Undertreatment of pain

Undertreatment of pain is presented as a real and longstanding problem that became entangled with the expansion of opioid prescribing. The effort to correct neglect brought pain into routine assessment and gave clinicians new reasons to treat it more aggressively. But the same shift made subjective pain easier to standardize than to understand, while commercial promotion and unequal medical judgments helped determine who received opioids, what risks were recognized, and who could obtain care after addiction developed.

The drive to make pain a medical priority

By the late 1990s, a new wave of opioid addiction was spreading through doctors’ prescription pads, even as medical and political institutions had developed extensive regulatory systems and the War on Drugs had been under way for decades. In 1996, the introduction of OxyContin coincided with a movement to treat pain as the fifth vital sign, placing it alongside blood pressure, heart rate, respiratory rate, and temperature. The change answered a serious concern: for too long, patients had suffered without adequate relief, in part because health workers feared that treating pain with opioids would cause addiction.

Hospitals were also becoming more attentive to patients as health care consumers. Formal satisfaction surveys, including those conducted by Press Ganey, allowed patients to rate their care, and hospitals and clinicians competed for strong scores that could affect reimbursement. This created an institutional incentive to respond to reported pain. In 1999, the Joint Commission approved mandatory standards for pain assessment and treatment, taking the new priority from an emerging principle into a formal requirement.

The book records the experience of John Burton, head of emergency medicine for Carilion Clinic, as an example of how that climate reached clinicians. Physicians were urged to take pain more seriously, but the consequences of increased opioid prescribing were not yet well understood. Burton later recognized that his own reassurance to residents—that a patient could not become addicted after a two-week supply of opioid pills—was wrong. The episode illustrates a central tension: the correction of undertreatment did not itself provide reliable guidance about which medicines, quantities, or durations were safe.

Measurement and the commercial opportunity

The new standards relied on the premise that pain could be assessed consistently, yet pain is not directly visible and its measurement depended heavily on a patient’s account. A transition in labor and a stubbed toe could each be rated ten, depending on the person’s tolerance. The scale could make procedures uniform while giving an impression of objectivity that the underlying experience did not warrant. The book notes that reliance on such scales did not correspond with improved patient outcomes and had the further effect of increasing opioid prescribing and abuse.

That institutional opening overlapped with Purdue Pharma’s effort to establish OxyContin as a treatment for far more than cancer pain. David Haddox promoted the drug for chronic pain and presented addiction rates as less than one percent. Purdue Pharma’s sales representatives carried that message to doctors and dentists across all fifty states, framing prescribing as responsible and compassionate not only for people dying of advanced cancer but also for patients with moderate back injuries, wisdom-tooth surgery, bronchitis, or temporomandibular joint disorder.

Purdue Pharma also saw the new hospital standards as a commercial opportunity. In its budget planning, the company anticipated becoming a leader in helping hospitals meet the Joint Commission requirements by providing pain-assessment and pain-management materials. Its planned branded materials included $300,000 in scroll pens, $225,000 in resource binders, and $290,000 in wall charts and clipboards devoted to pain as the fifth vital sign. The response to pain was thus shaped not only by clinical concern but also by a company positioning its product and brand within the systems that defined good pain care.

The problem the reform answered

A 2000 article in The New York Times captured the contemporary concern about pain left untreated. It described an older nursing-home resident with severe osteoporosis and pulmonary disease who had been given only Tylenol. The case drew attention to the possibility that outdated fears about addiction were preventing adequate relief. The story helped make the need for change concrete, but the question of what counted as adequate treatment remained unsettled. Greater attention to pain did not, by itself, resolve how to distinguish appropriate relief from excessive or risky prescribing.

The book treats this uncertainty as more than a technical flaw in pain scales. Quantifying pain offered hospitals a standardized way to assess patients, yet a number could not settle what care an individual needed or predict the consequences of an opioid prescription. The effort to remedy neglect therefore moved faster than the ability to measure benefit, define adequate relief, or understand the risks created by expanding supply.

