The Broken Thermostat: A Pain Doctor’s Journey from Fighting Fires to Tending the Forest of Chronic Pain

I remember the feeling well.

It was the late 1990s, and I was a young physician specializing in pain management.

I felt a sense of profound clarity and purpose.

My colleagues and I were on the front lines of a revolution, armed with a new, compassionate mandate: “Pain as the 5th Vital Sign”.¹

We were taught that pain, like blood pressure or heart rate, was a simple metric to be measured and corrected.

For too long, our predecessors had allowed patients to suffer needlessly.

We were going to change that.

The American Pain Society, the Joint Commission, and even the Veterans Health Administration had all endorsed this new philosophy, creating an environment where aggressive pain treatment wasn’t just encouraged; it was the standard of care.³

Our primary tool in this fight was a new generation of powerful long-acting opioid analgesics.

Pharmaceutical companies assured us, with what seemed like solid evidence at the time, that these medications were a safe and effective solution for chronic non-cancer pain.⁶

I remember reading a guide, sponsored by Purdue Pharma, which stated unequivocally that “there is no evidence that addiction is a significant issue when persons are given opioids for pain control”.¹

The logic seemed unassailable: assess pain on a simple 1-10 scale, and titrate the dose of a long-acting opioid until that number went down.

It was clean, modern, and righteous.

I saw myself as a liberator, freeing my patients from the shackles of their suffering.

Then I met Mr. Evans.

Mr. Evans (a composite of many patients I treated, to protect privacy) was a 45-year-old contractor who had been sidelined by a herniated D.Sc. His back pain was real, debilitating, and had a clear origin.

He was the perfect candidate for our new approach.

I followed the protocol to the letter.

We started with short-acting opioids for his acute pain, and then, to provide him with stable, around-the-clock relief, I transitioned him to a long-acting formulation.

But his pain, a 7 out of 10, didn’t budge.

So, I did what I was trained to do.

I increased the dose.

His pain persisted.

I increased the dose again.

And that’s when things started to go terribly wrong.

Instead of improving, Mr. Evans got worse.

The character of his pain began to change.

It was no longer just a deep ache in his lower back.

A strange, burning sensation began to creep down his legs.

Then, his arms started to hurt.

He complained of a diffuse, all-over sensitivity where even the light touch of his bedsheets was uncomfortable.

The medication that was supposed to give him his life back was shrinking his world.

He stopped working entirely.

He stopped going to his son’s baseball games.

He spent most of his days in a recliner, caught in a fog of pain, sedation, and despair.

I was stumped.

This wasn’t just tolerance, which I understood as a simple diminishing of effect over time.

This was something else, something paradoxical and monstrous.

I was following the map I had been given, but it was leading us deeper and deeper into a dark, unfamiliar forest.¹⁰

The experience with Mr. Evans was the first, deep crack in the foundation of my professional confidence.

It forced me to confront a terrifying possibility: that the very tools I believed were healing my patients might, in some cases, be the source of a new and more insidious kind of suffering.

I had been taught to treat chronic pain as if it were a simple house fire, to be extinguished by pouring on more and more water.

But what if it wasn’t a fire at all? What if it was a complex, damaged ecosystem, and my attempts to help were only making things worse? That question sent me on a journey—a forensic investigation into the true nature of chronic pain, the tools we use to treat it, and the flawed paradigm that had led us all so tragically astray.

Part I: The Old Paradigm – A Monoculture of Pain Management

To understand how I, and an entire generation of well-meaning physicians, ended up in that dark forest with patients like Mr. Evans, one has to understand the system that created our maps.

It was a system built on a dangerous oversimplification, a “monoculture” of thought that reduced the infinitely complex experience of chronic pain to a single number and a single solution.

The Rise of the “Fifth Vital Sign” and the Opioid Monoculture

The movement began with the best of intentions.

In 1996, the president of the American Pain Society, Dr. James Campbell, gave a speech in which he introduced the powerful concept of “Pain as the 5th Vital Sign”.³

The goal was to elevate the assessment of pain to the same level as temperature, blood pressure, pulse, and respiration, forcing clinicians to take it seriously.¹

The idea was compelling and spread like wildfire.

The Veterans Health Administration (VA) and The Joint Commission (then JCAHO) quickly adopted it, creating national standards that mandated regular pain screening for all patients.⁵

This mandate, however, had a profound and often-overlooked consequence: it created immense institutional pressure on clinicians.

Pain, a subjective and deeply personal experience, was flattened into an objective-seeming number on a 1-10 scale.

Patient satisfaction surveys, which were beginning to be linked to hospital reimbursement, often included questions about pain control.²

The message from the system was clear: get that number down.

We were prompted at every encounter by the presence of a pain score, and the most efficient way to respond was to write a prescription.¹²

Concurrent with this clinical pressure was a revolution in the pharmaceutical industry.

New long-acting opioid formulations, most famously OxyContin, were being aggressively marketed to physicians as the ideal solution for chronic non-cancer pain.⁶

We were told these drugs offered smooth, continuous pain relief without the peaks and valleys of short-acting pills, and, most critically, that the risk of addiction was low.⁸

This created a false sense of security that permeated the medical community, a belief that we finally had a safe and powerful tool to fulfill the mandate of the “Fifth Vital Sign”.⁶

The convergence of these two forces—institutional pressure to treat pain and the aggressive marketing of a seemingly perfect tool—led to the establishment of a clinical monoculture.

