When Jennie Burke’s 13-year-old daughter needed hernia surgery six years ago, it wasn’t the operation Burke feared — it was her daughter’s recovery from it, and whether she’d need opioids to keep the pain at bay.

At the time, Burke’s brother was “hitting rock bottom” from a heroin addiction that would later kill him. Like many Americans in the early 2000s, he became addicted to opioidsafter being prescribed OxyContin following an appendectomy. In 2020, the year he died, 68,630 people died from opioid overdoses.

Given her family’s history with addiction, Burke was determined to keep her daughter off opioids. But she didn’t have to worry. Though a discharge nurse gave her daughter a prescription for 44 oxycodone tablets after her surgery, she was able to control the pain by alternating between Tylenol and ibuprofen, and never complained of intolerable discomfort.

Burke, who lives in Baltimore with her family, was relieved — but also angry. If she hadn’t known better, she might have given her daughter all of the pills in the days following the operation. Studies show a person’s risk for chronic opioid use increases after they take the medication for longer than three days, and goes up even more sharply after five days.

“In many instances, it’s easier to get narcotics than it is to get other modalities of pain relief,” Burke said. “It makes no sense.”

But Burke and other advocates nationwide are hopeful that may soon change. The NOPAIN Act — which Congress passed in an end-of-year spending package — will take effect in 2025, setting up a separate Medicare payment for certain non-opioid pain management approaches in outpatient and ambulatory surgical settings.

The law aims to incentivize outpatient surgical centers to use pain relief methods like nerve blocks and long-acting numbing medications. They can help keep patients safe from chronic opioid use or addiction, although the alternative methods are more expensive. As enacted, the legislation expires at the end of 2027, meaning Congress would need to take further action to extend it.

An estimated 5 million people who are 12 years or older are addicted to prescription opioids in this country, according to data from the National Institute on Drug Abuse. Studies suggest that up to one-third of people who take opioids for chronic pain misuse them, and more than 10% become addicted over time.

The number of opioid prescriptions dispensed in the U.S. peaked in 2012 at 255 million and has dropped to 142 million in 2020, according to Centers for Disease Control and Prevention data.

As the availability of opioids has decreased in the country, research suggests that a smaller share of people struggling with opioid addiction started with prescription drugs. Data from a 2015 study of people entering treatment for opioid use disorder shows that about 24% of them reported oxycodone as the first opioid they used regularly to get high. In 2005, that share was about 42%.

But there still are U.S. counties where enough opioid prescriptions are dispensed annually for every resident to have one. In Baltimore in 2020, 68.6 opioid prescriptions were dispensed for every 100 people — higher than the nationwide average rate of 43.3 prescriptions per 100 people. In Talbot and Allegany counties, which had Maryland’s highest dispensing rates that year, 91 opioids were prescribed per 100 people.

As a whole, America prescribes more opioids per capita than any other country in the world — a disparity that may be partly explained by the fact that its medical system gives more autonomy to health care providers, imposes fewer regulations on practices, and is more permissive of drug companies marketing directly to providers, according to a 2021 report from the Congressional Research Service.

Experts and advocates say the difference in how opioids and non-opioids are reimbursed by insurance also feeds into the problem.

Opioids are reimbursed under Medicare Part D — meaning they don’t eat away at the payment a hospital receives for a surgery. The NOPAIN Act aims to create parity in how methods of pain relief are covered by removing non-opioid options from the payment, as well.

There’s pent-up demand for non-opioid pain relief options, said Chris Fox, executive director of Voices for Non-Opioid Choices, a Washington, D.C.-based organization that lobbied for the NOPAIN Act.

In 2019, when the Centers for Medicare and Medicaid Services made non-opioid options a separate payment for Medicare patients treated at ambulatory surgery centers, there was a 120% increase in the use of the anesthetic Exparelin the centers over the course of a year, Fox said.

Since changing how non-opioid methods are reimbursed reduces the amount of opioids prescribed, Fox and other advocates argued CMS should enact the law in 2024, a year earlier than scheduled. Maryland Gov. Wes Moore and 10 other governors, all Democrats, signed a letter in May to support early implementation.

“We’re making the case, doing what we can, to tell CMS and anybody who will listen that there’s a real opportunity here to save lives, prevent unnecessary addiction and exposure to opioids following an acute pain incident,” Fox said. “We really need to bring this relief to our communities, to our constituents, to our patients and to our health care professionals sooner rather than later.”

However, CMS didn’t take that step in July when the agency released its proposed Outpatient Prospective Payment System rule, which recommends Medicare payment rates and policies for outpatient and ambulatory surgical centers for the coming year.

In an emailed statement, a CMS spokesperson said the agency is required to implement the rule Jan. 1, 2025. To prepare for the change, the spokesperson said, CMS asked for comment on the devices and drugs that people believe would meet the definition of non-opioid treatments for pain relief.

Dr. Eric Shepard, director of anesthesia at the Frederick Surgical Center, is similarly frustrated with the length of time that will pass before the NOPAIN Act is implemented. He and advocates with Fox’s organization are urging CMS to reverse course before finalizing the outpatient rule in early November.

Since the 2019 CMS rule change, doctors at his center use “a fraction” of the opioids they did before, Shepard said. Now, patients who receive mastectomies at his center get long-acting nerve blocks and go home on Tylenol and ibuprofen. They don’t even get a prescription for a narcotic, Shepard said. Patients getting a total joint replacement get no opioids on the day of surgery and are prescribed a limited amount of oxycodone or tramadol afterward, in combination with an extended-release anesthetic.

He predicts that once the NOPAIN Act is implemented, more surgical patients will receive implantable, long-release medications and nerve blocks instead of opioids. And, he said, there should be pressure from Congress to get all insurance plans to cover non-opioid methods of pain relief.

“You’ve got to make sure that all payers are willing to reimburse for all these techniques and technologies that allow us to eliminate or minimize the use of opioids, because we’re not 100% there,” he said. “We’re about as close as we’ve ever been, and yet it’s not used the majority of the time.”

Dr. Sarah Merritt, a pain medicine specialist based at the Lifestream Health Center in Bowie, also expressed support for the NOPAIN Act. Surgeons and anesthesiologists want to write fewer opioid prescriptions, she said, and she hopes the law will help them do so.

But to further reduce opioid prescriptions, she said, doctors need to be better compensated for the extra time they spend with patients, educating them on pain management and keeping track of the other medications they take.

Burke, who wrote an essay for The New York Times about her daughter’s hernia surgery, encountered another hurdle in 2020 with her daughter, when the teen needed a spinal fusion. This time, Burke knew her daughter would need opioids to get through the surgery and the pain afterward. She had long talks with her daughter’s doctors about how to limit the teenager’s exposure to the drugs, and they came up with a plan to use an eclectic combination of pain relief methods.

Her daughter was off narcotics within five days of leaving the hospital.

“Opiates provide mercy,” Burke said. “We need them in society, but we also need a variety of medications. We need access to mental health care. We need education, and our physicians need time. They need to be given time by their employers to speak with their patients. The NOPAIN Act is one facet of addressing the opioid crisis.”

Since her brother’s death, Burke has found meaning in advocating for legislation like the NOPAIN Act and in her involvement with the Lutherville-based nonprofit, Love In The Trenches. It distributes Narcan, a nasal spray that delivers an opioid-overdose antidote, and offers support groups to the loved ones of those struggling with addiction.

But at the end of the day, she said, her brother is gone — a gut-wrenching reality that will never change, and one she shares with hundreds of thousands of Americans.

It’s a different kind of pain, she said, one “that can’t be alleviated with a pill.”