Too Little Too Late


So now we know that we’ve been human test subjects for a study performed by our US government (thanks to CIAAG, Lauren DeLuca & the administration of that Non-profit org.CIAAG website).

All along we’ve been discussing, writing and protesting with non violent rallies etc., to have our voices heard. The voices of the most chronically ill persons who have been living in an environment of fear, torture & Hell for the past 3 years, due to the CDC Guidelines. We know they were written in secret by a few addiction experts and others who had no knowledge of what chronic pain/disabling high impact chronic pain is all about. They don’t understand or know what it’s like to live with high amounts of ongoing, never ending pain 365/24/7.

Our government leaders allowed these people without any knowledge of chronic pain/painful disabling/lifelong illnesses, make medical decisions that changed and lost lives by the thousands and even hundreds of thousands. Here is a recent article by Dr Jeffrey Fudin, MD, in his blog “Practical Pain Management”. It is a great article and speaks to our government and it’s meddling in the lives of our own chronic pain patient community:

https://www.practicalpainmanagement.com/resources/news-and-research/too-little-too-late-us-government-backtracks-opioid-discontinuation

A Letter To RFK (Human Rights) Foundation


RFK Human Rights Group: Watch Video

Hello Luvs,

I was sent a video about the RFK, Human Rights Group. It’s led by Kerry Kennedy, daughter of the late Robert Kennedy. She is an attorney and she now leads this human rights group: RFK Human Rights group website

Immediately, I drafted a letter to her and sent it. Below, I have copied/pasted the exact letter that I sent to Ms. Kennedy. Something must change! The “Opioid Hysteria Crisis” is one of the worst nightmares I’ve witnessed &/or experienced. Watching a large group of approximately 26 million (out of the 100 million people living with chronic pain) human beings, systematically tortured to death has been horrendous. To be a witness to this despicable, willful & planned money making scheme, is nauseating to say the least! I’ve watched as the innocent chronically ill people in our pain community die and continue to die on a weekly basis. Maybe I will be next? So I pray that doesn’t happen and that I keep fighting.

I have been a very active advocate/activist in fighting for the rights of people in the chronic pain community. I have led the fight as far back as 2007, in spreading awareness, doing fundraisers, leading several online support groups & then being certified & leading “in-person” chronic pain support groups as well. I’m certified in pediatric RSD/CRPS, as well as being the Social media assistant for RSDSA. I’m a freelance writer with a blog (this one, @tearsoftruth.com) that has been nominated twice for “Best In show- blog by WEGO Health Awards. I was invited by IDA ( Invisible disabilities Association) to do & ultimately did a featured video on their “Invisible No More” YouTube channel. In 2016,’17 & ’18, I had 42 articles published. I was one of the many advocates/Drs/nurses etc., who helped edit & sign the letter to Brandeis University, demanding that Andrew Kolodny be fired for his leading role in the torture & deaths of multiple chronic pain patients (due to forced tapering & the 2016 CDC Guidelines).

Lastly, I was awarded the “US Pain Ambassador of the Year Award” in 2016. Afterwards, I was asked to be on the USPF Board of Directors (*a volunteer position which I accepted & later resigned after only 8 months. If you want to read more about that, visit: Why I resigned from the US Pain Foundation).

There’s more, but you get the idea. Sadly, since last Summer, 2018, I had my LA/ER pain medication forcibly & quickly tapered between July 22 –September 1st, 2018. I’d been doing reasonably well on a stable dose for 14 years. Since then I can often be found in my “Lazy boy” type of recliner, approximately 16 hours per day. I continue to do my best with my online support groups and I continue to fight for us via my blog/writing, support groups, mentoring for RSDSA, Social media Support for RSDSA & Deaf/HoH communications Director for CIAAG. I try to support everyone and stay out of any drama. I’m doing all that I can do at this point in time.

This is inhumane and torturous for the USA to be treating their citizens this way! Someone please help us!

Here’s the letter that I wrote to the Human Rights Watch group, run by Kerry Kennedy:

Dear Ms. Kennedy 

I’m writing to you today because I know that you help people who’ve had their human rights violated. I represent only one out of 100 million people in the chronic pain community. Out of that number, there are an estimated 26 million of us who urgently need your help.  Many people in the United States of America are  dealing with horrific pain on a daily basis.  I stand along with them  & implore you to help put an end to the violation of human rights that is taking place. 

