Pain-management movement

The Pain-management movement arose from a genuine concern: pain had often been undertreated, and outdated assumptions about addiction could leave patients suffering without adequate relief. Its call to make pain visible in routine care gained force just as OxyContin entered the market. In that convergence, a humane demand for better treatment became entangled with new measurement rules, reimbursement incentives, and pharmaceutical marketing—systems that could turn attention to pain into pressure to prescribe opioids.

Origins and institutional momentum

The movement took shape alongside the 1996 introduction of OxyContin and a broader change in how health care was evaluated. Patients were increasingly treated as consumers whose experiences could be recorded in formal surveys, including those conducted by Press Ganey. Hospitals and clinicians competed for strong scores, while reimbursement could be affected by patient assessments. Treating pain more liberally therefore carried institutional as well as clinical weight.

In 1999, the Joint Commission approved mandatory standards for pain assessment and treatment, extending the idea that pain should receive a status comparable to blood pressure, heart rate, respiratory rate, and temperature. Purdue Pharma recognized the commercial opportunity in helping hospitals implement the requirements. Its budget plan described a chance to be seen as a leader in pain expertise, and the company planned $300,000 in OxyContin-branded scroll pens, $225,000 in resource binders, and $290,000 in wall charts and clipboards organized around the fifth vital sign. The movement’s language of recognition and care thus entered hospitals alongside branded materials supplied by a drugmaker selling a powerful opioid.

The case for taking pain seriously was not merely a marketing invention. A 2000 New York Times story described an older nursing-home resident with severe osteoporosis and pulmonary disease who had been given only Tylenol. The account reflected a widespread concern that health workers sometimes withheld adequate pain relief because they mistakenly believed that treating pain could itself leave patients addicted. Yet the appeal to correct undertreatment did not settle what counted as adequate relief, or how clinicians could reliably measure it.

OxyContin and the expanding meaning of treatment

Purdue Pharma’s medical representative, David Haddox, promoted OxyContin for chronic pain beyond cancer, presenting addiction rates as below 1 percent and prescribing as a responsible response to pain. Pharmaceutical sales representatives carried the message to doctors and dentists across all fifty states, arguing that the drug was appropriate not only for dying patients but also for people with moderate back injuries, wisdom-tooth surgery, bronchitis, and temporomandibular joint disorder. The movement’s widened attention to pain and Purdue Pharma’s widened account of who might receive OxyContin reinforced one another, even though they were not the same project.

The marketing environment magnified that reach. After federal rules on pharmaceutical advertising were loosened, drug advertising grew from $360 million in 1995 to $1.3 billion in 1998, while companies increasingly used gifts and other inducements to reach clinicians. Purdue Pharma focused early sales on rural, small-town communities. Using data purchased from IMS Health, it identified doctors who prescribed high volumes of competing painkillers such as Percocet and Vicodin, then directed more representative visits to those with the greatest perceived potential. Representatives brought reminders such as OxyContin-branded clocks, and the company expected more than a million annual calls on doctors in hospitals and offices. The pitches emphasized the drug’s potency and longer-lasting action, and promoted it for noncancer pain, including low-back pain, osteoarthritis, and injury.

Purdue Pharma also framed low addiction risk as settled reassurance. Haddox told the company’s sales force that addiction was rare when opioids were taken as prescribed; a 1996 training session characterized doctor-caused addiction as exceptionally uncommon. That confidence helped make the expanding clinical ambition seem safe. But clinicians later described how little they understood about the consequences of prescribing. John Burton, head of emergency medicine at Carilion Clinic, recalled that physicians had been urged to prioritize pain and that he had once believed patients could not become dependent after a fourteen-day course of opioid pills—a belief he recognized as wrong.

Measurement, uncertainty, and local warnings

Pain scales made an invisible and subjective experience easier to fit into standardized procedures. Their apparent precision, however, could obscure the limits of what they measured: a patient’s reported pain depended on individual tolerance, and a transition in labor or a stubbed toe could each receive the highest score. Experts later acknowledged that the numbers were objective in appearance rather than in substance. Reliance on the scales did not reliably correspond to improved patient outcomes and was associated with increased opioid prescribing and abuse. The central tension was not whether pain mattered, but whether a score could stand in for the complex judgment needed to treat it well.

