In “Redefining Pain and Addiction: How Opioid Manufacturers Changed Medical Language to Foster Opioid Use,” Kaspari, Butler, and Fugh-Berman document how opioid manufacturers created or redefined four terms — opiophobia, pain as the 5th vital sign, breakthrough pain, and pseudoaddiction — to expand opioid prescribing for chronic pain.Reference Kaspari, Butler and Fugh-Berman 1 Drawing on litigation documents, the authors highlight how this manipulation of terminology, including the reframing of tolerance and dependence as normal rather than diagnostic, helped to manufacture a false evidence base around the use of opioids for chronic pain.
The redefining of medical language by opioid manufacturers to advance profit at the expense of best practices is an important phenomenon to document. Opioid industry actors exploited the elasticity of clinical concepts, turning terms like pseudoaddiction and opiophobia into marketing tools. And by blurring the line between diagnostic precision and promotional rhetoric, marketing obscured risk and reshaped clinical standards. In my own work,Reference Klein 2 I have highlighted Canadian pain advocates’ struggles to separate themselves from both industry partnerships and language. It is now nearly impossible to speak of untreated chronic pain or inadequate access to opioids — which some patients may legitimately experience — without replicating some facet of opioid industry language.
But while it may be tempting to dismiss mentions of opiophobia or breakthrough pain as mere fabrications, identifying a term’s industry provenance settles little about its future. Opioid manufacturers’ priorities around poorly treated pain often spoke to clinical realities. Yet once these terms became identified as promoted by industry, the clinical claims attached to them have come to look tainted by association.
Kaspari et al. recommend a broad investigation into pharmaceutical influence on medical knowledge and language — a worthwhile project. But once a term is shown to be co-opted by industry, what criteria determine whether it should be abandoned or re-appropriated? Absent to date are the principles by which the field keeps or retires industry-derived terms.
I contend that a term’s industry provenance is not itself sufficient reason to abandon the term. Instinctively discarding clinical language because of its corporate provenance risks conflating a claim’s history with its validity. I argue instead for a strategy of linguistic reclamation — a re-anchoring of clinical terms to their empirical foundations and clinical realities.
Industry Influence on Clinical Language
Drug companies rarely invent clinical concepts out of thin air; instead, they exploit real, preexisting patient experiences or clinical gaps to build their market.Reference Moynihan and Cassels 3 But the validity of these clinical constructs varies widely. For instance, the narrative of a “chemical imbalance” — aggressively promoted throughout the 1990s and 2000s to market antidepressants — oversimplified complex psychiatric etiology into a simplistic serotonin deficit. This was not a biological reality.Reference Moncrieff 4 By contrast, industry-led diagnostic categories like Social Anxiety Disorder (SAD) or Gastroesophageal Reflux Disease (GERD) represent legitimate psychiatric and pathophysiological realities.Reference Vakil 5 The problem came instead from industry efforts to widen those clinical thresholds by reframing temporary indigestion or ordinary social shyness as chronic conditions requiring daily pharmacotherapy. But the fault lay in how these terms were applied, not in the terms themselves.
In this vein, Kaspari et al. highlight a variety of terms with differing levels of industry origins and co-optation. They first point to opiophobia’s ongoing use in medical literature and popular media as evidence that the marketing campaign’s effects have outlasted the campaign itself. Opiophobia was indeed weaponized by industry and inappropriately applied to chronic pain. But if we are to accept the NIH’s current definition of opiophobia as “the underutilization of opioids by patients, caregivers, prescribers, and other healthcare professionals,”Reference Alsbrook and Hacker 6 the concept speaks to a real phenomenon of underutilization of opioids for certain types of pain, including cancer and palliative care, that has been extensively documented.Reference Roberto 7 This inadequate availability is also inequitable, with Black and Hispanic patients far less likely than white patients to receive any opioids near the end of life.Reference Enzinger 8 And health professionals continue to underprescribe opioid agonist therapies for opioid addiction due in part to the stigma (or “phobia”) of opioids more generally.Reference Stone 9 Indeed, the paperReference Ayoub 10 that the authors cite as evidence of the continued use of “opiophobia” is solely focused on cancer pain (where genuine gaps in opioid access exists) and explicitly defines opiophobia as “prejudice against the use of opioid analgesics because of exaggerated concerns….” This is a well-documented phenomenon and a valuable application of the term. Opiophobia therefore refers to a genuine phenomenon and has utility, but should be more precisely used.
Similarly, the authors accurately note that industry dangerously expanded the concept of breakthrough pain to “a distinct type of pain that needed separate treatment [that] was created and fostered by manufacturers of rapid- and short-acting fentanyl preparations.” Yet breakthrough pain also refers to a real phenomenon that was coined well before the industry popularized and expanded its use, in which a “sudden increase in pain that may occur in patients who already have chronic pain from cancer, arthritis, fibromyalgia, or other conditions.” 11 The appropriateness of opioids for each of these conditions differs and the term itself remains contested: Greenfield et al.Reference Greenfield 12 reviewed 65 heterogeneous studies and reported that definitions still varied without consensus, temporal characteristics varied widely, and a compromise on nomenclature remains necessary to collect reliable prevalence data. Despite this, cancer patients on around-the-clock opioids do experience pain as a dose wears off;Reference Fallon 13 the authors acknowledge this themselves before showing how Cephalon stretched “breakthrough pain” to cover migraines and injuries. Breakthrough pain clearly has utility as a term that refers to a clinical reality experienced by cancer and palliative patients that requires distinct management.
