Chronic pain and the opioid prescribing controversy

Chronic pain and the opioid prescribing controversy occupy an uneasy center in Dopesick: opioids could relieve disabling pain, yet their expanding use helped create an epidemic of dependence and overdose, and later efforts to control prescribing could leave patients without adequate care. The book rejects a simple choice between unrestricted prescribing and blanket suspicion. It follows the consequences on both sides of that divide, from the risks of prolonged opioid use to the financial, functional, and emotional costs borne by people who still need pain treatment.

Pain Relief and the Expanding Risk

The conflict is visible in the medical questions posed to Purdue Pharma executive David Haddox at a Richmond Academy of Medicine speech. Haddox urged physicians not to accept the emerging account of the opioid epidemic and described his company as working on new, safer painkillers. The doctors in the room were less interested in that reassurance than in a practical dilemma: how to relieve patients’ pain without exposing them to addiction. Haddox pointed toward local pain specialists, including the physician who had invited him, but there were not enough specialists to meet that need. Doctors were also encountering research that long-term opioid use could worsen pain for some patients, a condition known as opioid-induced hyperalgesia. The scene captures a change in clinical understanding: a medication prescribed to relieve pain could, over time, contribute to a more complicated pain problem.

Dopesick places that dilemma against a history of unequal medical attention. Don Wolthuis recalled that heroin use in Roanoke in the 1980s and 1990s involved only a few dozen people, and was treated as an isolated, largely unseen problem. The people associated with heroin were commonly imagined as an inner-city Black population; the drug was not yet widely understood as a danger to white communities. Later, Centers for Disease Control and Prevention data showed a different side of the racial divide: doctors prescribed painkillers to people of color at substantially lower rates than to white patients because they were less trusted not to misuse them. The book presents this disparity as a consequence of racialized clinical judgment, not as evidence of different underlying need. The same assumptions that restricted access to prescribed pain relief also shaped who was recognized as vulnerable to opioids.

Prescribing Rules and Their Limits

The book emphasizes how slowly major institutions adjusted to the accumulating risks. In 2016, the Centers for Disease Control and Prevention issued voluntary guidelines strongly recommending limits on opioids for chronic pain. The recommendations echoed calls that Barbara Van Rooyan had made to the Food and Drug Administration years earlier. The American Medical Association, meanwhile, took two decades to endorse removing the designation of pain as the fifth vital sign from its standards of care. Even as prescribing practices began to change, the book describes a substantial gap between new guidance and clinical practice: more than half of patients taking OxyContin remained on doses higher than the CDC’s recommended levels. It also notes that unused prescriptions—estimated at three-quarters of all opioid prescriptions—could remain in household medicine cabinets and become targets for theft, while surgeons continued to prescribe large quantities.

The story does not treat tighter oversight as an uncomplicated remedy. A former colleague of the author had a sixty-four-degree curve in her lumbar spine, slipped disks, and severe arthritis pain. Pain medication had allowed her to keep working and continue gardening, cooking, and beekeeping, while avoiding surgery that carried the possibility of serious impairment. Her scoliosis specialist later ended her pain management without advance notice or a plan developed with her. She understood the new prescribing guideline to have frightened him into abandoning patients. For arthritis she took the synthetic opioid Tramadol; for neuropathy she used gabapentin, which was increasingly sought on the black market for its sedative effects. Her new practitioner required pill counts, lower doses, and more frequent refill visits, increasing her out-of-pocket expenses. Her experience shows how population-level guidance could become, in practice, a new burden for a patient whose pain treatment had supported daily life. The controversy grew so intense that the two employees responsible for drafting the CDC guideline received death threats.

Addiction Treatment and the Care Gap

The book also traces the treatment obstacles facing people who develop opioid dependence, a necessary part of the prescribing debate because reducing medication supply does not by itself provide a route to recovery. Jesse Bolstridge had already attended a ten-week rehabilitation program in Jacksonville that included counseling, medical detox, and a brief period on buprenorphine. His mother, Kristi Fernandez, still owed $25,000 for that stay despite insurance coverage; Jesse paid $25 a week through automatic deductions from his checking account. He was taken off buprenorphine after three weeks. National Institute on Drug Abuse director Nora Volkow later emphasized that the evidence supported long-term medication maintenance alongside behavioral treatment and recovery support, rather than short detoxification aimed at abstinence. The contrast underlines the distance between evidence about sustained care and the short treatment models patients could encounter.