We became reliant on a single class of drugs to treat a vast and heterogeneous array of pain conditions.¹³

The rich, diverse ecosystem of pain management, which should include physical therapies, psychological interventions, and a wide range of non-opioid medications, was paved over.

We lacked the training, the time, and the systemic support to do anything else.¹²

The prescription pad became our primary, and often only, tool.

The Unraveling – When the Cure Becomes the Problem

This monoculture was built on a fundamentally flawed foundation: a purely biomedical model of pain.

This model, a legacy of 17th-century philosophy, views pain as a straightforward signal of tissue damage—the more damage, the more pain.¹⁵

While this holds true for acute injuries, it fails spectacularly in the context of chronic pain, where the nervous system itself becomes dysregulated and begins to generate and amplify pain signals long after the initial injury has healed.

We were using a simple mechanical model to treat a complex biological adaptation.

This mismatch created an impossible trap for clinicians.

As the devastating consequences of our prescribing practices became apparent in the form of the opioid crisis, we found ourselves caught in a “Catch-22”.¹⁶

On one hand, we were still under pressure to alleviate our patients’ suffering.

On the other, we were witnessing an epidemic of addiction, misuse, and overdose deaths unfolding before our eyes.⁶

The fundamental goals of medicine—to relieve suffering and to do no harm—were now in direct opposition.

The regulatory response to the crisis, while necessary, only tightened the vise.

The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, for example, was intended as a flexible guide but was widely misinterpreted by health systems, insurers, and pharmacies as a set of rigid, absolute rules.⁸

The guideline’s suggestion to “use caution” when exceeding certain dosage thresholds was often translated into hard limits, leading to forced tapers and abrupt discontinuation of medication for stable patients.¹⁷

A climate of fear descended upon the medical community.

The threat of investigation by the Drug Enforcement Administration (DEA) or state medical boards became a constant, looming presence.¹⁸

Many physicians, afraid of the scrutiny, began to undertreat pain or simply refused to accept new patients who were taking opioids, effectively abandoning them.⁶

The pendulum had swung from one extreme to the other.

The very system that had pushed us to prescribe with abandon was now punishing us for it, leaving both doctors and patients stranded in a landscape of fear, mistrust, and confusion.

We had failed to see that the problem wasn’t just the tool (opioids) or the user (physicians); it was the entire conceptual framework.

We had misdiagnosed the nature of chronic pain itself.

Part II: The Epiphany – Pain Management as Ecological Succession

My journey out of that dark forest began when I finally admitted that my map was wrong.

The mechanical metaphor—the idea that the nervous system was a machine with a broken wire that just needed the right chemical to patch it—was failing me and my patients.

The turning point came when I started exploring a different field entirely: ecology.

It was there I found a new metaphor, a new paradigm that didn’t just give me an answer, but gave me a whole new way to see the problem.

The nervous system isn’t a machine; it’s a living, adaptive ecosystem.

And a nervous system subjected to chronic pain and long-term opioid therapy isn’t just “broken”; it’s a disturbed ecosystem undergoing a process of ecological succession.

The Ecological Analogy: From Clear-Cut Forest to Climax Community

Imagine a healthy, old-growth forest.

It’s a complex, resilient, and balanced system.

Now, imagine a catastrophic event, like a clear-cutting.

This is acute injury.

The original ecosystem is gone, leaving behind bare, vulnerable soil.

In the immediate aftermath, the first things to grow are fast-growing, opportunistic “pioneer weeds.” This is the role of short-acting opioids.

They cover the bare ground quickly, providing immediate relief and preventing further erosion.

They are essential in the acute phase.

But they do not rebuild the original forest.

They create a new, temporary, and often unstable environment.

The real problem begins when we try to manage this new landscape with a single, powerful tool over a long period.

The prolonged, escalating use of opioids doesn’t just fail to work; it actively and fundamentally changes the ecosystem.

It’s like spraying a powerful, non-selective herbicide that, over time, poisons the soil and allows aggressive, invasive species to take over.

In the context of chronic pain, these invasive species are Central Sensitization and Opioid-Induced Hyperalgesia (OIH).

• Central Sensitization: The Poisoned Soil: This is a phenomenon where the “soil” of the central nervous system itself becomes hypersensitive and reactive.²⁰ The neurons in the spinal cord and brain get stuck in a persistent state of high alert, a process sometimes called “wind-up”.²⁰ They amplify pain signals, so that a stimulus that should be mild is perceived as severe (
  hyperalgesia), and stimuli that shouldn’t be painful at all, like a gentle touch, are experienced as pain (allodynia).²¹ This is why chronic pain can feel so widespread and disconnected from the original injury. The problem is no longer just in the periphery; it’s in the processing centers of the nervous system itself. The system’s thermostat is broken, stuck on high.
• Opioid-Induced Hyperalgesia (OIH): The Paradoxical Weed: This is the most insidious “invasive species,” the one that explained Mr. Evans’s baffling decline. OIH is a paradoxical state where the very opioid being used to treat pain begins to increase the patient’s sensitivity to pain.¹⁰ The herbicide starts acting like a fertilizer for a new, more aggressive type of weed. While the exact mechanisms are still being unraveled, we know it involves complex neuroplastic changes, including the activation of pronociceptive pathways like the NMDA receptor system, which opioids normally don’t interact with.¹⁰ This creates a new pain state, one that is often diffuse, burning, and unfamiliar—exactly the symptoms my patient described.

