The opioid crisis has reshaped communities and altered the practice of medicine in the United States. In an effort to address the devastation, state and local governments came together to launch the National Prescription Opioid Litigation, otherwise known as the Opioid multi-district litigation (MDL), a consolidation of thousands of lawsuits targeting pharmaceutical companies, distributors and pharmacies. The goal was to hold corporate actors accountable for their role in fueling the epidemic.
Many of the parties in the lawsuits have reached settlements that are funding public health abatement programs. While well-intentioned, these programs often come with more stringent state auditing, Prescription Drug Monitoring Program (PDMP) enforcement and rigorous documentation standards for clinicians.
For the physicians, distributing pain medicine in the U.S. has become a high-wire act. They must navigate a delicate balance: treating patients in genuine pain while avoiding regulatory scrutiny. Even prescribing that is legally compliant can feel vulnerable to audit when a clinician’s pattern appears atypical or falls outside payer or state norms.
In 2022, the Centers for Disease Control (CDC) released updated guidelines for prescribing opioids, emphasizing individualized care and warning against “rigid application” of dose thresholds. Still, some clinicians fear that deviating from lower thresholds still invites legal or administrative scrutiny, regardless of the guideline’s intent.
At the start of this year, the Department of Health and Human Services (HHS) and Drug Enforcement Administration (DEA) extended COVID-era telehealth flexibilities through December 31, 2026, allowing the continued prescription of controlled medications to patients without a prior in-person visit. However, the looming permanent DEA framework creates significant uncertainty for remote pain management.
This is a multilayered and evolving issue, but this article explores an overview of opioid prescribing risk and the current CDC guidelines.
The ripple effects of the National Prescription Opioid Litigation
When billions of dollars in settlement funds flow into states, the intention is “abatement”—programs designed to treat addiction and prevent future harm. For the practicing physician, this often translates into intensified oversight. The logic follows that to prevent diversion, every prescription must be tracked, and every prescriber monitored.
Some physicians within the Sermo community have noticed direct impacts of the litigation. In a poll asking members how the Opioid MDL and related legal/regulatory climate has most impacted their practices, 26% said they’ve noticed no significant impact. Among those who have been impacted, increased documentation burden (22%), increased use of prescription monitoring programs (PDMPs) (22%) and increased difficulty managing chronic pain patients were the most commonly reported effects.
The sentiment among Sermo members is that accountability is necessary, but that it’s falling too heavily on physicians. “The Opioid MDL has made accountability more accurate at the top of the supply chain, but less balanced at the point of care,” a gastroenterologist on Sermo writes. “While corporate actors are finally being held responsible for structural drivers of harm, clinicians often experience a chilling effect that complicates appropriate pain management. True fairness would better align accountability with actual control over risk, pairing oversight with clearer regulatory safe harbors and stronger support for evidence-based, patient-centered care.”
A dermatologist also weighed in: “The Opioid MDL does not distribute accountability entirely fairly, as it often places excessive responsibility on physicians while underestimating the clinical challenge of balancing adequate treatment of severe chronic pain with the real risks of opioid addiction,” they write. A general practitioner in the U.S. believes physicians need more resources for managing chronic pain, especially in patients on Medicaid.
An ophthalmologist has seen progress but room for improvement. “I believe accountability for opioid-related harms is more fairly distributed now than in the past, with greater scrutiny on manufacturers, prescribers, and systems and not just patients,” they state. “However, gaps remain, especially in how harms are regulated and addressed across stakeholders.”
The evolution of opioid prescribing guidelines and physicians’ fears in 2026
In 2016, the CDC released guidelines that, while intended as recommendations, were widely interpreted by insurers and state legislators as hard limits. This led to rapid tapers and patient abandonment. Recognizing this harm, the CDC released updated guidelines in 2022, explicitly emphasizing individualized care and advising against the rigid application of dose thresholds.
Theoretically, this should have been a breath of fresh air for physicians. It was an invitation to use clinical judgment rather than a calculator. However, discussions on Sermo show that the fear of 2016 lingers. State laws and payer policies often lag behind clinical guidelines, and many doctors worry that “individualized care” looks like “overprescribing” to an auditor.
In a poll, Sermo asked members to what extent they feel regulatory changes are moving opioid prescribing toward clearer, more stable standards. Most respondents describe regulatory changes as producing only incremental clarity in opioid prescribing. While two-thirds report some movement toward clearer standards, few see a substantial shift, and a notable minority remains skeptical or uncertain.
In community discussions, members have pointed to ongoing confusion. “This is a difficult crisis to navigate; ensuring patients’ pain is adequately treated while staying within established and evidence-based guidelines and various regulatory parameters,” writes a radiologist in the U.S.
Members describe a practice environment defined by caution. “There has been too limited training and integration of non-opioid modalities to treat pain,” believes an OBGYN in the U.S. “That said, fear has become a defining factor in prescribing/using opioids. Some of that fear is founded; some is not.”
Some members have detailed their careful approaches. “We have a [responsibility] as physicians to be very careful when prescribing [controlled] substances,” writes a family medicine doctor. “I tell patients to stick with NSAIDs and acetaminophen if possible, even for fractures. And prescribe as little as possible. Same for benzo and even amphetamines that our children receive like candy.”
