higher priority. In his view, the result was increased opioid prescribing without a sufficient understanding of the consequences. He also recalled telling residents that a fourteen-day supply could not make a patient addicted, a judgment he later recognized as wrong. His account illustrates how a clinical norm can change faster than practitioners’ understanding of its risks.

The evidence about long-term opioid therapy was not uniform, and disagreement did not amount to a settled case either for or against treatment. In a 1996 paper, Seddon Savage identified consequences and risks of long-term therapy; in the same paper, Dennis Turk cautioned that arguments on both sides drew on small portions of pain populations with distinctive psychosocial, behavioral, and disease characteristics. That qualification complicates any simple story in which all opioid treatment is either necessary or harmful. Patients’ conditions and responses differed, while policy and marketing often favored broad, portable rules.

Later evidence also raised questions about prescribing beyond chronic pain. A systematic review found that opioid analgesics were commonly left unused after surgery, indicating that prescriptions could exceed what patients ultimately took. Meanwhile, the medical dispute itself carried costs for people whose pain was legitimate: reporting on the controversy described patients as fearful amid divisions over painkillers. The effort to correct overtreatment could therefore risk renewed undertreatment if caution hardened into indiscriminate restriction.

Pain, addiction, and the limits of access

The book places the debate over pain treatment beside the human course of addiction, without reducing every addiction story to a chronic-pain prescription. Kristi Fernandez sought to understand how her son, Jesse Bolstridge, had moved from being a high-school football player and construction worker to dying of a heroin overdose. Her questions show the limits of explanations that stop at a diagnosis or a prescription: families confront a progression whose details may remain difficult to reconstruct.

The later treatment landscape offers another measure of the distance between recognizing suffering and providing sustained care. Tess Henry received buprenorphine during pregnancy through a Virginia facility willing to treat patients using medication-assisted treatment. For another course of addiction treatment, Jesse had received buprenorphine briefly and was then weaned off after three weeks. These accounts are not evidence that chronic pain alone caused either person’s addiction; rather, they show why the book’s discussion of opioid medicine extends beyond the initial decision to prescribe. Treatment length, eligibility, cost, and local availability shaped what help people could actually receive.

The book’s account ultimately holds two truths together. Pain had been minimized, and patients needed care that took it seriously. Yet making pain measurable, rewarding higher reported satisfaction, and promoting opioids as broadly safe did not resolve what relief should mean or how its risks should be managed. Chronic pain thus becomes not merely a symptom to assess, but a test of how medical standards, commercial interests, clinical judgment, and access to continuing care interact—and of who bears the consequences when those systems mistake a number, a promise, or a prescription for an answer.