This ecological framework revealed the critical error in my old approach.

By continuing to increase Mr. Evans’s opioid dose, I wasn’t putting out a fire.

I was fertilizing the invasive species, making the entire ecosystem more toxic and hostile.

This reframes the entire goal of chronic pain management.

We cannot magically regrow the original, pristine forest.

That ecosystem is gone forever.

The new, more realistic, and more compassionate goal is to act as a skilled ecologist, guiding the process of succession toward a stable, resilient, and functional climax community.

This new ecosystem might still have some “weeds” (residual pain), but it is diverse, largely self-regulating, and, most importantly, allows the person to have a rich and meaningful life.

This shifts the primary therapeutic endpoint from the impossible goal of “zero pain” to the achievable one of “maximal function and improved quality of life”.²⁴

Differentiating the Invasive Species: A Clinician’s Guide

The first job of a good ecologist is to correctly identify the species they are dealing with.

In the clinic, this means differentiating between the common phenomena that cause opioid therapy to lose effectiveness.

The most critical distinction is between simple pharmacologic tolerance and the paradoxical state of OIH.

Increasing the opioid dose is the standard response for tolerance, but it is precisely the wrong response for OIH, leading to a vicious cycle of escalating doses and worsening pain.¹¹

The following table is a tool I developed in my own practice to help make this crucial distinction at the bedside.

Feature	Opioid Tolerance	Opioid-Induced Hyperalgesia (OIH)	Withdrawal-Associated Hyperalgesia (WAH)
Definition	A diminished analgesic response to the same dose of an opioid over time, requiring dose escalation to achieve the original effect.28	A paradoxical increase in pain sensitivity caused by opioid exposure, where the medication itself makes the nervous system more pronociceptive.10	A transient state of diffuse pain and heightened sensitivity that occurs during opioid withdrawal or between doses.30
Pain Characteristics	The quality and location of the pain remain the same as the original underlying pain; it is simply less well-controlled by the current dose.	The pain often changes character (e.g., becomes burning or sharp) and spreads to areas unrelated to the original injury. Diffuse allodynia (pain from non-painful stimuli) is a hallmark.10	Characterized by diffuse, flu-like symptoms, including body aches, muscle cramps, and joint pain.31
Response to Dose Increase	Pain temporarily improves. The dose “catches up” to the tolerance.	Pain worsens. Increasing the opioid dose “feeds” the hyperalgesic state, leading to a vicious cycle.11	Not applicable, as the condition is caused by a lack of opioid effect. Symptoms resolve when the opioid dose is administered or stabilized.
Key Differentiator	A loss of analgesia. The drug is working less effectively.	The addition of a new, abnormal pain state. The drug is actively causing a new problem.	A time-limited phenomenon directly linked to the timing of opioid doses and withdrawal.
Ecological Analogy	The original “pioneer weeds” have become resistant to the herbicide, requiring a stronger concentration.	The herbicide is now acting as a fertilizer, causing a new, more aggressive “invasive weed” to grow.	The temporary distress of the ecosystem when the herbicide is withheld.

Part III: A Field Guide to the New Pain Ecosystem

Adopting the ecological paradigm is not just a philosophical shift; it demands a completely different set of clinical tools and strategies.

It requires us to move from being simplistic firefighters to patient, observant forest rangers.

This means surveying the land before we act, choosing our interventions with surgical precision, and fostering biodiversity to create long-term resilience.

Surveying the Land: The Biopsychosocial Assessment

A good ecologist would never intervene without first conducting a thorough survey of the land, analyzing the soil, the climate, and the existing flora and fauna.

In pain medicine, this survey is the biopsychosocial model.¹⁵

It requires us to abandon the myopic 1-10 pain scale and embrace a holistic assessment of the entire person and their environment.

• The “Bio” (The Physical Landscape): This involves a traditional medical workup to understand the biological drivers of nociception—the state of the tissues, the nature of the injury or disease, and any contributing comorbidities.³⁴ This is the bedrock of our assessment, but it is only the beginning.
• The “Psycho” (The Soil Conditions): This is where we assess the psychological factors that can dramatically alter the “soil conditions” of the central nervous system. States like anxiety, depression, fear of movement, and pain catastrophizing (a pattern of negative thinking about pain) are not just reactions to pain; they are powerful amplifiers of central sensitization.³⁴ They can keep the nervous system’s thermostat stuck on high. In the clinic, this means asking different questions. Instead of just “How bad is your pain?” we must ask questions like: “What are you most afraid this pain will stop you from doing?” or “When your pain flares up, what are the thoughts that run through your head?”.³⁶ This helps us understand the cognitive and emotional landscape that is shaping the pain experience.
• The “Social” (The Habitat): This involves assessing the patient’s social “habitat.” Do they have a strong support system? Is their work environment accommodating or stressful? Are they facing financial instability or social isolation? These factors profoundly influence a person’s ability to cope with their condition and engage in the hard work of rehabilitation.³⁴ A patient without stable housing or food security will have immense difficulty managing their pain, no matter what medication I prescribe.³⁶

This comprehensive survey gives us a true map of the patient’s unique pain ecosystem, allowing us to tailor our interventions strategically instead of just blindly spraying herbicide.