Telemedicine and the ‘controlled substance cliff’
The COVID-19 pandemic necessitated a rapid shift to telemedicine, including the remote prescribing of controlled substances. These flexibilities were set to expire but have been extended through December 31, 2026. This creates a “transitional zone”—a period of grace, but also of anxiety.
It remains unclear what will happen in 2027. The DEA is working on a permanent framework, but the uncertainty makes it difficult for practices to plan.
Under the federal extension, many COVID-era telemedicine flexibilities remain in place, allowing clinicians to prescribe schedule II-V controlled substances via telemedicine without a prior in-person medical evaluation, provided they act in accordance with applicable federal and state laws.
Defensive medicine and the undertreatment of pain
With the threat of audits and liability hanging over their heads, there is a growing number of clinicians opting for “defensive medicine”—making decisions based on protecting their license rather than solely on patient need. This can manifest as refusing to accept chronic pain patients or rapidly tapering stable patients.
Defensive medicine in pain clinics can lead to the undertreatment of legitimate pain. Physicians may avoid prescribing opioids even when indicated, or they may discharge patients who display “complex” behaviors to avoid liability. This can lead to care disruptions, increased suffering and in desperate cases—patients turning to illicit sources for relief.
When asked “Do you feel the current legal environment encourages physicians to practice ‘defensive medicine’ by undertreating legitimate pain?”, 68% of polled Sermo members said yes.
Members’ comments reinforce these numbers. Regulations have ”transformed us into practising defensive medicine rather than concentrating on patient care,” writes a U.S.-based family medicine doctor. A radiation oncologist describes “fear around treating pain appropriately, even when it is clinically indicated,” and a general practitioner highlights a “risky prescription burden, which leads to defensive medicine.”
One internist shared a similar view. “Even when you follow the guidelines and prescribe appropriately, there’s always the worry of being flagged or audited,” they explain. “That inevitably makes doctors more cautious, sometimes at the patient’s expense.”
4 key challenges of Prescription Drug Monitoring Programs (PDMP)
Prescription Drug Monitoring Programs (PDMPs) are state-run electronic databases that track controlled substance prescriptions. While they are essential tools for identifying potential misuse, their mandatory use has introduced significant workflow challenges.
When polled on the biggest challenge they face with the mandatory use of Prescription Drug Monitoring Programs (PDMPs), the Sermo community identified the following:
Time consumption and integration issues with the EHR
The most cited issue (37%) was the lack of seamless integration. “I think that the PDMP really needs to be well integrated into the EMR and easily accessible,” asserts a neurologist in the U.S. “The process of opening up another application is unnecessarily time-consuming.”
Inaccurate or incomplete data leading to flawed decisions
15% of respondents worried about data integrity. If a dispense isn’t logged correctly, a physician might make a decision based on false or incomplete information, potentially denying care to a compliant patient.
Limited access to PDMP data across state lines
Pain doesn’t respect state borders, but PDMPs often do. 12% of physicians struggle with accessing data for patients who live near state lines or travel frequently, creating blind spots in the patient’s history.
Increased mistrust and friction in the patient-physician relationship
14% felt that the mandatory check creates an adversarial dynamic, where the appointment starts with an investigation rather than a conversation.
Despite the challenges, some see a path forward. An emergency medicine physician called for “new processes to help patients over a period of time to move away from opioids.”
Physician perspectives on shared accountability
The Sermo community weighed in on how they think accountability for the opioid crisis should be distributed. The responses reveal a desire for a more nuanced understanding of accountability.
A general practitioner pointed to a “potentially reduced pain threshold due to chronic treatments,” in the aging population, noting that it can make managing dosages difficult. “I would venture to say that we also bear some responsibility, given the lack of more intensive training and education on how to treat and manage these patients routinely with better-established protocols,” they add.
A U.S.-based radiologist pointed out a factor they believe is overlooked. “It is noteworthy that patient conduct is not considered as contributory to the issue,” they write. “Patients who seek or abuse drugs have agency as well, and creating a passive victimology that treats well-intentioned doctors as dealers is now just having the counter-effect of doctors fearing to treat.”
A family medicine doctor in the U.S. similarly expressed that patients may insist on taking medication despite a physician advising otherwise: “Most of the patients that I inherited from other doctors in my career it’s been very uncomfortable to converse to switch from opiates or to even consider an alternative option.”
An overarching theme is that the Opioid MDL’s distribution of accountability is imperfect. “The Opioid MDL casts a wide net that has brought many powerful companies to account, but it does not always weigh each one’s blame with perfect balance,” a pathologist in the U.S. writes. “While it has moved the story toward responsibility and repair, the results can feel uneven, with justice shaped as much by timing and strategy as by true fault.”
Navigating the ‘secondary crisis of care’
The Opioid MDL has forced large corporations to pay for their role in the crisis. But in doing so, it has inadvertently created a “secondary crisis of care.” Physicians now navigate a minefield where clinical guidelines say “individualize,” but regulatory frameworks say “standardize.”
If you are feeling the weight of these regulations, the Sermo community can help you navigate these shifting tides. Join the conversation today to share your experiences, learn from your peers and find support in a network of doctors who understand exactly what you’re up against.
