A prescription is not a treatment plan

Two stories have run American pain medicine for a decade. In the first, physicians manufactured an overdose crisis by writing too many prescriptions. In the second, the correction overshot, and patients with real disease were tapered, discharged and abandoned.

Dr. Gurpreet Singh Padda, MD, MBA, MHP sits in neither story. The failure was never only overprescribing. It was treating the prescription as the treatment.

"Pain is the final pathway," he says. "It is the body screaming something has gone wrong. A prescription answers the report, but it may not answer the thing being reported."

This page is the map. The detail lives on two pages: opioid tapering for chronic pain and non-opioid pain treatment.

What does opioid stewardship mean here?

Four rules.

• Treat the generator. Find the joint, nerve root or endplate producing the pain. Confirm it with a diagnostic block. Treat it directly, under image guidance.
• Treat the terrain. Visceral fat secretes interleukin-6 and tumor necrosis factor alpha. Those cytokines sensitize nerve endings and lower the threshold at which the nervous system reports pain. Insulin resistance starves nerves of blood flow. The pain has a metabolic address.
• Let the dose fall as a result. When the generator is treated, the need for systemic opioids frequently falls on its own. No taper imposed as an end in itself.
• Never abandon the patient. An abrupt taper is not safety. It is a second way to injure the same person.

Stewardship does not mean zero. The practice's preference is to avoid opioids altogether. In every complex case that is not achievable. The target is the lowest exposure that keeps a person functioning.

Why did overdose deaths rise after prescribing fell?

Because the prescription count was never the mechanism. Using CDC data, the Padda Institute has published Missouri's record:

• Opioid prescriptions fell from 93.3 per 100 residents in 2013 to 44.3 in 2024. A 53 percent cut.
• The overdose death rate rose from 17.9 per 100,000 in 2015 to 35.8 in 2022.
• It then fell to a provisional 19.7 by the end of 2025, while prescribing kept falling.

That is population-level co-movement, not proof of cause. It does kill the simple pill-count thesis. Dispensing fell for a decade. Deaths rose, peaked and fell on their own timetable, driven by an illicit supply that prescribing rules never touch.

Supply-side policy cannot fix a demand-side problem. Exposure is necessary for addiction. It is almost never sufficient. The Addictionology Center puts the demand side bluntly: the real issue is boredom and loneliness, and opioids are a short-term cure for boredom. When pills got harder to get, people who abused them moved to heroin, then to illicit fentanyl.

Meanwhile the blunt pill-control policies landed on the wrong people. Patients who had been functioning were cut off, left in misery, unable to find another physician, sometimes contemplating suicide. Those are the pain refugees.

What happens to patients who arrive on high doses?

They come down, in person, on their physiology rather than a calendar. The practice publishes its own numbers and always names the group each one describes. These are practice-reported figures from our own population, not trial outcomes, and individual results vary.

Arriving patients average more than 90 MME per day after more than two and a half years in pain. Under active interventional treatment, 21% are completely weaned off opioid pain medication within 90 days and 34% within one year. Among established patients, fewer than 1% remain above 90 MME.

The full figure set, the evaluation, the pacing and what a patient is required to do are on the opioid tapering page. The procedures, in-office therapies and metabolic care that carry the load as medication comes down are on the non-opioid treatment page.

What does the practice publish for pharmacists and physicians?

Its whole protocol, in public. The Padda Institute does not describe itself one way to clinicians and another way to patients.

Three positions stand out.

No medication-only management. Long-term opioid therapy without interventional support is not consistent with evidence-based practice, so the practice does not offer it. Nearly 100% of patients receive interventional care.

No consolidation for the optics. Pharmacists, insurers and regulators ask several times a month: why not swap many short-acting tablets for one long-acting tablet twice a day? The answer is no, in writing. Fewer tablets improve the prescribing ratio. Continuous receptor occupancy worsens the pharmacology. The practice would rather defend a higher unit count at a low total dose than a tidy count achieved through receptor saturation.

Pharmacists are part of the safety system. Patients sometimes present one way in clinic and another way at the counter, where their guard is down. The practice asks pharmacists to report what they see and acts on it. Credible reports of aberrant behavior end the treatment relationship. Every prescription is electronic. A verbal or telephoned prescription claiming to come from this clinic did not come from this clinic.

Dr. Padda is board certified in anesthesiology, pain medicine, interventional pain management, addiction medicine and obesity medicine. He is President of the Missouri Society of Interventional Pain Physicians lectures nationally for ASIPP, and taught in its Comprehensive Review Course in Controlled Substance Management in 2007. He holds a Controlled Substance Management Competency Certification (2010), published "Opioid use and misuse in chronic pain management" in 2011, and teaches pain and addiction to psychiatry residents at KCU Freeman Health System. For verification: NPI 1508067208, Missouri license MD 100572, Illinois license MD 036-103773.

