ZDoggMD on Pain Management After the Opioid Crackdown: The Pendulum Swung Too Far

This article discusses ideas from ZDoggMD — Dr. Zubin Damania, MD , Stanford/UCSF-trained internist, founder of the Health 3.0 movement. Full archive: zdoggmd.com | YouTube @zdoggmd

The opioid epidemic produced a regulatory and cultural crackdown on opioid prescribing. That crackdown was necessary in many respects. ZDoggMD has also documented its unintended consequence: the undertreated pain crisis, where patients with legitimate chronic pain conditions have been unable to access medications they need because physicians are too afraid of DEA scrutiny to prescribe appropriately.

The Overcorrection

In response to opioid prescribing guidelines (which were meant to inform, not mandate) and DEA enforcement activity, many physicians dramatically reduced or eliminated opioid prescribing — including for patients with genuine chronic pain conditions for whom opioids were medically appropriate and who had been stable on their regimens for years.

The result: a wave of patients with cancer pain, sickle cell disease, severe osteoarthritis, spinal cord injuries, and other painful conditions who found their medications abruptly discontinued or their doses reduced below therapeutic levels — not because of any change in their clinical status, but because their physician was afraid. Some of these patients sought relief on the street market; some had their pain go untreated; some died by suicide.

The CDC's Own Response

The CDC — whose 2016 guidelines were misapplied as mandatory dosing caps — explicitly revised those guidelines in 2022, clarifying that there is no specific dosage threshold above which opioids should be discontinued and that patient-specific clinical judgment should govern prescribing. ZDoggMD welcomed this clarification while documenting the harm done during the years of misapplication.

The core tension ZDoggMD has identified: opioid prescribing is a genuine public health problem AND undertreated pain is a genuine public health problem. A policy that solves one by creating the other isn't a solution — it's a different harm distribution.

Pain Management Is Documentation-Intensive

PDMP checks, consent forms, risk assessments, urine toxicology, treatment agreements — pain management generates significant charting. NoPajamaTime handles it in real time so documentation doesn't become a barrier to appropriate care.