Why zero is not the goal for irreversible pain

Harm reduction in the context of human frailty, not a gestapo policy that treats every milligram as a moral failure. Some pain is generated by tissue that will never be fully repaired — a nerve root scarred from surgery, a joint that has lost its cartilage, a spine that has fused. For that category of pain, untreated severe pain has its own well-documented costs: it wrecks sleep, it isolates people from work and family, and it drives its own physiological damage through chronic stress signaling. A policy that chases zero opioids regardless of what is actually wrong is not sobriety, it is abandonment wearing a compliance badge.

Arriving vs. established, honestly

Patients who arrive at this practice after 2.5 or more years of unmanaged pain average more than 90 morphine milligram equivalents a day — a number that reflects years of a system reaching for dose increases instead of a diagnosis. Under interventional treatment here, 21% are fully weaned within 90 days and 34% within a year. Across the established population — patients further along in care — fewer than 1% remain above 90 MME. Practice-reported figures from our own population, not trial outcomes, and individual results vary. The gap between the arriving number and the established number is the entire argument for this page.

Why an interventional plan changes the math

An opioid dose is covering for something. If a facet joint is the actual source of a patient’s low back pain and a medial branch block confirms it, radiofrequency ablation can remove a meaningful share of that signal directly — which means the opioid dose that was covering it is no longer covering as much. The dose comes down not because a taper schedule says so on a calendar, but because the input it was managing got smaller. That is the mechanical reason interventional care and opioid tapering are the same conversation here rather than two separate referrals. Radiofrequency ablation.

Avoiding withdrawal while the dose comes down

Withdrawal is not a symptom to power through, and a taper that produces it usually gets abandoned by the patient, not completed. The pace of a taper here is set by how fast the interventional and metabolic pieces are actually reducing the pain generator, not by an arbitrary percentage per month. That is also where the behavioral side of the practice matters: sleep and dopaminergic drive are both disrupted during a taper, and the in-house behavioral clinician is part of managing that, not an afterthought. Sleep, movement and behavior.

The other direction: when the dose becomes the problem

Early in my career I treated dose escalation as the default answer to pain that was not responding — more milligrams for more pain, a straight line. The physiology does not actually run in a straight line. Opioids activate glial cells through toll-like receptor 4 signaling, and that glial inflammatory response is a documented driver of opioid-induced hyperalgesia: a state in which the drug itself lowers the threshold for pain, so escalating the dose can make the underlying sensitivity worse rather than better. That is a different problem from tolerance, and treating it with more of the same drug is treating the fire with the thing that is feeding it.

Which is why the practice distinguishes a stable, low-dose regimen that restores function — a person who can work, sleep and move because of a steady, modest dose — from an escalating one that keeps chasing a pain level that the escalation itself may be sustaining. The first is a legitimate long-term plan for irreversible pain. The second gets a different conversation, and usually an interventional or metabolic alternative gets tried before the dose goes up again.

Who this practice is not for

This is not a practice built around initiating opioid therapy for pain that has not been diagnostically worked up, and it is not a source for dose increases without an interventional or metabolic plan attached. If the goal walking in the door is a prescription with no diagnosis behind it, that is not what this page is describing.

Common questions

Related reading

• About Dr. Padda
• Radiofrequency ablation
• Sleep, movement and behavior
• When injections stop working
• What to expect at the first visit