The CDC, DEA and “Big Brother” Pharma companies are “hurting” the American chronic pain Community. We are losing access to medically necessary medications that enable us to live some semblance of a life. 

We are and have been losing access to our pain relieving medications since the implementation of 2016 CDC Guidelines.  We are  being “lumped together” with illicit drug users and addicts. Every time a celebrity dies of an overdose, they blame the pain meds as the cause of death. But really it’s the misuse and abuse of pain medications along with the use of recreational street drugs. 

A Dr. should not be afraid to prescribe Opioid pain medications to their patients because of repercussions from the CDC or DEA. But our pain Physicians are leaving in droves because of them & the 2016 CDC Guidelines. 

The  “Opioid epidemic” is about illegal/illicit fentanyl brought here from Mexico & China. It’s not about us, the 100 million chronic pain patients in the USA. Only 1% of legitimate chronic pain patients who are legitimately prescribed opioids, for high amounts of pain, ever become addicted. It’s as though our country is now torturing and punishing people for being ill.

Ms. Kennedy, we are not addicts and we are not “addicted”.  A person can be “dependent” on a medication and not be addicted! They are two very different situations. We are not addicted to our medications and we do not get cravings nor do we get “high” from them. An addict seeks out their “drug of choice” at any cost.  They look forward to taking them because of the “high” they get. A legitimate chronic pain patient who’s done well for years on a stable dose of opioid pain medication, doesn’t get any sort of “high”.  We also take our medications responsibly.  We get some relief and reprieve from the daily chronic pain that we live with. 

Please help us get back the physician / patient relationship, without interference from Pharmacy’s, insurers, the government and politics.  Please help us to keep our Drs in charge. It should be the decision between patient/physician to choose what is necessary and best for our pain control. They went to medical school and the government did not.

Many pain management Dr’s are leaving the practices they’ve built and the profession they’ve worked hard at, to achieve. They’re  afraid because they are being wrongly targeted by the DEA . They aren’t free to prescribe medications that help to relieve pain anymore. 

People in the USA in 2019 are being tortured and hurt by this on a daily basis. Just yesterday, I read the story of a 94-year-old woman who shattered her kneecap and was taken to the hospital emergency room. They immobilized her knee and sent her home without any pain control at all. Can you even imagine shattering your kneecap and not getting any thing to help with a torturous pain like that?
Ms. Kennedy, please help us? I understand there are people who die from overdoses. But they are a totally separate group of people who need a different kind of help. It shouldn’t be at the expense of an entire separate community of citizens. People In pain are being taken off of their Opioid pain medication during one visit to the Dr’s office. Often it’s a Dr. that they’ve gone to for years and they’d been living some semblance of a life while on a regimen of medication for pain control. But because of “fear”, Dr’s are taking away the little bit of life that some of us have left. 

I also don’t believe that anyone should be FORCED to have an invasive surgery in their spine or anywhere for that matter; when an inexpensive & safe pill, with little side effects can help so much. 

I implore you to help the estimated 26 million chronic pain patients in the USA, who are “dependent” on opioids for pain control & who are diligent and take these medications responsibly. Help us to get back the freedom of choice. Get us back to the pain management medication regimens that are life sustaining for us with more tolerable pain levels.

Please read my letter and talk to me if you’d like. We need you to understand that we are “chronic pain patients” and not “addicts”! We are just real people living with unfortunate circumstances & high pain illnesses. Please help us to receive the medications that give us some semblance of a life for ourselves & our families.

Sincerely,

Suzanne B. Stewart
Recipient of U.S. Pain Ambassador of the Year Award‘16, Mentor & Social Media Coordinator @RSDSA, freelance writer, Blogger/Blog “Tears Of Truth” @tearsoftruth.com, Patient leader WEGO Health, HoH/ASL, Director of communications for Deaf/HoH for CIAAG, patient advocate for Deaf/HoH
“Out of suffering have emerged the strongest souls; the most massive characters are seared with scars” ~Khalil Gibran~
DISCLAIMER: The contentI is not intended to be a substitute for professional medical advice, diagnosis, or treatment. We do not recommend the self-management of health problems. We can not and do not give you medical advice. The information in this e mail should not be considered complete. Information obtained in this e mail is not exhaustive and does not cover all diseases, ailments, physical conditions or their treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this e mail. If you think you may have a medical emergency, call your doctor or 911 immediately. I do not represent to be an authority but I’m just helping pass information from other organizations, advocates and or websites.

