America Still Has a Pain Problem

Pain is universal. We experience it when we scrape a knee, give birth, recover from surgery, live with arthritis, or face serious illness. It is one of the most basic signals our bodies send and one of the most common reasons people seek medical care.

Yet pain is also profoundly personal. How we experience, express, and tolerate it varies across people and cultures. Unlike blood pressure or blood glucose, no simple test can tell a clinician exactly how much pain another person is experiencing. Pain affects millions of Americans. In 2023, 24.3% of U.S. adults experienced chronic pain, and 8.5% had pain that frequently limited their lives or work. Chronic pain also cost the U.S. an estimated $722.8 billion in medical care and lost productivity in 2021.

Beginning in the 1990s, opioid prescribing expanded sharply, fueled partly by aggressive pharmaceutical marketing and a growing clinical emphasis on treating pain. This increase helped drive the first wave of opioid overdose deaths. The crisis later shifted to heroin and then illicitly manufactured fentanyl. From 1999 through 2023, approximately 806,000 Americans died from opioid-involved overdoses, and another 54,045 died in 2024.

Health care responded with tighter prescribing, monitoring programs, greater awareness of addiction risk, and more scrutiny of long-term opioid use. The national opioid dispensing rate fell from 81.3 prescriptions per 100 people in 2012 to 35.4 in 2024. Much of that change was necessary.

America has simultaneously overtreated some pain and undertreated other pain.

But opioids are not inherently bad. They remain important for severe acute pain, cancer-related pain, palliative care, and other circumstances. The failure was treating them as a broadly applicable answer to an extraordinarily complex problem. Reducing our reliance on opioids raised a question that remains inadequately answered: If a prescription is not the answer, what are we offering patients instead?

We may have changed prescribing, but we have not built a better pain-care system. Pain-management training remains inconsistent across medical schools in the United States, and access to specialists is particularly limited in rural communities. Nonpharmacologic treatments such as physical therapy, massage, acupuncture, and mindfulness may be difficult to find or are inadequately covered, and are therefore costly or time-consuming for patients.

These barriers shape who receives multimodal care. Among adults with new chronic pain, Medicaid patients were more likely than commercially insured patients to fill pain-medication prescriptions but less likely to receive physical or occupational therapy or complementary and integrative care. When medication is easier to obtain than restorative care, patients do not have a meaningful choice.

The problem becomes even more complicated when we ask whose pain gets believed. Because pain is subjective, its assessment leaves room for bias. Women, patients of color, people with lower incomes, and rural residents can face different burdens of pain and different paths to care. A systematic review and meta-analysis found that Black and Hispanic patients were less likely than White patients to receive opioid analgesics. Other experimental research found that observers underestimated the pain of women and people of color, with the largest gap for women of color.

While working in Baltimore, one of us saw these failures firsthand. A man living with debilitating pain from a prior gunshot wound had his symptoms repeatedly minimized. Instead of receiving a clear path to treatment, he spent months moving from one clinician to another through a maze of referrals. His pain went unrecognized, his treatment remained unclear, and the care he needed stayed unnecessarily and painstakingly out of reach.

We can do better than offering patients a prescription versus nothing at all.

Better measurement can help. The familiar 0-10 pain scale offers a useful shorthand, but a 7 for one person may not mean the same thing as a 7 for another, and a number reveals little about how pain affects daily life. The CDC recommends assessing function alongside pain intensity, using tools such as the three-item PEG scale, which measures pain intensity and its interference with enjoyment of life and general activity. Standardized assessment and treatment protocols can promote more consistent care, although no checklist can eliminate bias.

The opioid epidemic and the undertreatment of pain are not competing narratives. America has simultaneously overtreated some pain and undertreated other pain, while geography, income, gender, race, and insurance have helped determine who receives which kind of care and when. The answer is not to move from prescribing opioids too readily to avoiding them reflexively. It is to give clinicians and patients a wider, more accessible range of evidence-based options.

That range may include medication, exercise or physical therapy, psychological treatment, mindfulness, yoga, tai chi, acupuncture, massage, or multidisciplinary rehabilitation. No single approach works for every person or condition, and the strength of the evidence varies. For example, acupuncture has demonstrated benefits for several forms of chronic pain, while multidisciplinary rehabilitation can improve pain and function among people with chronic low-back pain. The question is not whether a treatment is “conventional” or “complementary,” but what works, for whom, for which type of pain, and under what circumstances?

The World Health Organization’s guideline on chronic low-back pain reflects this principle by applying an evidence-based standard to conventional and complementary treatments alike. Traditional origins should not exempt a therapy from rigorous evaluation, but neither should they exclude a potentially useful treatment from consideration.

When treatments work, health systems and insurers should make them realistically accessible. That means more comprehensive pain education for clinicians; assessment that considers function, not only intensity; stronger safeguards against bias; more research comparing pharmacologic and nonpharmacologic approaches; and coverage that makes multimodal care available to more than those who can afford to pay for it themselves.

The opioid epidemic has shown what can happen when we treat an extraordinarily complex human experience with an overly simple solution. The lesson is not that treating pain is dangerous—treating pain poorly is. We can do better than offering patients a prescription versus nothing at all.