Where does addiction treatment fit?

Pain is often where the addiction starts. More than 57% of patients with opiate addiction report chronic pain as the reason they started. Both conditions run on genetics and environment. Both need treatment built for both.

The Addictionology Center, Suite 101 in the same building on Woodson Road, treats opioid, alcohol and drug use disorder in person. Evaluation, examination and prescribing happen in the clinic. Detox happens at home, in a familiar environment, with the provider reachable throughout.

• Opioid use disorder: buprenorphine/naloxone (Suboxone), started when the provider judges it appropriate, with a personalized course of comfort medications.
• Follow-up: clinic visits at least monthly, with a drug screen at least monthly at the start.
• Support: counseling, support groups and Clinical Support Specialists who help with pharmacy and payment problems.
• Pain in recovery: a pain program for people in recovery, entering treatment, or simply wanting a more conservative approach. Patients will not find an opiate-centered practice there.

Call the Addictionology Center at (314) 463-0100, or see addiction treatment in St. Louis.

How does IntellaRx take stewardship to public agencies?

IntellaRx is the Compassionate Compliance Program, a nonprofit division and registered trade name of Sevadar Foundation Inc., a 501(c)(3) public charity. It works with health departments, Medicaid programs, corrections and reentry health services, county and municipal public-health authorities, and the task forces they convene. It is not a consumer service.

The problem it attacks: the analytics used to find bad actors read prescription counts without a diagnosis or a treatment intent. That instrument cannot tell a pill mill from the one specialist in a region who takes the hardest patients. It flags both. Patients caught between lose access.

IntellaRx does two things about it:

• Supplies clinical context. Diagnosis, treatment plan, prior therapy, comorbidity and metabolic profile, delivered to the people deciding at the moment they decide.
• Closes the identification gap. Confirms that a controlled medication reaches the person it was written for, and that a test result belongs to the person it is attached to.

Around those sit delivery partnerships with licensed pharmacies, naloxone and safe storage, behavioral health screening, social determinants assessment and population-level analysis of the local drug supply. IntellaRx does not prescribe, dispense, diagnose or treat. It declines deployments built to make enforcement cases against patients. See the opioid safety program for public agencies.

How does DWARAA apply it to older adults?

DWARAA is the fourth division of Sevadar Foundation Inc. Its name is a Gurmukhi word meaning "through," "by way of" or "gateway." Its six letters name six steps, in order: deprescribing for health optimization, well-being and cognitive enhancement, assessment of individual care needs, reducing medication burden, advocating for non-pharmacological interventions, and adjusting care plans on ongoing evaluation.

An older adult arrives at a facility carrying the decisions of three prescribers, none of whom saw the whole list. Nobody set out to build an eleven-drug regimen. It assembled itself, one reasonable decision at a time.

The classes that most need review are opioids, benzodiazepines, Z-drugs and antipsychotics. In an older body the same dose does more, the same fall does more damage, and sedation gets read as decline instead of a side effect.

DWARAA's rule matches the clinic's. Every drug earns its place or is reconsidered, with the person rather than to them. Nobody is left in withdrawal or untreated pain because a number on a chart looked wrong to someone who never met them. DWARAA writes separately for prescribers, facility owners, families and front-line staff. It does not prescribe, deprescribe, diagnose or treat. See deprescribing for older adults and the parent Sevadar Foundation.

What opioid stewardship is not

It is not an offer to prescribe. The Padda Institute does not accept patients seeking opioids as the treatment.

It is not a threat either. You do not have to come off opioids to be seen, and nobody is tapered into withdrawal.

How do I get help?

The Padda Institute is at 4477 Woodson Rd, Suite 100, St. Louis, MO 63134, next to the airport, with a second office on Natural Bridge Road. Call (314) 481-5000 or text (314) 886-5902. Same-day and emergency appointments are available. The text line is never used for prescription refills or medication requests.

Not sure which organization fits? Tap the directory assistant, the light in the corner of this page, and it will point you to the right place. More on Dr. Padda and the full pain and metabolic medicine section.

Frequently asked questions

Is opioid stewardship the same as being anti-opioid?

No. Opioids have a legitimate role, particularly in acute, cancer and perioperative pain. The concern is chronic, continuous exposure with no plan to reduce it.

Can a pharmacist reach the prescriber directly?

Yes. Call (314) 481-5000. For urgent pharmacist queries, text (314) 886-5902 or email the clinic. In-person meetings are welcome, and the practice calls pharmacists itself when questions arise.

My county wants better opioid data. Who do we talk to?

IntellaRx. Tell it what you are trying to change, and it will tell you plainly whether the program helps. It works with agencies, not individuals.

Does DWARAA review my mother's medications?

No. DWARAA supplies the framework, the evidence and a shared vocabulary so a family, a nurse, a facility and a prescriber can read the same list and mean the same thing. Her prescriber makes every decision.