Opioid Stewardship and Tenacity: Why Pain Is Not Suffering

Opioid stewardship rests on one rational rule: give each person the smallest opioid exposure that keeps them working and moving, and never less than they truly need. It is harm reduction, not a ban. It also has to reach past the injury to the suffering wrapped around it: dread, not knowing, being alone, and finding no point in the hurt. Each of those responds to treatment.

Why am I writing about pain and suffering now?

Because I just ran the experiment on myself. Before sunrise on Sunday, October 11 (about 5:50), I was gym-bound when I saw a car burning on the highway and stopped to get the woman inside out of it. We were halfway to the shoulder when a second car slammed into me at speed; its driver kept going. She did well. Full account: why I said no to opioids in the ER.

The inventory: a broken medial malleolus and a broken fibula on the left, a roughly 15 cm gash at the ankle that tore the tibial artery, about 40% of my blood volume gone, a trauma activation, and two ribs broken. No surgery. The wound was closed.

The ER offered opioids more than once, and I turned them down every time. Reason one: years of opioid use tend to trace back to a single first exposure, and beginning a medicine I might never require struck me as a bad trade. Reason two: my endorphin and epinephrine levels were high, which kept the early hours surprisingly quiet. That was my call, in my body. It may not be yours. Nothing about this makes me a martyr. Plenty of patients need opioids, and they should receive them.

After the adrenaline faded, the pain was considerable. The suffering was slight. The rest of this article explains why.

What is the rational basis of opioid stewardship?

With irreversible pain, nobody should be aiming for zero opioids. It is the minimum effective exposure with function kept intact. My rule is to treat the patient I find in the room, never the one I anticipated.

The first exposure earns extra care because the data keep landing on it:

• In commercially insured, cancer-free adults starting opioids for the first time, the odds of long-term use climbed with each day supplied, with the sharpest steps after day 5 and day 31.¹
• Medicare patients who drew a high-intensity emergency prescriber (a 24.1% prescribing rate, against 7.3% for low-intensity colleagues in the same hospital) had 1.30 times the adjusted odds of long-term use.²
• After minor and major surgery alike, 5.9% to 6.5% of opioid-naive adults developed new persistent use, against 0.4% of people with no operation. What predicted it was the patient’s history: smoking, substance use, mood or anxiety disorders, and pain from before. The size of the operation did not.³
• Workers’ comp data on 8,443 fresh low back injuries showed 21% receiving an early opioid, inside the first 15 days. Above 450 mg of morphine-equivalent, disability lasted 69 more days, surgery became three times as likely, and later opioid use six times as likely. Injury severity mattered too; this is association, not proof.⁴
• Ten adults with chronic low back pain took oral morphine every day for a month, and scans showed changes in 13 brain regions; the right amygdala showed losses that scaled with dose. Roughly 4.7 months after the morphine stopped, many of those changes had not reversed. A blinded placebo group of nine, scanned over six weeks, did not change.⁵

If the injury hurt that much, why didn’t I suffer?

Pain is a signal; suffering is what the mind builds around it. I understood exactly what was broken. I had a plan for every day of the next two weeks. I had a reason: the injury was the price of pulling over to help. I had people around me. And I expected to recover.

Flip each of those and you get the four things that make pain unbearable: fear, uncertainty, isolation and meaninglessness. Pool 335 studies (65,340 patients) and catastrophizing plus fear of pain line up with disability, anxiety, depression and negative mood at medium-to-large effect sizes; with pain intensity, at a medium one.⁶ In the lab, simply making volunteers unsure how others rated a heat stimulus made their own pain worse, tracking activity in the brainstem’s periaqueductal gray.⁷ Even a photo of a person’s romantic partner, held in view, lowered pain in a lab test.⁸

Viktor Frankl wrote in Man’s Search for Meaning: “Suffering ceases to be suffering at the moment it finds a meaning, such as the meaning of a sacrifice.” That sentence is my October 11.

How does memento mori make pain smaller?

