There's a quiet lie embedded in modern pain care: the idea that dependence and addiction are the same thing.
They're not.
And the people living inside the system instinctively know it, even when they're not using the words.
Addiction announces itself through behavior: escalating doses, compulsion, deception, and harm pursued despite consequences.
Dependence, by contrast, is biological; it's the body adapting to a medication that allows basic function to continue.
One's a pattern of conduct, the other a condition of survival.
The tragedy isn't that medicine struggles to treat addiction; it's that it no longer seems able to recognize dependence when it sees it.
Barbara, a 75-year-old with documented degenerative disc disease, spinal stenosis, and multiple joint replacements, spent years on a low, stable dose of hydrocodone, which never eliminated her pain; it simply reduced it enough to function.
Every month, she needed to submit urine samples, appear in person to pick her prescriptions up, and answer the same bloody questions.
Eventually, she walked away from pain management altogether, not because she no longer needed relief, but because she was tired of being treated like a criminal.
Her life shrank and she stopped going out. The pain remained, but at least a level of humiliation ended.
I relate 100% with Barbara: I walked away from pain management for the same reasons. What really ticked me off was that, when I had my face-to-face with my primary care provider in November, I should've been clear that I could continue refills without another face-to-face appointment six months later.
Instead, the healthcare provider's lawyers changed the protocol, requiring me to drive 45 minutes one-way to see my PCP every quarter and adding a few more hoops for me to jump through.
My situation pales in comparison to many of you, but on my level, it wasn't convenient. When I complained to a nurse, the PCP I've seen since 2006 told me, "Why are you surprised? This is how we've always done it." Fortunately, I had an inside source who told me about the new changes a week before I was officially informed, so I knew the explanation was wrong because the lawyers had changed things at a higher level the week before, and I decided then that I would no longer be a pawn.
So, I quit my oxycodone, which I'm now regretting because I've had some tremendous stretches of pain.
I'm not sure what to do.
Dan, a retired engineer, put the distinction plainly, writing that some people can manage opioids responsibly if allowed stable access, while others can't. The difference, he noted, lies in accepting residual pain rather than chasing zero pain.
In his words, people demanding complete relief often end up both addicted and still in pain. His point wasn't permissiveness, but discernment: A system that can't tell the difference punishes the wrong people, while failing to protect the right ones.
Rick, living in Wisconsin, described how medication options dwindled as fear replaced judgment. Epidurals only provided weeks of relief, while other medications caused side effects that disrupted his daily life.
Now, he limits his travel, avoids stairs, and structures his days around pain management rituals that offer little relief, but that are a constant reminder of what he's lost.
Mislabeling carries a higher cost for veterans. Bill, a 27-year combat veteran, described being shot, blown up, and surviving multiple crashes. He's taken the same small dose of narcotic medication since 2005, without escalation, abuse, or failed tests.
Still, every new doctor treats him with suspicion; he's prescribed Narcan as if they're anticipating an overdose he's never approached.
Other people describe rationing medication, not to addiction, but to avoid attention. Ron, an attorney dealing with post-herpetic neuralgia, deliberately takes less than prescribed. He banks pills against future shortages, while fearing that asking for an increase, even during worsening pain, will be interpreted as drug-seeking.
He lives with more pain than necessary because restraint feels safer than honesty.
Joanne, 75, takes Norco only when pain makes getting out of bed impossible. Twenty-eight pills last her months. Still, she was harshly treated by a longtime physician and now plans to never mention pain medication at all to her new doctor.
She doesn't smoke, drink or seek euphoria, she simply wants mobility.
These are not people who lose control, they're trying desparately to hold on to it.
Yet, despite these facts, the system responds as if addiction is always the starting assumption; monthly urine screens, pill counts, contracts, and short appointments focused more on compliance than care. Addiction has patterns; these people don't show them.
There aren't abstract consequences; lives contract, travel disappears, social invitations stop, and people retreat into chairs and heating pads, not because they want to, but because navigating care costs more dignity than the relief is actually worth.
In some cases, there's a fatal cost: one contributor wrote of a brother who took his own life after years of chronic pain and doctors who were too afraid to help.
Others describe contemplating the same path, not because of failed medication, but because it was taken away from them.
Nobody suffering from chronic pain is arguing that addiction doesn't exist; nobody is asking for medicine without limits; these voices are simply asking for recognition from clinicians and regulators to understand that dependence, in the context of irreversible injury or lifelong illness, isn't a moral failing.
It's often the least bad option among many bad ones.
There needs to be a system that's capable of nuance that holds both truths at the same time. It could treat addiction seriously while allowing dependent patients to live with some measure of trust and autonomy.
Right now, our current system does neither well.
Until modern medicine relearns the difference, the people least responsible for the opioid crisis will continue to bear its highest costs.
I Want to Hear From You
These chronic pain columns exist because people are willing to speak honestly in a system that often punishes honesty.
Read My Chronic Pain Series here.
If you're living with chronic pain and have had to learn to stay quiet just to survive care, your experience matters. Whether your story is long or short, clinical or personal, it helps expose what life inside the system actually looks like.
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