America’s Chronic Pain Community Being “Used as Study Subjects”?


What you are about to read will truly surprise you; or maybe not? As you may know, Lauren DeLuca, President and Founder of CIAAG (Chronic Illness Advocacy and Awareness Group)  & Shasta Harner, Director of CIAAG; have been In Washington DC this week.  They are in our nations capital working tirelessly for the chronic pain community. While others including Jayne Flanders, C0-founder & Vice President, Andrew Auell, Director of Research, Peggy O’Connor, Legal analyst have been working “behind the scenes” on social network, writing, making phone calls to legislators etc.  The information that Lauren and Shasta have unraveled is very interesting and may or may not surprise you.  Read on…..

As  you know, we are in the middle of an Under-treated and Untreated Pain crisis and that is what the “Opioid crisis” truly is all about.  The efforts of the CDC, FDA and addiction specialists etc., to reduce opioid prescribing in the USA, has resulted in only a rise in overdoses and suicides. Prescribing of these medications for the treatment of chronic pain and high pain chronic illnesses is at the lowest point it has been in 25 years. Yet the overdose rate has increased because the addicts will find a way to get what they want and need even through illegal and drastic measures. They are getting illicit/illegal fentanyl and carafentanyl from China and Mexico and they are overdosing.  The suicide rate has gone up because the pain community is being tortured and persons with one or multiple High pain illnesses, are being left to suffer endless pain and ultimately torture.

How did this happen?  Lauren and Shasta have come to a conclusion about this while they’ve been doing lots of research and attending meetings in D.C. Their findings indicate this:  “that the CDC guidlines are actually part of a massive population-based study- a clinical trial if you will- that has been implemented into the national healthcare delivery system without the consent or knowledge of the American citizens impacted.  In review of the CDC guidelines’ execution, our organization has discovered what appear to be serious conflicrs of interest, potential financial incentives between parties intimately involved in the study, privacy, as well as of the constitutional, legal, ethical and moral rights of the citizenry.  Please send inquiries to lldeluca@ciaag.net or by phone at (774) 262–6671.”

Lastly, I have a CALL TO ACTION for the Pain Community: “Please Register (it is free to become a member) to beome a member of CIAAG. Next, if you would please show your support by mentioning CIAAG on your Twitter profile to show that you are a member. Please take this proposal and the info that CIAAG has found and disseminate it out into the community to your physicians, politicians, pharmacists, insurers, caretakers, family and friends; along with your state Dept.’s of Health.

****Just a reminder there are many flyers that are free to download from the CIAAG website (www.CIAAG.net) .  You are welcomed to please download this information and also disseminate all of that information into the community as well.  Thank you so much to everyone who has done so much to fight for the rights of the chronically ill, disabled and those who live with high impact chronic pain on a daily basis. If you would like to help a bit more, please remember to use the #CIAAGstrong

 

 

 

 

Frontal lobotomy for the relief of intractable pain • CERGM


Hello Luvs,

Ohh My Goodness!!! Has our society gone completely mad now? These “sickos” may be taking us back in time to a period when people were given a Frontal lobotomy for the relief of intractable pain!! This is absolutely crazy, when a safe pill, called an “opioid” can help our chronic intractable pain patients. Who in their right mind would choose a frontal lobotomy over a safe an effective pill? The opioids that are getting a bad rap from anti-opioid zealots (read more about them, here: Anti-Opioid Zealots ), are not hurting the legitimate chronic pain patients. People who’ve been prescribed opioids for years, (a decade or even more) & have done well; are NOT addicted! Only about 1% of true chronic pain patients actually ever become “addicted” (Writer Josh Bloom, gives you statistics here: The Opioid Epidemic in 6 Charts, Designed to Deceive You ). It’s not prescription opioids that are the problem! It’s the illegal fentanyl from China & Mexico that are hurting, addicting & killing people! Addiction and dependence are two very different situations. You can find out more information about that here: Addiction & Dependence Are Not The Same

Who are the bad actors? Government, Healthcare or Patients? • CERGM
— Read on cergm.carter-brothers.com/2019/03/28/frontal-lobotomy-for-the-relief-of-intractable-pain/

The Nightmares of Pain Refugees


Hello Luvs,

I was deeply touched by 2 stories that I’m about to share with you! I’d like to personally say “thank you” to Sheri Owen & Maria Higgenbothem. They are the 1st and then the 2nd chronic pain patients in the video below. I want to thank them for their bravery and their candidness.