Cultivating Keystone Species: A Nuanced Approach to Long-Acting Opioids

In this new paradigm, long-acting opioids are not a monoculture crop to be planted everywhere.

They are highly specialized “keystone species,” to be introduced carefully and for specific ecological purposes.

Their primary benefit lies in their pharmacokinetics: by design, formulations like extended-release (ER), controlled-release (CR), or sustained-release (SR) tablets and patches provide more stable plasma concentrations over time.³⁷

This stability helps avoid the dramatic peaks and troughs of short-acting opioids, which can create a rollercoaster of euphoria and withdrawal that reinforces drug-taking behavior and may even drive hyperalgesic processes.³⁹

The goal of using a long-acting opioid is to establish a calm, steady foundation upon which other therapies can be built.

However, not all keystone species are the same.

Choosing the right one for the right ecological niche is critical.

Deep Dive: Methadone – The “Soil Remediator”

• Ecological Role & Mechanism: Methadone is unique among opioids. It is a powerful mu-opioid agonist, but it also acts as an N-methyl-D-aspartate (NMDA) receptor antagonist.⁴⁰ This dual mechanism is its superpower. The NMDA receptor is a key player in the development of central sensitization and OIH.¹⁰ By blocking this receptor, methadone can directly counteract these processes. It is, in effect, a “soil remediator,” capable of neutralizing the hypersensitive state that other opioids may have caused or exacerbated.
• Use Case: This makes methadone an invaluable tool for patients with complex, refractory pain, particularly neuropathic (nerve-related) pain or when OIH is strongly suspected.⁴⁰ It is often effective when all other opioids have failed. Furthermore, it is extremely inexpensive, making it an accessible option.⁴⁰
• Risks & Clinical Pearls: Methadone is also one of the most dangerous opioids in inexperienced hands. Its pharmacology is notoriously complex. It has an incredibly long and variable elimination half-life (ranging from 15 to over 60 hours), which does not correlate with its duration of pain relief (typically 6-12 hours).⁴¹ This creates a profound risk of “dose stacking,” where repeated doses build up in the body over several days, leading to unexpected and potentially fatal respiratory depression. The cardinal rule for methadone is
  “start low, go slow,” with dose increases no more frequently than every 5-7 days.⁴² It can also prolong the QTc interval in the heart, creating a risk for dangerous arrhythmias, which necessitates baseline and follow-up EKG monitoring.⁴¹ Converting a patient from another opioid to methadone is not a simple linear calculation and requires specialized knowledge and charts, as its relative potency changes at higher doses.⁴¹

Deep Dive: Buprenorphine – The “Ecosystem Stabilizer”

• Ecological Role & Mechanism: Buprenorphine is a partial agonist at the mu-opioid receptor.⁴⁴ This means it binds very tightly to the receptor but activates it only partially. This property gives it a “ceiling effect” for respiratory depression; beyond a certain dose, taking more does not further suppress breathing, making it significantly safer than full agonists like morphine or oxycodone.⁴⁵ It acts like a stable, slow-growing ground cover that provides consistent coverage while preventing more aggressive, dangerous weeds from taking root.
• Use Case: Buprenorphine is an outstanding option for long-term pain management, particularly for patients who are at higher risk for opioid use disorder (OUD) or for whom the risks of full agonists are too great.⁴⁶ It is also a first-line treatment for OUD itself, providing a unique bridge for patients with co-occurring chronic pain and addiction.⁴⁵
• Risks & Clinical Pearls: The greatest barrier to the use of buprenorphine has been its high affinity for the mu-receptor. If it is given to a patient who has a full agonist (like oxycodone or fentanyl) in their system, it will aggressively displace those molecules from the receptors, leading to a sudden and severe state of precipitated withdrawal.⁴⁹ For years, this meant patients had to stop their full agonist and endure a period of miserable withdrawal before starting buprenorphine. However, a critical clinical innovation has changed the game:
  micro-dosing, also known as the Bernese method or an overlapping transition. In this approach, tiny doses of buprenorphine (e.g., from a buccal film or patch) are started while the patient is still taking their full agonist. The full agonist dose is then slowly tapered down as the buprenorphine dose is slowly tapered up over several days.⁵¹ This allows for a smooth, gradual transition without precipitating withdrawal, making this incredibly valuable medication accessible to many more patients.

