The opioid crisis is more severe in the United States than in any other country. This may be due, in part, to a cultural problem related to pain: Americans have come to expect quick, easy, physician-provided pain relief. Pharmaceuticals can neither cure injuries nor correct the underlying cause of any chronic musculoskeletal condition. Fortunately, people who regularly exercise have less pain, and guidelines for the management of painful chronic conditions already recommend exercise therapies over passive care. This suggests that self-care approaches emphasizing exercise are the logical, lowest-cost, first-line treatment. For patients who require guidance with exercise, the stepped-care approach to pain management commonly taught in medical school curricula should include guided physical rehabilitation early, if not first. This has been shown to be associated with fewer high-cost services and less opioid medication. Keeping people opioid naïve, when appropriate, could save tens of thousands of American lives annually and many more globally. Attitudes, behaviors, and policies must evolve to shed the culture of first-line pharmaceutical pain management. .