Sheri had a level-7, spinal fusion and did not receive any pain care in the hospital after her surgery; outside of the normal regimen that she’s been on for years at home.

Secondly, we have Maria Higinbotham, who went on “Nightly news with Lester Holt and Kate Snow. What’s happening to the Chronic Pain community is torturous and wrong! It’s inhumane and I would’ve never thought this would be happening in the United States of America in 2019. It’s almost like the old practice of eugenics. As if they want us to be gone? So that we’re not a burden on society anymore? This is so morally wrong! Please go to http://www.Videoyourpain.com.

Share your pain story with our legislators, politicians, government, doctors, and pharmacists. Let’s share these painful stories with the world and command that this torture be stopped!

I’ve put the two videos together for your convenience and to CC for the Deaf and Hard of Hearing communities/audiences.

Also, I’d like to add that there are several advocates & groups who trying so hard to do all that they can to help the pain community! I thank you all from the bottom of my heart.

Here’s the link to the original “Nightly News” piece on NBC. (Lastly, there are two news media outlets that are listening to us. Fox News and NBC now have their ears and attention turned to the pain community. Let’s tell them everything that’s happening. Talk to Lester Holt, Kate Snow at NBC & Greg Gutfeld at Fox News. Go to Twitter and find them by putting their name in the search bar. Talk to them! Tell everyone you’re story of under treated and/or untreated pain. They are now listening and we need their help and their voices!

I’d like to say a special “thank you” to David Weiland for posting the video in CIAAG Facebook group.

Here’s the Link to the Facebook Page for “Nightly News” with Lester- NBC Holt

This is the “Chronic Illness & Awareness Advocacy Group (CIAAG) and Non-Profit .org 501(c)(3), Founded & run by Lauren DeLuca & Jayne Flanders: Here’s the link to “CIAAG” Chronic illness awareness and advocacy group on Facebook

Here is the online link to the CIAAG website at www.ciaag.net

Here also are the links to listen to Dr Kline, MD, at Jonelle Elgaway’s Show on Conspiracies Against Wellness Network (CAW): You Tube page for CAW

Here are the links to the C-50 states group page run by Valorie Hawk: Link to Coalition of State Leaders Group C-50

Please everyone try your best to come together and let’s fix this problem! Because it’s a huge problem, a national emergency and a humanitarian crisis.

Here are two more links to a couple of great videos about #1: several pain patients stories of torture: The Link to “Fight for Our Lives”, a short Video that I made regarding this opioid hysteria & untreated pain crisis and #2 is a video about Suboxone. Link to my video, ”Pain, Politics & Suboxone” (It’s a good drug if you’re an addict but has a very low analgesic effect on chronic pain. Not a good choice for persons living with chronic pain illnesses)

Thank you for reading and please share!

Are Imposters Preying On Unsuspecting Patients In Our Pain Community Again?


Hello Luvs

Once again I’m so sorry to be giving the news regarding the possibility of imposters (or at the very least, these are persons who don’t have the best interest of our pain community in their hearts) infiltrating our pain community. Last I wrote about this subject, was a month ago, inside of several groups, to warn them! It was regarding the notorious “Kate Ashworth” aka “fake RSD/CRPS guru”(see article link below). She was back again; hurting unknowing chronic pain patients! Those affected, just happened to be persons who also live with the unbearable pain of RSD/CRPS. (To find out more about RSD/CRPS, please visit: For Real Facts & Information About RSD/CRPS, follow this link to RSDSA Home Page (Reflex Sympathetic Dystrophy Syndrome Association)

*(To Read the article about the imposter,“Kate Ashworth”,who recently came back a second time & infiltrated the RSD/CRPS community; visit this link: This is the Link to the article about Kate Ashworth, an Imposter to the Chronic Pain Community) “Strangers Among Us”

On Tuesday night 3-6-29; I saw a message from a long time RSD/CRPS friend on Facebook. I saw the message very late in middle of the night and it was written by Mary Mattio, in a “closed & secret” Facebook support Group for RSD/CRPS. Posting with permission, this is what I read at approximately 11:30 pm:

I’ll show you everything that was written underneath. But first I want to say “thank you” to Mary Mattio for posting about this to the Facebook group, . When digging deeper, I’d like to say “thank you” also to Tracey Tipton-Morales & Marisa Gravett for their “detective work”, involvement and postings. But we need to all give a special thanks to Sarah Lesley, for being the first to figure out all of this mess which I’m going to try to explain. So thank you to everyone who’s been involved in getting the word out, sharing, reporting and blocking these alleged fakes.(I have to say “alleged” but I believe it is true, with my whole heart!)