By contrast, several terms perpetuated by the opioid industry should be entirely abandoned. While pain as the fifth vital sign focused clinical attention on patient discomfort, pain — unlike heart rate or blood pressure — resists objective measurement.Reference Christidis 14 And requiring patients to score it on a numeric scale pushed prescribers toward aggressive, medication-centered treatment instead of broader approaches to care.Reference Mandell 15 Similarly, pseudoaddiction — introduced by Weissman and Haddox to reframe drug-seeking behaviors as proof of undertreated painReference Weissman and Haddox 16 — lacks empirical validation, is functionally indistinguishable from addiction, and served primarily as a promotional construct to justify escalating opioid dosages.Reference Greene and Chambers 17 These terms should therefore be abandoned.
The Trade-Offs of Re-Appropriating Opioid Industry Language
Abandoning co-opted words in favor of new terms might seem like an option with minimal downsides. There are good arguments in favor of entirely eliminating industry-driven language in favor of new terminology. The practice would allow the medical community to start fresh with new terms via an unbiased, evidence-based lens rather than relying on concepts previously shaped by marketing. And entirely abandoning a tainted term would lower the cost of building consensus, since a new term carries no contested history for professional societies to have to negotiate.
But these apparent advantages are far outweighed by the drawbacks. First, if medicine surrenders terms weaponized by industry, corporate marketing effectively gains veto power over the boundaries of medical discourse. Indeed, if industry adoption alone disqualifies a term, any firm seeking to neutralize a concept need only embrace it. Industry co-optation would then become another tool for stripping medicine of its vocabulary. Tobacco companies have already tested the strategy on language public health itself developed; British American Tobacco and Philip Morris International adopted “harm reduction” from the 2001 Institute of Medicine report on tobacco harm reduction and made the term central to their corporate messaging.Reference Silvy Peeters and Gilmore 18 Public health has not responded by renaming the concept; instead, it has kept the term and contested the industry’s use of it.Reference Dewhirst 19 Pain medicine can do the same.
Second, when a term captures a genuine physical or psychological reality — such as a cancer patient experiencing severe pain spikes despite baseline medication (breakthrough pain), or a health system withholding end-of-life morphine out of unwarranted fear (opiophobia) — abandoning it risks trivializing patient suffering, regardless of intention.
Third, specialized vocabulary forms the backbone of clinical guidelines, global health metrics, and legal treaties. Forcing health organizations to abandon it threatens decades of international consensus, legislative progress, and established policy frameworks. The European Society for Medical Oncology’s cancer pain guideline, for instance, has built its dosing around breakthrough pain, setting the rescue dose at 10% to 15% of total daily opioid dose. 20 Abandoning vocabulary means renegotiations at each of these levels, with no guarantee that successor terms will converge.
Fourth, constant terminological shifts impose further cognitive load on overextended healthcare professionals. Unlike everyday social jargon, medical and policy vocabularies rely on stability for diagnostic precision and prescribing guidelines. Frequent shifts risk semantic fatigue, making it harder for practitioners to keep pace with evolving guidelines and increasing the risk of miscommunication at the bedside. Pain medicine has already attempted some of these changes, to minimal effect: The European Association for Palliative Care Research Network proposed in 2016 that “episodic pain” replace “breakthrough pain” as the umbrella term,Reference Løhre 21 yet the literature has not adopted the substitute, and a systematic review of 65 studies found the field still working from overlapping, inconsistent definitions that undermine reliable prevalence data. 22 Oncology nurses and palliative care physicians also commonly lack confidence in defining the term, further exacerbating underdiagnosis and undermanagement. 23
Finally, beyond this cognitive load, endlessly coining new terms creates sociolinguistic gatekeeping. BourdieuReference Bourdieu and Thompson 24 described command of legitimate language as a form of capital, unevenly distributed and often entrenching inequalities in medicine. Each round of renaming consequently re-concentrates this capital among institutional insiders while marginalizing frontline health workers, patients, and advocates who are not privy to the latest academic consensus.
Moving Forward: Avoiding Guilt-by-Provenance
Guilt-by-provenance is not a useful approach to dictating the direction of medical language. Surrendering concepts like breakthrough pain or undertreated pain because the opioid industry exploited them would leave clinicians and patients without the linguistic tools necessary to articulate genuine suffering. And in abandoning useful vocabulary to corporate history, medicine and public health risk inadvertently ceding the representation of patient experience back to commercial actors. By distinguishing legitimate diagnostic terms from mere marketing tools, medicine and public health can hold industry accountable while retaining the precision required to care for people in pain. Future attention should be paid to the trade-offs of abandoning versus reclaiming industry-influenced clinical language more broadly.
Disclosures
The author has nothing to disclose.