Unequal exposure and unequal care

The distribution of opioid prescribing did not follow a single, uniform path. Before the suburban heroin crisis drew sustained attention in Roanoke, heroin was widely regarded as an inner-city drug. Don Wolthuis, a federal prosecutor, recalled that in the 1980s and 1990s only a few dozen people in the city were using heroin. He described a small, largely invisible group, mostly African American, whose members were commonly understood to use the drug in isolation rather than in public. This history complicates any account in which opioid-related harm began only when addiction entered white suburbs.

By 2014, however, doctors were prescribing painkillers to people of color at much lower rates than to white patients. Centers for Disease Control and Prevention data cited in the book associated that disparity with doctors’ distrust that patients of color would use opioids safely. The result was a grim reversal: the same racial stereotyping that restricted access to pain medication appeared to protect people of color from the sharp increase in overdose deaths affecting young white people. By 2014, young white people were dying from overdose at three times their 2002 rate, while the death rate among people of color had changed relatively little.

That relative protection did not mean equal treatment in the wider response to drug use. The book contrasts the public refrain that arrest alone could not end the opioid crisis with the continued imprisonment of people such as Ronnie Jones for heroin distribution. It notes that people of color made up three-quarters of federal drug offenders and 57 percent of people imprisoned for drug offenses in state systems. The contrast reveals how different institutions could restrict one group’s access to pain medication while exposing that group disproportionately to punishment for drug offenses. Medical care and criminal justice were not separate arenas in the consequences of the epidemic.

Treatment gaps after addiction

The book follows the distinction between preventing undertreatment of pain and ensuring treatment for people who become dependent on opioids. Kristi Fernandez could not afford to move Jesse Bolstridge directly into another rehabilitation program after his dismissal, and an earlier ten-week program in Jacksonville had left him owing $25,000. During that program he had briefly taken buprenorphine, but he was tapered off after three weeks. Nora Volkow, director of the National Institute on Drug Abuse, later emphasized that evidence supported long-term medication maintenance alongside behavioral treatment and recovery support, rather than short-term detoxification aimed at abstinence.

Access barriers also shaped Tess Henry’s care during pregnancy. Few Virginia facilities accepted patients receiving medication-assisted treatment, so her family found a private center that could take her for the final month of pregnancy. Insurance covered most of the $20,000 cost, while her father paid the $6,500 deductible from her college savings. Later, although insurance covered much of Tess’s buprenorphine medication, visits with her addiction doctor required substantial cash payments, sometimes for four appointments in a month. Her mother, Patricia, described the cash-only system as costly, while waiting lists further limited access. These examples show how the availability of a medication did not guarantee a continuous, affordable path to care.

In early 2017, volunteers with Roanoke’s Hope Initiative tried to navigate that fragmented system with a five-page spreadsheet listing 36 rehabilitation and aftercare providers across the southeastern United States. They matched options to patients’ finances and available beds; some also arranged outpatient medication-assisted treatment, although volunteers disagreed about its use. Patients could seek help at the Bradley Free Clinic on the second Monday of each month, but police first had to find no outstanding warrants before volunteers could pair them with care navigators. Social workers could help eligible patients apply for Medicaid. The referral list was practical and specific, but its very existence registered how many steps separated a person seeking help from treatment.

The book also records attempts to shorten those gaps. Warren Bickel received a $1 million grant for a Virginia Tech Carilion Research Institute pilot linking emergency-room overdose patients directly to outpatient buprenorphine, including through the newly approved monthly injection Sublocade. Yet Roanoke’s community services board had added medication-assisted treatment for only 21 patients, contingent on counseling, and Carilion Clinic still had a three-week wait for outpatient treatment. Across these accounts, the problem is not simply that pain was once ignored or that opioids were later overprescribed. It is that care was repeatedly governed by incomplete measures, uneven access, and institutional rules that could make treatment difficult to begin and harder to sustain.