This was the full post shared from Sarah Lesley & Marisa Gravett:

⚠️ ATTENTION CHRONIC PAIN COMMUNITY⚠️

* Shared from Sarah Lesley & Marisa Gravett *

Okay CRPS Community: If you are in the group “RSD/CRPS and Neuropathic Pain Syndrome” beware… This was brought to my attention this morning. One of the admins actually works for a treatment center that focuses on getting pain patients to stop talking about their pain, basically making it seem like it’s all in our heads. I just saw a YouTube video shared in a post on that page this morning of him doing a presentation about his research and recovery centers and how it focuses on getting pain patients to stop focusing on their pain and to be able to return to be active members of society again. Basically making it sound like we don’t really need medical care, treatment etc…

I am infuriated at some of the things that I have seen and found out. We believe that many of the admins are either fake or using fake names and or involved in depth with Dr. Rand and his treatment centers as one of his treatment centers is referred to as the Bay Area and the last name of many of the admins is Bay…

Think of this as a conspiracy theory if you wish but I have just seen with my own eyes a YouTube video by Dr. Rand speaking about these treatment centers and it is very clear that this group and possibly other groups that we may all be involved in with similar admins, maybe using the information that we give against us as research, or to turn it in to help with their research or so-called research.

It is clear that this group is not created to help others. Many of the members I am sure do their best to help many people in this group to share information to ask questions and I do not blame or think any of the members are involved except for the ones that are listed as admins.

If you are in this group you are advised to check it out for yourself and if you feel the same way to delete the posts that you have in that page as well as get out of it. Also I would advise all of us to take a better look at who the admins are in many of our groups if we do not know or have never checked it out. We need to do all we can to look out for ourselves and our fellow CRPS Warriors and if there is any chance that this group is not on the up-and-up or could be using our information for any purpose other than to help each other live a life with this horrendous evil monster of a disease, I want no part of it and I do not want any of you to as well.

I was originally going to tag everybody in the post within the group that I’m friends with but there are so many of you I ran out of room on a piece of paper writing your names. I’ll be tagging as many as it will allow. Please if you are a CRPS Warrior check out this group check out the information for yourself and be careful out there.

I urge you all to please report all the fake profiles & all the groups that the fake profiles created & are Admins of, it’s the only way we can get them shut down. This post is now public, please feel free to share. Marisa Gravett has additional information on this as well.

Look up Jerrod Rand on YouTube if you want to see for yourself. Be careful out their Warriors. We are finding way too many wolves in sheeps clothing within our community.

** BELOW ARE SCREENSHOTS OF THE ADMINS & A FEW OF THE GROUPS & PAGES THAT ARE LINKED TO THEM **

**BEFORE I REPORTED & BLOCKED THIS “JERROLD RAND” facebook account (whether someone is using his name, or it is truly this person; we don’t know yet?)- I FOUND THIS POST VERY INTERESTING & TELLING OF PROBLEMS ON/WITH THAT PAGE:

I wanted to add that we all need to be vigilant, but we cannot allow ourselves to overreact or get too upset over this. Though it is very upsetting, our main goal is to stay calm and get the “word out” to the RSD/CRPS & Pain Communities. If everyone who reads this can go and report each of these groups and the 5 accounts that appear to be for the sole purpose of “pushing” these 30 or so “support groups” on unknowing people in pain! If we all can do that, Facebook will be able to shut them down!

Please understand that I’m in no way condemning those who have joined these groups. It’s not their fault. It’s the admins (whoever they truly are??) of those groups who are to blame. They are violating our community and others. Once again, people had recently been asked to send in photos of their Rsd/CRPS affected limbs. People, please don’t send your photos to anyone who asks. If you’re friends with someone who you know & feel comfortable with; and you want to share a photo; go for it! But please, just a bit of advice from my heart: “please don’t send your personal medical photos to anyone who requests them from you”. Also, PLEASE don’t take any medical advice from anyone online. They could be impersonating anyone! Only take therapeutic, medical advice from your own personal medical professionals. The ones who know you and your personal mecical history.