Art Van Zee challenged Purdue Pharma after seeing serious problems in his region. In August 2000, he wrote to Haddox asking the company to investigate local prescribing patterns and warned that the affected communities might be early sentinel areas. Purdue Pharma responded with adverse-event forms. At a forum for local doctors and families, researchers described the physical and psychological strain of opioid withdrawal and explained that addiction could be a lifelong, relapse-filled condition. When researchers recommended less abuse-prone drugs for patients with severe pain, a Purdue Pharma representative in the audience argued that inadequate pain treatment, not OxyContin abuse, was the problem.

Van Zee’s response sharpened into two specific requests: end aggressive OxyContin marketing for noncancer pain and reformulate the drug to make it harder to abuse. He pointed to Talwin, whose manufacturer had added the opioid blocker Naloxone in 1982, reducing diversion and misuse. He also attended a meeting of the Purdue-funded Appalachian Pain Foundation, a professional association that amplified the movement’s central claim that pain remained undertreated. The association’s appeal and Van Zee’s demands show how the same concern could support opposed conclusions: expand opioid treatment, or change a product and its marketing in response to evidence of harm.

The surrounding consequences were visible in nearby Tazewell County, Virginia. Between August 1999 and August 2000, 150 people were charged with OxyContin-related felonies in a county of 44,000; the area had also experienced ten armed drugstore robberies in eighteen months. One unemployed miner, Doug Clark, became dependent after surgery for injuries from a mine accident and later stole copper to fund another purchase. Such accounts do not reduce the crisis to a single cause, but they make concrete the distance between a clinical promise of reliable relief and the social and legal harms that followed.

Access to care and unequal consequences

The longer course of the opioid crisis exposed another gap: even when people sought help, sustained treatment could be hard to obtain. Kristi Fernandez’s son, Jesse Bolstridge, had attended a ten-week rehabilitation program in Jacksonville in 2013, including counseling, detox, and a brief course of Buprenorphine. He was weaned off the medication after three weeks, a short-term approach that became increasingly controversial. The treatment cost left him with a $25,000 debt despite insurance coverage. Later, Kristi could not afford to send him immediately to another program after his dismissal from treatment.

Tess Henry’s experience similarly shows how treatment options depended on money, eligibility, and location. Pregnant and recently released from jail, she found a private center that accepted people receiving medication-assisted treatment; insurance covered most of the $20,000 cost, while her father paid a $6,500 deductible from her college savings. She took Buprenorphine in the form of Subutex, then recommended for some pregnant patients. Later, the medication helped her feel normal, but her addiction-doctor visits were cash-only: an initial $700 payment and $90 to $100 for each follow-up, potentially four visits in a month. Her mother, Patricia, described the cash-only practices and waiting lists as barriers to care.

At the time, federal rules capped each certified medication-assisted-treatment prescriber at 100 patients; the limit rose to 275 later that year. In 2017, Hughes Melton worked with state officials to broaden Medicaid reimbursement and include counseling and care coordination, in part to encourage clinics that had relied on cash payments to accept insurance. The change widened access, but the need for treatment still reached communities slowly. In Roanoke, volunteers at the Hope Initiative built a five-page spreadsheet listing thirty-six rehabilitation and aftercare providers, matching possible referrals to patients’ finances and the availability of beds. Some volunteers arranged outpatient medication-assisted treatment, while others remained opposed to treating addiction with medication, despite evidence supporting it. The movement’s insistence that pain and suffering deserved recognition had not, by itself, created a reliable route from recognition to continuing care.

The uneven legacy also sits within a racially unequal system of prescribing and punishment. In 2014, Centers for Disease Control and Prevention data indicated that doctors prescribed painkillers to people of color at lower rates than to white patients, amid distrust that patients of color would misuse opioids. At the same time, drug enforcement and imprisonment fell disproportionately on Black and Hispanic people. The book contrasts the broad appeal to treatment when discussing many white opioid users with the much harsher criminal framing applied to people such as Ronnie Jones, imprisoned for heroin distribution. These differences caution against treating the movement’s expanded attention to pain as a universal change experienced equally: access to medication, exposure to addiction risk, and the consequences of drug policing were shaped by different institutional judgments.

Significance

The Pain-management movement made neglected suffering harder to ignore and helped establish pain assessment as a routine clinical responsibility. Its history also demonstrates the danger of treating a worthy goal as a complete clinical method. Standardized scores could make pain legible without making its treatment more accurate; patient satisfaction could encourage liberal prescribing; and commercial actors could present broader opioid use as the compassionate answer to a genuine problem. The movement’s lasting significance lies in that unresolved distinction: taking pain seriously is essential, but the act of measuring pain, the choice of treatment, and the conditions that make continuing care possible are separate questions.