Tess Henry’s treatment during pregnancy shows how access depended on both medical eligibility and family resources. After leaving jail nearly seven months pregnant, she spent a month with her mother before the family found a private treatment center willing to accept her during her final month of pregnancy. Insurance covered most of the $20,000 cost, and her father paid the $6,500 deductible from the remainder of Tess’s college savings. The Life Center of Galax was among the few Virginia facilities that accepted patients receiving medication-assisted treatment. Tess took Subutex, a form of buprenorphine then recommended for some pregnant patients. Her experience makes clear that medication treatment was not simply a matter of whether an effective drug existed: a suitable facility, insurance, a large family contribution, and the timing of pregnancy all affected whether it could be obtained.

The barriers continued after treatment began. Tess said buprenorphine helped her feel normal, and insurance covered 80 percent of the medication, but her addiction doctor required cash payment: $700 up front and $90 to $100 per follow-up visit, as many as four visits each month. Her mother, Patricia, objected to cash-only practices, while waiting lists restricted entry to many clinics. At the time, federal rules capped the number of patients that a certified medication-assisted-treatment physician could treat at 100; the limit rose to 275 later that year. In Roanoke, volunteers with the Hope Initiative built a spreadsheet listing thirty-six rehabilitation and aftercare providers, matching possible referrals to patients’ finances and available beds. Some helped arrange outpatient medication treatment, but volunteers disagreed about its value, with some opposing treatment of addiction with another medication despite contrary scientific evidence. The list of providers was therefore also a map of a divided system: a patient’s access depended on beds, costs, eligibility, and the beliefs of those trying to help.

Unequal Exposure to Care and Punishment

The same institutional gaps appear across health care and criminal justice. The book contrasts the refrain that arrest alone cannot end the epidemic with the treatment of people such as Ronnie Jones, imprisoned for distributing heroin. It describes white opioid users who dealt drugs or committed property crimes to stave off withdrawal as a group for whom the need to move beyond arrest was often acknowledged, while Black and brown people arrested for selling drugs were more readily subjected to punishment. Three-quarters of federal drug offenders were Black or Hispanic, and people of color made up 57 percent of those imprisoned for drug offenses in state systems. Read alongside the lower rates at which doctors prescribed painkillers to people of color, these figures show how unequal medical access and unequal criminal enforcement could operate together without producing equal protection or care.

The book also points toward alternatives that connect treatment with the practical conditions of reentry. Bryan Stevenson described an approach used by the Equal Justice Initiative in which clients could be sent to cities with more jobs and harm-reduction services. Police could divert addicted people charged with low-level drug or prostitution offenses before prosecution, while housing assistance, case management, and employment services addressed obstacles that could otherwise return former offenders to drug dealing. The argument is not that chronic pain and addiction are interchangeable, but that a system organized around suspicion and punishment is poorly equipped to respond to either medical need or dependence.

The Balance the Book Leaves Open

By the book’s later chapters, the response to opioid harm had expanded, but the treatment gap remained evident. Warren Bickel received a grant to test faster transitions from emergency care to outpatient buprenorphine, including a once-monthly injection for patients who had overdosed. In Roanoke, the community services board had added medication-assisted treatment for twenty-one patients, conditional on their first engaging in counseling, while Carilion still had a three-week wait for outpatient treatment. These efforts concern addiction treatment rather than chronic-pain prescribing, but they expose a central limitation of policy that focuses only on reducing opioid use: care must also be available when dependence or overdose occurs.

Chronic pain remains the book’s necessary counterweight to a narrative focused solely on addiction. Some patients depend on opioids to function, and some experience renewed barriers when prescribers interpret broad guidance as a reason to withdraw care. At the same time, the evidence described in Dopesick includes the risks of long-term opioid treatment, commercial reassurance that failed to answer physicians’ concerns, and treatment systems too costly or limited to absorb patients who need help. The tension is not resolved by returning to indiscriminate prescribing or by treating every patient as suspect. It is sustained by the book’s insistence that pain relief, addiction prevention, racial fairness, and access to continuing care must be considered together.