Any questions, please don’t hesitate to ask: Sarah Lesley, Mary Mattio, Marisa Gravett, Tracey Tipton-Morales or you can ask me & I’ll do my best to get the right answers for you.

Please share this public blog post everywhere that you can. We need to look out form& take care of each other! Thank you for your time!

Lastly, here’s a link to a video by Jerrold Rand who seems to be the ringleader:

1: “Dr” J. Rand on Opiate use” at his Youtube channel called “Bay Recovery”

2: “Dr” J. Rand talks about Methadone on his Youtube channel

3: THIS ONE MAY UPSET YOU- if you’re fighting for your life-saving pain medication right now (just forewarning you): “Dr.” J. Rand’s patient talking about chronic pain etc. (On Youtube)

I hope that you will all just take this information and do what’s in your heart. I cannot honestly write here, that I know anything “for sure” about this quack! I’m writing an opinion piece (because we are all allowed to have our own personal feelings and opinions). But my opinion is that this guy and his 30+ Facebook groups, fake admins (possibly?) and several fake accounts, are frauds! I’m just sayin’—–check the one photo screenshot above especially!! The one that shows that his license was revoked in 2012!! Then look at the News story underneath that one! About him self-prescribing sleeping pills etc! Also, it appears from that News piece, that he somehow may have been responsible for a women’s death??

Sorry for the bad news! But I love you all with my whole heart & soul. I feel an inner tug at my heart to protect you in any way possible.

Pushing Pain Patients into Labels “Opioid Misuse”


Hello Luvs,
My fellow advocate and friend, Bob Schubring sent me this message via email. I wanted to share with his permission. It’s regarding a bit of a turn around regarding this under-treated & untreated pain crisis. So without further ado, here is the message sending love & light:
“I’ve taken the liberty of clipping and dropping the entire article below.  It is compelling and I believe highly representative of the experience of many chronic pain patients.  Please feel free to reference these published findings in your own editorial or advocacy work.  I also attempted to submit a comment,  but NEMJ isn’t accepting input from non-subscribers.  I’ll look for a comment gateway direct to the editors. 

Title:  Reported Outcomes for Mister O are Highly Representative

As a non-physician advocate for chronic pain patients with 22 years experience, I see the story of Mr O repeated widely and horrendously.  The current regulatory environment on opioid analgesic therapy is grossly distorted by mythologies about who becomes addicted and from what sources.  Public policy is actively denying treatment to hundreds of thousands of people in agony.  Doctors are fleeing practice, deserting their patients;  those who do not flee are refusing the therapies that are often the only effective measures.

The largest mythology is the least acknowledged:  physician over-prescribing did not cause and is not sustaining our public health crisis in addiction and mortality.  CDC statistics reveal no cause and effect relationship between State by State prescribing rates vs opioid-related mortality from all sources, legal, diverted, or illegal. Contribution of medically managed opioids is so small that it gets lost in the noise of street drugs.  Moreover, the demographics don’t work and never have.  Seniors have the highest prescription rates and the lowest mortality due to opioids. People under 30 are six times more likely than seniors to die of opioids. 
Regards, 
Richard A “Red” Lawhern PhD

Director of Research

Alliance for the Treatment of Intractable Pain  

on Twitter: @theatipusa
Facebook:  https://www.facebook.com/ATIPUSA/
My Publications: http://www.face-facts.org/Lawhern
Personal Website:  http://www.lawhern.org

https://www.nejm.org/doi/full/10.1056/NEJMp1811473

Structural Iatrogenesis — A 43-Year-Old Man with “Opioid Misuse”

