On chronic pain

What It Covers

Drug Story examines chronic pain, affecting 50 million Americans, through patient Paul's 15-year ordeal, the history of pain medicine from John Bonica's 1953 textbook through the opioid crisis, and the 2025 FDA approval of Journavix, the first new non-opioid pain drug in two decades.

Key Questions Answered

• •Chronic Pain Neuroscience: Chronic pain is not an ongoing injury but a central nervous system malfunction where nerve receptors become permanently oversensitized, creating a neurological feedback loop. Pain and anxiety mutually amplify each other, and overlapping trauma or life stressors make both harder to manage, meaning effective treatment must address psychological factors alongside physical ones.
• •The Fifth Vital Sign Trap: In the late 1990s, the American Pain Society designated pain the fifth vital sign, requiring physicians to log patient-reported scores on a zero-to-ten scale. This created an obligation to treat the number rather than the patient, directly enabling opioid overprescription. The AMA formally reversed this policy in 2016, acknowledging physician culpability in the epidemic.
• •Opioid Crisis Scale: Purdue Pharmaceutical's OxyContin marketing relied on a single one-paragraph letter in the New England Journal of Medicine to claim addiction risk below one percent. That figure was never a controlled study. Over one million Americans have died of opioid overdoses since 1995, and 55,000 died in 2024 alone, though that figure represents a 35% decline year-over-year.
• •Journavix Access Reality: FDA-approved in January 2025, Journavix targets only the peripheral nervous system, bypassing brain reward centers and carrying no addiction potential. It costs roughly $1,000 monthly. Vertex offers a $30 savings program, but only for two months. Insurance covers only 14-day acute-pain prescriptions, leaving chronic pain patients paying full out-of-pocket costs for any extended off-label use.
• •Multidisciplinary Pain Treatment: Academic pain clinics modeled on John Bonica's 1940s military approach, combining neurology, psychiatry, physical therapy, injections, cognitive behavioral therapy, and pain reprocessing therapy, produce better outcomes than single-specialty clinics. Insurance restrictions increasingly block access to this model, with coverage often limited by diagnosis category, such as acupuncture covered for back pain but not pelvic pain.