Deep Dive: Fentanyl Patch – The “Canopy Specialist”

• Ecological Role & Mechanism: The fentanyl patch is a potent, synthetic mu-agonist delivered via a transdermal system that releases the medication slowly and continuously over 72 hours, providing very stable plasma levels.⁵⁴ It is a highly specialized tool, like a tall canopy tree that thrives only under very specific conditions.
• Use Case: Its use should be restricted to opioid-tolerant patients who have stable, predictable chronic pain and who have already been on other opioids and shown they can manage them responsibly.⁵⁵ It is absolutely not for opioid-naïve patients, for acute pain, or for pain that is intermittent or poorly controlled.
• Risks & Clinical Pearls: Fentanyl’s high potency means there is a narrow margin for error. The most significant and unique risk is accelerated absorption due to heat. Exposing the patch to external heat sources like heating pads, hot tubs, electric blankets, or even a high fever can dramatically increase the rate at which the drug enters the bloodstream, potentially causing a fatal overdose.⁵⁴ Patient education on this point is non-negotiable. Proper application to clean, dry, non-hairy skin and safe disposal of used patches (by folding them sticky-side-in and returning to a pharmacy or flushing as directed) are also critical safety measures to prevent accidental exposure to children or pets.⁵⁴

A Comparative Arsenal for the Modern Pain Ecologist

To effectively manage a complex ecosystem, a ranger needs to know the specific properties of every tool in their arsenal.

The following table compares these three keystone species across the most clinically relevant domains, providing a strategic guide for choosing the right long-acting opioid for the right patient at the right time.

Medication	Mechanism/Ecological Role	Ideal Patient Profile & Use Case	Critical Risks & Management	Key Clinical Pearl
Methadone	Mu-agonist + NMDA antagonist. The “Soil Remediator” that can reverse hypersensitivity.40	Patients with refractory neuropathic pain or suspected Opioid-Induced Hyperalgesia (OIH) where other opioids have failed. A cost-effective option.40	Dose Stacking/Overdose: Due to long, variable half-life. QTc Prolongation: Risk of cardiac arrhythmia. Complex Conversions: Non-linear potency.41	“Start low, go slow.” Dose increases should not occur more than once every 5-7 days. Obtain a baseline and follow-up EKG. Consult an experienced clinician for conversions.
Buprenorphine	Partial mu-agonist. The “Ecosystem Stabilizer” with a ceiling effect on respiratory depression, offering a superior safety profile.44	Patients requiring safer long-term therapy, those with a history of or high risk for Opioid Use Disorder (OUD), or those transitioning from high-dose full agonists.47	Precipitated Withdrawal: High receptor affinity will displace full agonists, causing sudden, severe withdrawal if started improperly.49	Use a micro-dosing/overlapping transition. Start with very low doses (e.g., buccal film) while slowly tapering the full agonist to ensure a smooth, withdrawal-free conversion.52
Fentanyl Patch	Potent mu-agonist. The “Canopy Specialist” providing steady, continuous analgesia for a very specific niche.54	Opioid-tolerant patients only, with stable, predictable chronic pain who have demonstrated responsible use of other opioids. Not for acute or intermittent pain.55	Heat-Induced Overdose: External heat can dangerously accelerate absorption. Accidental Exposure: Improper application or disposal is a major risk.54	Patient education is paramount. Counsel extensively on avoiding all external heat sources on the patch and on the critical importance of safe application and disposal procedures.

Fostering Biodiversity: The Power of Multimodal Care

Finally, the most resilient ecosystems are the most diverse.

A forest ranger knows that a healthy forest is more than just its canopy trees; it’s the shrubs, the fungi, the insects, and the animals.

In pain management, this means recognizing that opioids, even when used skillfully, are only one part of a successful strategy.

Long-term success depends on fostering biodiversity through a multimodal approach.

This means integrating non-opioid medications that can directly target the “soil conditions” of central sensitization, such as anticonvulsants (gabapentin, pregabalin) and certain antidepressants (SNRIs like duloxetine, and tricyclic antidepressants).²⁰

It also, and perhaps more importantly, means championing non-pharmacological therapies that empower the patient to become an active participant in their own recovery.

Physical therapy helps restore function and demonstrates that movement is safe, while cognitive-behavioral therapy (CBT) gives patients the tools to reframe maladaptive thoughts and calm a hyper-reactive nervous system.²⁴

These therapies are not “add-ons”; they are essential components for cultivating a truly resilient, self-regulating pain ecosystem.

Part IV: The Forest Ranger’s Peace – Healing the Healer

The journey from frantic firefighter to patient forest ranger was not just a professional evolution; it was a personal one.

It changed how I viewed my patients, my practice, and myself.

It was the path that finally led Mr. Evans, and me, out of the woods.

The Success Story: Mr. Evans Revisited

After we hit rock bottom with the old paradigm—escalating doses, worsening pain, and a shrinking life—I sat down with Mr. Evans and confessed that my map had failed us.

I proposed a new approach, one based on this ecological model.

First, we did a full biopsychosocial assessment, acknowledging for the first time the fear and catastrophizing that were acting as fuel for his pain.

Based on his symptoms—the diffuse, burning pain and allodynia—I made a clinical diagnosis of severe OIH.

Instead of another dose increase, we did the opposite.

We began a slow, careful transition from his high-dose full agonist to buprenorphine.

Using a micro-dosing protocol with buccal films, we were able to make the switch over two weeks without him experiencing any significant withdrawal.⁵²

Simultaneously, we enlisted a psychologist to begin CBT for pain, helping him challenge the belief that any sensation of pain meant further damage.

