As a teen growing up in Lansdale, Pat Allan may have experimented with painkillers.
But what put him in serious trouble, his family believes, was the Vicodin prescribed after his wisdom teeth were removed in high school. He escalated into abusing prescription opioids bought on the street and their cheaper cousin, heroin.
He was 30 years old when New York City police called to say he had been found dead of an overdose. His little sister Kay listened on her dad's speakerphone.
When her own wisdom teeth came out the next month, she declined the Vicodin.
"My whole family does," said Kay, now a 20-year-old nursing student at Penn State.
Last week, the federal government made its biggest move yet to educate Americans on the dangers of prescription painkillers, issuing detailed recommendations on their use.
The Centers for Disease Control and Prevention's "Guideline for Prescribing Opioids for Chronic Pain" unrelated to cancer is aimed at primary-care doctors. The 12 points range from trying nonaddictive therapies first to testing patients' urine to offering the overdose-reversal medication naloxone for families of high-risk patients to have at hand in case of disaster.
They say initial prescriptions should be for limited amounts. Research shows that many unused pills wind up in the hands of a child or sold on the street.
The guidelines largely agree with existing recommendations from other medical groups. But how they were announced guaranteed attention, especially from doctors: publication in the prestigious Journal of the American Medical Association, which also ran five related pieces. A sixth was published in the New England Journal of Medicine.
"They give us a lot more visibility," said Michael Ashburn, an anesthesiology professor at the Hospital of the University of Pennsylvania and director of the Penn Pain Medicine Center.
More than 20,000 Americans a year die from prescription pain-medication overdoses. Thousands more die of heroin use, which some seek to avoid withdrawal sickness.
"That's a small city each year that's dying from these things," Ashburn said.
In the 1980s and '90s, physicians realized that pain was generally undertreated. Many worried about giving patients addictive painkillers, but pharmaceutical marketing reassured that their pain medications were safe. The government allowed direct-to-consumer prescription drug advertising for the first time, fueling demand.
Opioid prescriptions skyrocketed, reaching 259 million - more than a bottle for every adult - in 2012, and then declining slightly. Many were long-term scripts for drugs like Percocet that were intended for short-term use.
There still are no gold-standard randomized trials of these drugs' effectiveness for chronic pain. Other studies have shown little benefit, and even harm for most, but not all, patients.
"Every day I have had new caution, new concern about prescribing narcotics," said Charles Cutler, an internal medicine physician in Norristown and president-elect of the Pennsylvania Medical Society.
For decades, doctors "focused on pain when we should have focused on function," said Chris Echterling, medical director for vulnerable populations for WellSpan Health, a central Pennsylvania hospital group.
"If your goal is to go biking, then we can get you biking with a little back pain," he said, using other therapies without overdose risk. "If you solely track the pain out of context of function you may not be improving things."
Charles P. O'Brien, founding director of Penn's Center for Studies of Addiction, said most doctors have little or no training in addiction, let alone prescription opioids.
O'Brien said the first thing he teaches medical residents is to respect the addiction potential of opioids. That doesn't mean not to use them, he said, but to understand when they are appropriate and what to expect, like withdrawal.
"Physical dependence is a normal adaptation; you take a drug and your body adapts to it and changes. When the drug stops, your body reacts to that change," O'Brien said.
"Addiction is getting a high, doctor-shopping, doing all those things. It's pathological." Genetic differences, he added, influence who goes from the first to the second.
In the absence of federal guidelines, many state medical societies created their own. Massachusetts Gov. Charlie Baker last week signed a law limiting initial opioid prescriptions to a seven-day supply.
New Jersey has voluntary guidelines in the works. Pennsylvania, where death rates from prescription-drug overdoses are lower - but rising faster - than the national average, released a series of recommendations for different specialties over the last year. They are posted at www.pamedsoc.org/opioidguidelines.
Pennsylvania's guidelines make no mention of federal recommendation No. 9 - checking the Prescription Drug Monitoring Program, a database designed to detect doctor-shopping - because it is one of only two states that doesn't have one. (That should change in August.)
But patients who fear losing the drugs they need are worried about the new guidelines. "Three days or less will often be sufficient" is one example of a recommendation that some say could make doctors cut off needed medication.
Julie Odell says the nerve condition brought on by walking into a steel beam four years ago causes her so much pain - "as if somebody stabbed you with a screwdriver in the back of your head and the tip came out your eye" - that she'd have to give up her job teaching college writing without Vicodin tamping it down.
The 51-year-old from Roxborough has tried numerous alternatives: Botox, nerve ablations, acupuncture, yoga, Alexander technique, massage, physical therapists, chiropractors, IV lidocaine, and nearly 20 medications. That would more than satisfy the guidelines, so she's not worried about losing her access to Vicodin.
But she worries about people who can't try so many options, like some of the people in her chronic pain support group on Facebook. "These are people in tiny towns, no specialist for 200 miles," Odell said.
"I think she has reasonable fears," said Echterling, the WellSpan physician based in York, Pa., who nevertheless strongly supports the guidelines.
Ashburn, the pain doctor at Penn, frames the question of whether and how much to prescribe this way: "Being liberal likely increases the risk of death, which of course is irreversible. . . . If you end up prescribing a little bit too low," he said, "you have an opportunity to adjust the prescription and make it right."