  • Scott Stonington, M.D., Ph.D., 
  • and Diana Coffa, M.D

Mr. O., a 43-year-old man with severe, destructive rheumatoid arthritis, had been receiving acetaminophen–hydrocodone at low doses from his primary care provider (PCP) for 15 years. He worked in an auto-parts factory in southeastern Michigan, and pain control was essential to maintaining his employment. His pain had been well managed on a stable regimen, and he had not shown evidence of opioid use disorder.
In 2011, his primary care clinic began requiring patient–provider agreements (“pain contracts”) and regular urine drug testing. Mr. O. participated willingly, and his tests were consistently negative for unprescribed substances. In 2014, his insurance company began to require annual prior authorization for all controlled-substance refills. Although there were small delays in receiving medication once a year when the authorization was due, the patient was able to keep his pain level stable on his usual regimen.
In 2016, Mr. O.’s PCP retired, and his care was transferred to another PCP in the same office, who followed the patient’s existing pain-management plan. The same year, the insurance company began requiring more frequent prior authorizations and then that prescriptions be sent to the pharmacy every 15 days. The new PCP was occasionally late providing these prescriptions and approving prior authorizations because of the required multistep interactions with the insurance company. Mr. O. did not own a car and had difficulty making frequent trips to the pharmacy. He began to have several-day gaps in medication. During these gaps, he experienced severe pain and mild withdrawal, as a result of which he performed poorly at work and received a citation. He became very concerned about losing his job.

Mr. O. made an appointment with his PCP and requested an increase in his number of pills, wanting to “stockpile pills so that I’ll never run out.” The PCP noted that Mr. O. seemed nervous during the conversation. She noted in the chart that the interaction “made her uncomfortable.” She knew that the previous PCP had reported that Mr. O. had shown no evidence of opioid misuse, but in the current environment of vigilance regarding the risks posed by opiates, she did not feel comfortable increasing the number of pills.

Three months later, the patient submitted a urine sample that tested positive for unprescribed oxycodone. When the PCP discussed the result with Mr. O., she learned that he had obtained oxycodone from a friend during one of his gaps in medication. 

The following month, oxycodone was once again found in his urine. Already overwhelmed by the frequent need for prior authorizations, and noting that Mr. O. had “violated his contract” by submitting two urine samples containing unprescribed opioids, the PCP referred him to a local pain clinic.

The wait time for an appointment at the clinic was 4 months. The PCP continued to provide prescriptions during that period, planning to stop prescribing as soon as Mr. O. had his first appointment. When he arrived at the pain clinic, Mr. O. learned that it had a policy of not prescribing opioids for the first two visits. Facing a prolonged period without his usual regimen, and having previously failed to obtain any “extra” acetaminophen–hydrocodone from his PCP, Mr. O. began purchasing his full narcotic regimen (in the form of oxycodone) from a friend.

Social Analysis Concept: Structural Iatrogenesis

Through a series of events, Mr. O.’s therapeutic relationship with his PCP deteriorated, and he became compelled to obtain medications outside the medical setting, which in turn increased his risk of overdose, as well as his risk of arrest for possession of unprescribed opioids. This shift was not precipitated by physiological changes in Mr. O.’s disease, need for medication, or personal attributes. Rather, it was caused by structural forces outside his control, ranging from clinic policies (pain agreements, a drug-testing initiative, a moratorium on prescribing) to corporate bureaucracies (insurance companies, factory management) to larger-scale social forces (poverty, lack of availability of transportation, lack of opportunities for work appropriate for someone with a painful condition).

We call this type of harm “structural iatrogenesis” (see box). Drawing on a long history of social science scholarship,1the use of the term “structure” emphasizes that Mr. O.’s poor outcome was determined by social forces and structures outside his control. The term “iatrogenesis” specifically focuses on the harmful role of bureaucratic structures within medicine itself. In Mr. O.’s case, many of these structures had been instituted to protect patients at risk for opioid use disorder: clinicians acted according to prevailing standards of care in chronic pain management; his prior clinic’s pain contract and urine drug screens were meant to prevent deviation from prescribed opioid use that might place him at risk for overdose or addiction; the pain clinic’s protocol of delayed prescribing was meant to prevent patients from “shopping” for opioid prescriptions; prior authorizations required by the insurance company were intended to reduce overprescription of potentially harmful (and costly) medications. But these systems were not beneficial to Mr. O. in the context of his economically and socially precarious life, which was shaped by a lack of transportation and a need to perform painful manual labor for economic survival.

Structural Iatrogenesis

Structural iatrogenesis is the causing of clinical harm to patients by bureaucratic systems within medicine, including those intended to benefit them.