We also started a graded physical therapy program, beginning with simple stretches and progressing as his confidence grew.

The results were astounding.

Over three months, his total daily opioid dose, measured in morphine milligram equivalents (MME), plummeted by over 80%.

But as his dose went down, his function soared.

The diffuse, burning pain receded.

He started walking his dog again.

Then, he started helping coach his son’s baseball team from the dugout.

Six months after we started, he was back to working part-time as a contractor.

He wasn’t “pain-free,” but the pain no longer defined him.

He had his life back.

We hadn’t magically regrown the old-growth forest, but together, we had cultivated a new, vibrant, and functional ecosystem.²⁶

From Firefighter to Forest Ranger: A New Professional Identity

The transformation in Mr. Evans was mirrored by a transformation in me.

I was no longer a firefighter, rushing from one blaze to the next with a single, often counterproductive, tool.

I had become a forest ranger.

My work was slower, more patient, more observant.

It required less brute force and more wisdom.

It involved listening more than prescribing, and collaborating more than commanding.

It was a more challenging way to practice medicine, but it was also infinitely more rewarding.

This journey also gave me the language to understand the profound distress I saw in so many of my colleagues.

It’s a distress that has been called burnout, but I now believe that is the wrong word.

Burnout suggests a deficiency in the individual—that they simply weren’t resilient enough.

What many of us experienced, and continue to experience, is more accurately described as moral injury.⁶⁰

Moral injury is the wound that occurs when you are forced, by the constraints of a broken system, to act in a way that violates your deepest-held moral beliefs.⁶²

For a physician, that core belief is to always put the needs of the patient first.

The old pain paradigm was a factory for moral injury.

It trapped us in an impossible double bind: either undertreat pain and watch patients suffer, or follow the aggressive prescribing mandates and risk causing addiction and harm.

We were caught between the demands of the system, the needs of our patients, and the terrifying reality of the crisis we were helping to create.

This conflict between our professional duty and the systemic pressures was a constant, grinding assault on our integrity.

I believe that adopting this new, ecological paradigm of pain management is a form of healing for the healer.

It provides a coherent, ethical, and evidence-based framework that allows us to navigate the immense complexities of chronic pain without feeling trapped or compromised.

It gives us a way to be compassionate without being reckless, and to be cautious without abandoning our patients.

It restores a sense of purpose and integrity to our work.

It is a path forward, one that can help mend the broken trust between patients, physicians, and the healthcare system, allowing us to finally begin the slow, patient work of tending to the entire forest, one precious ecosystem at a time.

