‘Laws, Like Sausages, Cease to Inspire in Proportion as We Know How They Are Made.’ — John Godfrey Saxe (1816-1887)
Opinion Columnist, Chester “Trip” Buckenmaier III, MD, COL (ret.), MC, USA
Purportedly, the American poet John Saxe made his comment regarding laws and sausage-making in the Daily Cleveland Herald on March 29, 1869. Variations of the quote regarding the unsavory nature of the legislative process abound in American literature. Politics in a democracy is, at best, the art of compromise between competing interests, but the slaughterhouse floor reality of most legislation is messy and disgusting to behold by the public.
I recently had an opportunity to visit the buildings where our nation’s law-sausages (to continue the metaphor) are made. I was asked to participate in a lobbying effort sponsored by the nonprofit organization Voices for Non-Opioid Choices (VNOC). My background in seeking nonopioid options for analgesia in wounded servicemembers from Iraq and Afghanistan was consistent with the message VNOC was trying to impress on Congress. Unbeknownst to most patients, physician clinical decision-making often is dictated by what products a particular medical institution has approved on its medication formulary, rather than what a clinician deems best for their patients. Insurance companies, pharmaceutical companies and the health industry heavily influence these formularies through healthcare legislation that determines what Medicaid, federal medicine and other third-party payers cover. Admittedly, the VNOC effort was sponsored by healthcare companies seeking to expand their market for new analgesic devices and medications not currently covered by most federal formularies. I have no issue with this type of congressional influence, since I am a capitalist at heart. Businesses that have “built a better mousetrap” should be free to financially support activities that bring innovative solutions to the attention of our lawmakers.
The VNOC organization was made up principally of citizens who have lost a child or loved one to opioid overdose. One startling statistic is 80% of heroin users report using prescription opioids, prescribed by a clinician first.1 Unfortunately, if the only tool on the healthcare facility formulary to manage acute pain is an opioid, that is what the clinician is going to utilize? The opioid “one-size-fits-all” approach to patient analgesia has plagued American medicine since the Civil War. Opioids are cheap, readily available and consistently effective in managing acute pain, if the longer-term side effects of these medications are ignored. Out of sheer necessity, America’s most protracted conflicts in Iraq and Afghanistan forced military medicine to find and develop nonopioid approaches to acute pain management. Despite this innovation, many federal formularies do not cover these novel nonopioid pain therapies.
For example, an orthopedic surgeon colleague on my VNOC team, who works part-time in a VA hospital, described his experience performing total knee replacement surgery (one of the most common and painful surgeries) in a civilian institution with a modern formulary during our congressional visits. Patients in his civilian practice who were exposed to nonopioid perioperative pain management advances typically only required a 23-hour (overnight) stay in the hospital. Similar VA patients he would operate on, who only had access to the traditional formulary focused on opioid pain management, would require 3–4 days to recover.
There has been progress. The NOPAIN (Non-Opioids Prevent Addiction in the Nation) Act became law on Dec. 29, 2022. This legislation minimizes financial barriers for the inclusion of nonopioid perioperative pain options for Medicare surgical patients. The most recent VNOC activity that I participated in is an effort to pass similar legislation for VA patients. It would seem intuitive that veterans, perhaps one of our most vulnerable patient populations, should be “first in line” to receive any pain management innovation that could reduce dependence on opioid medications and opioid related deaths.
I have been to Capitol Hill multiple times in my role as a leader in pain care for the military. All these visits were highly vetted and supervised, since there are strict rules against military members influencing Congress. Now that I have set my military uniform aside, it was a refreshing experience to step up for some “sausage-making” on an issue about which I am passionate and without a military congressional babysitter (congressional liaison officer).
Our visit coincided with a group lobbying against the administration’s so-called Big Beautiful Bill due to the threat this legislation poses to citizen health insurance coverage and the potential closure of rural hospitals. The congressional office buildings were packed with concerned citizens attempting to sway their representatives in another direction. Sadly, from my perspective, that legislation has since been signed into law. Although their effort failed, my personal belief in our system of government was reinvigorated by this mass of patriots trying to move government policy in a different direction through discourse rather than violence.
It might be nasty, messy and vulgar to watch, but I’m all for the sausage-making process. I have seen the alternative approach in Iraq and Afghanistan, and that experience was far more unpalatable.
- https://nida.nih.gov/publications/research-reports/prescription-opioids-heroin/prescription-opioid-use-risk-factor-heroin-use. Accessed July 7, 2025.
