523 ISSN 1758-1869 10.2217/PMT.12.52 © 2012 Future Medicine Ltd Pain Manage. (2012) 2(6), 523–526 Images of the proverbial swinging pendulum abound in current discussions of the state of pain management. There are many who would have us believe that over the last 20 years we have gone, quite simply, from an epidemic of undertreated pain and its resultant public health problem of worldwide magnitude, to its polar opposite, an epidemic of overprescribing and, as a consequence, a major public health crisis of prescription drug abuse and overdose deaths, particularly in the USA. An alternative view, bleaker, but more consistent with existing data, is that we now have the worst of both worlds or, in contemporary parlance, the concurrence of two ‘perfect storms’, that is, a continuing epidemic of undertreated pain and, in some countries, such as the USA, a more recent epidemic of prescription drug abuse and overdose deaths. If this assessment is accurate, then an ethically and clinically sound public policy response will not discount or disfavor one crisis in order to obsessively focus upon the other. Rather, the overarching philosophy of an enlightened public health policy on pain management will strive to achieve balance between the dual and potentially, but not necessarily, conflicting goals of insuring effective pain relief for patients in need, while minimizing the risk of prescription drug abuse, addiction, diversion or overdose. In the language of a recent WHO publication: “All countries have a dual obligation with regard to these medicines (controlled substances) based on legal, political, public health and moral grounds. The dual obligation is to ensure that these substances are available for medical purposes and to protect populations against abuse and dependence. Countries should aim at a policy that ultimately achieves both objectives, in other words, a balanced policy” [1]. Let us first endeavor to put to rest the simplistic notion that underprescribing of opioids could not persist in an era of escalating prescription drug abuse. The 2011 Institute of Medicine report, ‘Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research’, confirms in great depth and detail that undertreated pain remains a major problem [2]. Similarly, one of the seminal articles documenting that undertreatment of pain was a problem even for cancer patients appeared in 1994 [3]. In 2011, an article updating that much earlier study found that knowledge deficits and failure to follow existing pain management guidelines continue to be pervasive and problematic for cancer patients [4].