Works cited

1. The fifth vital sign: A complex story of politics and patient care – Cleveland Clinic Journal of Medicine, accessed on August 12, 2025, https://www.ccjm.org/content/ccjom/83/6/400.full.pdf
2. The fifth vital sign: A complex story of politics and patient care, accessed on August 12, 2025, https://www.ccjm.org/content/83/6/400
3. The 5th Vital Sign and America’s Painkiller Epidemic, accessed on August 12, 2025, https://healthsciences.arizona.edu/news/blog/5th-vital-sign-and-americas-painkiller-epidemic
4. Pain as the 5Th Vital Sign Toolkit | VA.gov, accessed on August 12, 2025, https://www.va.gov/painmanagement/docs/toolkit.pdf
5. The Fifth Vital Sign: An Overview the Opioid Crisis and Its Effects on Veteran’s – Stetson University, accessed on August 12, 2025, https://www2.stetson.edu/advocacy-journal/wp-content/uploads/2020/03/Fues_2020.pdf
6. Chronic Pain Management and Opioid Misuse: A Public Health Concern (Position Paper), accessed on August 12, 2025, https://www.aafp.org/about/policies/all/chronic-pain-management-opiod-misuse.html
7. On Opioids – The Doctors’ Perspective – NCCI, accessed on August 12, 2025, https://www.ncci.com/Articles/Pages/II_OnOpioids-Doctors.aspx
8. Reducing the Risks of Relief — The CDC’s Opioid-Prescribing Guideline – PMC, accessed on August 12, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC4852278/
9. The Opioid Epidemic: It’s Time to Place Blame Where It Belongs – PMC, accessed on August 12, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC6140023/
10. A Comprehensive Review of Opioid-Induced Hyperalgesia – :::::Pain Physician:::::, accessed on August 12, 2025, https://www.painphysicianjournal.com/current/pdf?article=MTQ0Ng%3D%3D&journal=60
11. Opioid-induced hyperalgesia (Chapter 38) – The Essence of Analgesia and Analgesics, accessed on August 12, 2025, https://www.cambridge.org/core/books/essence-of-analgesia-and-analgesics/opioidinduced-hyperalgesia/1FD9B4AB6CE2F6044509472D8C2EEBE2
12. PAIN AS THE 5TH VITAL SIGN: EXPOSING THE VITAL NEED FOR PAIN EDUCATION – PMC – PubMed Central, accessed on August 12, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC3888154/
13. Pain Management and the Intersection of Pain and Opioid Use Disorder – NCBI, accessed on August 12, 2025, https://www.ncbi.nlm.nih.gov/books/NBK458655/
14. How Should Medical Education Better Prepare Physicians for Opioid Prescribing?, accessed on August 12, 2025, https://journalofethics.ama-assn.org/article/how-should-medical-education-better-prepare-physicians-opioid-prescribing/2019-08
15. Evaluating Psychosocial Contributions to Chronic Pain Outcomes – PMC – PubMed Central, accessed on August 12, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC6067990/
16. Prescription of Controlled Substances: Benefits and Risks – StatPearls – NCBI Bookshelf, accessed on August 12, 2025, https://www.ncbi.nlm.nih.gov/books/NBK537318/
17. The Other Opioid Epidemic | ASH Clinical News | American Society of Hematology, accessed on August 12, 2025, https://ashpublications.org/ashclinicalnews/news/4706/The-Other-Opioid-Epidemic
18. DEA Enters New Territory, Health Law & Policy Institute, accessed on August 12, 2025, https://www.law.uh.edu/healthlaw/perspectives/Food/011109DEA.html
19. Fact Sheet: Stigma – HHS.gov, accessed on August 12, 2025, https://www.hhs.gov/sites/default/files/pmtf-fact-sheet-stigma_508-2019-08-13.pdf
20. Central Pain Syndrome – StatPearls – NCBI Bookshelf, accessed on August 12, 2025, https://www.ncbi.nlm.nih.gov/books/NBK553027/
21. What is Central Sensitization? – Institute for Chronic Pain, accessed on August 12, 2025, https://www.instituteforchronicpain.org/understanding-chronic-pain/what-is-chronic-pain/what-is-central-sensitization
22. Opioid-induced hyperalgesia in chronic pain patients and … – Frontiers, accessed on August 12, 2025, https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2015.00104/full
23. Opioid Induced Hyperalgesia | Pain Medicine – Oxford Academic, accessed on August 12, 2025, https://academic.oup.com/painmedicine/article/16/suppl_1/S32/2472483
24. Learning About Safe Use of Long-Acting Opioids – MyHealth Alberta, accessed on August 12, 2025, https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=abo7821
25. Clinical Practice Guideline on management of opioid therapy for chronic pain – VA.gov, accessed on August 12, 2025, https://www.va.gov/painmanagement/docs/cpg_opioidtherapy_summary.pdf
26. Best Practices, Research Gaps, and Future Priorities to Support Tapering Patients on Long-Term Opioid Therapy for Chronic Non-Cancer Pain in Outpatient Settings – NAM, accessed on August 12, 2025, https://nam.edu/perspectives/best-practices-research-gaps-and-future-priorities-to-support-tapering-patients-on-long-term-opioid-therapy-for-chronic-non-cancer-pain-in-outpatient-settings/
27. Opioid Induced Hyperalgesia: Clinical Implications for the Pain Practitioner, accessed on August 12, 2025, https://www.painphysicianjournal.com/current/pdf?article=MTIzMg%3D%3D&journal=49
28. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 | MMWR, accessed on August 12, 2025, https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
29. Opioid Tolerance: A Key Factor in Addiction and Overdose Risk – Lake County Government, accessed on August 12, 2025, https://lakecountyin.gov/departments/health/Nursing-Clinic/Prevention/Opioids/opioid-tolerance-a-key-factor-in-addiction-and-overdose-risk
30. Opioid Induced Hyperalgesia, a Research Phenomenon or a Clinical Reality? Results of a Canadian Survey – MDPI, accessed on August 12, 2025, https://www.mdpi.com/2075-4426/10/2/27
31. Opioid-Induced Hyperalgesia: Clinically Relevant or Extraneous Research Phenomenon?, accessed on August 12, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC3165032/
32. A Comprehensive Review of Opioid-Induced Hyperalgesia – ResearchGate, accessed on August 12, 2025, https://www.researchgate.net/publication/50409896_A_Comprehensive_Review_of_Opioid-Induced_Hyperalgesia
33. The Biopsychosocial Approach – MedCentral, accessed on August 12, 2025, https://www.medcentral.com/pain/chronic/biopsychosocial-approach