I have met death at close range and at a distance, more than once. Roughly 40% of my blood volume went with the October 11 crash. The Stoics kept facts like that in view deliberately, with a habit called memento mori, which translates from Latin as “remember that you will die.” They treated it as a ruler rather than a shroud, a way of sizing a hardship correctly. Marcus Aurelius, in Meditations 2.11 (tr. George Long), wrote: “Since it is possible that thou mayest depart from life this very moment, regulate every act and thought accordingly.” Measured against that, a broken ankle is a repair job with a timeline. Sort what matters from what does not, and fear and pointlessness stop feeding on the pain. One correction, though: Stoicism is not clenching your jaw in silence. Report your pain to your clinician honestly and in full; that report belongs in the plan. Needing an opioid is not a test anyone flunked.

Is tenacity a brain function you can train?

Yes, and it has an address. Negative emotion, pain and the effort of self-control all light up an overlapping strip of cortex, the anterior midcingulate cortex (aMCC). It works as a hub that links what a choice will cost or pay to the motor systems that carry it out.⁹ When surgeons electrically stimulated this region in two awake patients, heart rate changed and both described the sense of a challenge coming, with a determined attitude to get through it.¹⁰

One review calls the aMCC the hub for tenacity: it runs the cost-benefit math on persistence and predicts how much energy a goal will need.¹¹ People differ along a line from tenacious to apathetic, and part of motivation is whether the price of effort seems worth paying.¹² “Superagers” aged 60 to 80, with memory as good as people decades younger, keep their aMCC thickness.¹³

The region also responds to treatment. Two-thirds (66%) of 151 chronic back pain patients who got pain reprocessing therapy reached little or no pain; placebo managed 20% and usual care 10%. Their aMCC and anterior prefrontal responses to back pain fell, and the gains lasted a year.¹⁴

Training shows up in tolerance, not in the alarm. Across 15 studies of 899 people, athletes tolerated more pain (g = 0.87), but the difference in pain threshold was not significant once high-bias studies were removed.¹⁵

Why can a pill shortcut the training?

Relief is a reward. The bigger the pain, the bigger the relief, and people rate that relief as pleasant.¹⁶ In mostly animal work, the reward of pain relief depends on opioid signaling in the anterior cingulate, on midbrain dopamine neurons, and on dopamine release in the nucleus accumbens.¹⁷ In rats with bone cancer, morphine produced a brief, roughly five-fold larger burst of accumbens dopamine than in rats without pain. Blocking mu-opioid receptors in the cingulate erased that extra burst but left morphine’s own reward intact.¹⁸ Rat studies, so read them as mechanism, not verdict.

My reading: when relief comes from moving, sleeping and following a plan, the cingulate learns that effort pays. A pill can pay out the same reward without the work. No judgment of anyone who takes one: it is simply why we let the work earn the relief first when we can.

What does clinical care look like when it treats suffering directly?

It answers the four drivers by name. Explain the injury so fear has nothing to feed on. Lay out the plan so uncertainty shrinks. Keep the patient connected to people, because loneliness drives chronic pain. Name the expected recovery so the pain has a direction.

Randomized in the emergency department, 411 patients with fresh arm or leg pain did as well at two hours on ibuprofen with acetaminophen as on any of three opioid combinations.¹⁹ A review of 381 trials found pain was lower during or right after TENS than with placebo, with no serious adverse events.²⁰ My own kit for those first days: ibuprofen, acetaminophen, TENS, EMS, a vibration plate on the injured area, and infrared light. They feed the nervous system competing input. Nothing magic. See what a TENS therapy session or a vibration therapy session involves. Not one workday was lost. October 26 brought full function back, along with full procedure days.

And when a patient needs an opioid, they get one, dosed to the person. Someone already taking opioids who wants a lower dose gets interventional procedures that shoulder the pain as the taper proceeds, with withdrawal kept off the table. Read opioid tapering: medication is a bridge and the rest of our opioid stewardship library.

Frequently asked questions

Does opioid stewardship mean I will be refused opioids?

No. Stewardship means the dose fits the person. Withholding an opioid from someone who needs it is its own harm.

How is pain different from suffering?

Pain is the nervous system’s signal. Suffering is the extra weight that dread, not knowing, loneliness and pointlessness pile onto that signal.

What if I am already on opioids?

You are treated as we find you. If you want to taper, we pair it with interventional procedures and other tools so the pain stays covered and you stay out of withdrawal.

Sources

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Medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP · Last reviewed October 30, 2026

Dr. Gurpreet Singh Padda, MD, MBA, MHP