Structural iatrogenesis is a type of “structural violence,” defined as the systematic infliction of disproportionate harm on certain people by large-scale social forces such as resource distribution and hierarchies of race, gender, or language.2,3 “Iatrogenesis” points to the causation of such harm by bureaucratic systems that are potentially under clinicians’ or health systems’ control.4

Clinical Implications: Stopping Structural Iatrogenesis

Clinicians who identify structural iatrogenesis may alter structures or create action plans to prevent them from causing harm. Generalizing from Mr. O.’s case, we would offer the following approach:


1. Recognize and alter structures that systematically harm patients.
 Clinicians may be the first to identify a structure that is systematically harming patients and can then advocate for or directly effect change. For example, in the 1980s, the Food and Drug Administration and physician organizations recommended that women undergo pelvic exams before receiving hormonal contraception. Some clinicians noted that these exams were a barrier to contraceptive access and stopped requiring them in their own clinics. By the 1990s, these local changes led to removal of the recommendation from national policy, which increased access to contraception and rates of effective use.5

Similarly, if Mr. O.’s PCP noticed that her clinic’s opioid-prescribing policy generated frequent gaps in medication coverage for patients in general, she could have advocated for a new approach. It’s important, however, to avoid the pitfall of thinking that structural harm emerges only from “broken” systems. All structures carry a risk of harm, even when they are functioning “properly.” 
The policy in Mr. O.’s PCP’s office might have been working well for most patients, but it turned out to be a poor fit for Mr. O.


2. Bend policies according to context.
 Attempts to standardize clinical care in order to ensure high quality often inadvertently lump complex phenomena into simplistic categories. Such oversimplification, in turn, can create structures within clinical care that harm patients more than help them. By questioning how such categories (such as “opioid misuse”) apply to particular patients and types of patients, clinicians can work to reduce the risk of structural iatrogenesis. The label of “opioid misuser,” for example, negatively affected Mr. O.’s care by failing to acknowledge reasons that he might be acquiring medications outside the clinic.
Similarly, clinic policies that penalize patients for arriving late to appointments disproportionately harm people who don’t own a car or control their work schedule. And policies of rewarding clinicians on the basis of quantitative measures of practice quality, such as reductions in glycated hemoglobin levels, may ignore complex disease interactions and the social factors contributing to diabetes and may create an incentive for clinicians to drop particularly sick patients. Instead, one might identify patients with particular vulnerabilities and adjust policies on the basis of their life context
3. Address implicit agendas head-on. Mr. O.’s care deteriorated when he was labeled an “opioid misuser.” This designation was putatively a clinical diagnosis, but it also marked a tacit category shift from “good patient” to “bad patient,” reflecting the mixing of clinical reasoning with moral judgment. Similarly, the insurance company’s rationale for requiring more frequent prescriptions mixed a harm-reduction agenda (reducing risk for addiction and death) with a profit motive (reducing payouts for medications). Mr. O’s poor clinical outcome was due in part to tensions between these implicit agendas. Clinicians often consider such agendas to be outside their purview, but given that they have such a significant impact on clinical outcomes, it may be more effective clinically to identify these agendas, assess their interactions, and decide which ones to prioritize. The staff of Mr. O.’s clinic, for example, could recognize the moral judgment involved in the diagnosis of “opioid misuse” and instead set an explicit goal of identifying behaviors that could increase a patient’s risk of addition, overdose, or dangerous side effects. They could then assess whether their established protocols were achieving that goal and how to balance it with other goals.

Case Follow-up

At Mr. O.’s next visit, his PCP expressed concern about risks of overdose and legal harm from use of unprescribed oxycodone. She persuaded him to return to the pain clinic, and in the meantime she agreed to continue prescribing his opioids. A medical assistant appealed for an exemption to the insurance company’s 15-day prescription rule, citing Mr. O.’s lack of transportation, fragile work circumstances, and long-standing treatment. At the time we wrote this article, it remained unclear whether these modifications would stabilize Mr. O.’s treatment and prevent his use of unprescribed opioids.

Disclosure forms provided by the authors are available at NEJM.org.

The editors of the Case Studies in Social Medicine are Scott D. Stonington, M.D., Ph.D., Seth M. Holmes, Ph.D., M.D., Helena Hansen, M.D., Ph.D., Jeremy A. Greene, M.D., Ph.D., Keith A. Wailoo, Ph.D., Debra Malina, Ph.D., Stephen Morrissey, Ph.D., Paul E. Farmer, M.D., Ph.D., and Michael G. Marmot, M.B., B.S., Ph.D.

The patient’s initial and some identifying characteristics have been changed to protect his privacy.

Author Affiliations

From the Departments of Anthropology and Internal Medicine, University of Michigan, and the Veterans Administration Medical Center, Ann Arbor (S.S.); and the Department of Family and Community Medicine, University of California, San Francisco, San Francisco (D.C.)