34. What is the biopsychosocial model of pain? – European Pain Federation, accessed on August 12, 2025, https://europeanpainfederation.eu/what-is-the-bio-psycho-social-model-of-pain/
35. The biopsychosocial model of pain and pain management (Chapter 3), accessed on August 12, 2025, https://www.cambridge.org/core/books/behavioral-and-psychopharmacologic-pain-management/biopsychosocial-model-of-pain-and-pain-management/2CC3BB51B68A337072F00E3F7C3C896C
36. Managing Chronic Pain with the Biopsychosocial Model – CAPC …, accessed on August 12, 2025, https://www.capc.org/blog/shifting-perspectives-how-to-manage-chronic-pain-with-the-biopsychosocial-model/
37. www.cancer.org, accessed on August 12, 2025, https://www.cancer.org/cancer/managing-cancer/side-effects/pain/cancer-pain/opioid-pain-medicines-for-cancer-pain.html#:~:text=Opioids%20that%20are%20called%20extended,day%20to%20treat%20chronic%20pain.
38. A Comparison of Long- and Short-Acting Opioids for the Treatment of Chronic Noncancer Pain: Tailoring Therapy to Meet Patient Needs – PubMed Central, accessed on August 12, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC2704132/
39. (PDF) Opioid Pharmacology and Pharmacokinetics – ResearchGate, accessed on August 12, 2025, https://www.researchgate.net/publication/303602757_Opioid_Pharmacology_and_Pharmacokinetics
40. Methadone for Chronic Pain: A Review of Pharmacology, Efficacy, and Safety Concerns, accessed on August 12, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC11879063/
41. Methadone for the Treatment of Pain | Palliative Care Network of Wisconsin, accessed on August 12, 2025, https://www.mypcnow.org/fast-fact/methadone-for-the-treatment-of-pain/
42. Methadone challenging option for treatment of chronic pain | I.M. Matters from ACP, accessed on August 12, 2025, https://immattersacp.org/archives/2014/09/methadone.htm
43. Methadone – safe and effective use for chronic pain – bpac NZ, accessed on August 12, 2025, https://bpac.org.nz/BPJ/2008/December/docs/bpj18_methadone_pages_24-29.pdf
44. Buprenorphine Buccal (chronic pain): MedlinePlus Drug Information, accessed on August 12, 2025, https://medlineplus.gov/druginfo/meds/a616019.html
45. Buprenorphine – about, usage, side effects and alternatives – Healthdirect, accessed on August 12, 2025, https://www.healthdirect.gov.au/buprenorphine
46. About buprenorphine for pain – NHS, accessed on August 12, 2025, https://www.nhs.uk/medicines/buprenorphine-for-pain/about-buprenorphine-for-pain/
47. Buprenorphine for Pain: An Evidence-based, Practical Approach – ASAM eLearning, accessed on August 12, 2025, https://elearning.asam.org/products/buprenorphine-for-pain-an-evidence-based-practical-approach
48. Buprenorphine for the Management of Chronic Pain National Guidance Document March 2024 – VA.gov, accessed on August 12, 2025, https://www.va.gov/formularyadvisor/DOC_PDF/CRE_Buprenorphine_for_Chronic_Pain_MAR_2024.pdf
49. Case report: Successful induction of buprenorphine in medically complex patients concurrently on opioids: a case series at a tertiary care center, accessed on August 12, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC10960361/
50. Case Report: Buprenorphine Induction Using Transdermal Buprenorphine in a Veteran With Opioid Use Disorder and Psychosis, Managing Precipitated Withdrawal – Oxford Academic, accessed on August 12, 2025, https://academic.oup.com/milmed/article/185/9-10/e1872/5823069
51. Successful buprenorphine transition while overlapping with a full opioid agonist to treat chronic pain: a case report – American Osteopathic Association, accessed on August 12, 2025, https://osteopathic.org/2023/01/03/successful-buprenorphine-transition-while-overlapping-with-a-full-opioid-agonist-to-treat-chronic-pain-a-case-report/
52. Successful buprenorphine transition while overlapping with a full opioid agonist to treat chronic pain: a case report – PubMed, accessed on August 12, 2025, https://pubmed.ncbi.nlm.nih.gov/36282967/
53. Successful buprenorphine transition while overlapping with a full opioid agonist to treat chronic pain: a case report – Journal of Osteopathic Medicine, accessed on August 12, 2025, https://jom.osteopathic.org/abstract/successful-buprenorphine-transition-while-overlapping-with-a-full-opioid-agonist-to-treat-chronic-pain-a-case-report/
54. How and when to use fentanyl – NHS, accessed on August 12, 2025, https://www.nhs.uk/medicines/fentanyl/how-and-when-to-use-fentanyl/
55. Fentanyl (transdermal route) – Side effects & dosage – Mayo Clinic, accessed on August 12, 2025, https://www.mayoclinic.org/drugs-supplements/fentanyl-transdermal-route/description/drg-20068152
56. Fentanyl patches for use in the management of chronic persistent pain – West Suffolk Hospital, accessed on August 12, 2025, https://www.wsh.nhs.uk/CMS-Documents/Patient-leaflets/PainService/5531-1FentanylPatchesForUseInTheManagementOfChronicPersistentPain.pdf
57. Fentanyl Transdermal Patch: MedlinePlus Drug Information, accessed on August 12, 2025, https://medlineplus.gov/druginfo/meds/a601202.html
58. Therapeutic Class Overview Long-acting Opioids – Medicaid.nv.gov, accessed on August 12, 2025, https://www.medicaid.nv.gov/Downloads/provider/Long-Acting_Opioids_2014-0918.pdf
59. Chronic pain: Medication decisions – Mayo Clinic, accessed on August 12, 2025, https://www.mayoclinic.org/diseases-conditions/back-pain/in-depth/chronic-pain-medication-decisions/art-20360371
60. Moral Injury in Health Care Workers – PTSD: National Center for PTSD, accessed on August 12, 2025, https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury_hcw.asp
61. Reframing Clinician Distress: Moral Injury Not Burnout – PMC, accessed on August 12, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC6752815/
62. Moral Injury – PTSD: National Center for PTSD, accessed on August 12, 2025, https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp
63. “Preventing Moral Injury in Medicine” | PubHub by MSU Libraries, accessed on August 12, 2025, https://pubhub.lib.msu.edu/read/preventing-moral-injury-in-medicine