Benefits and Risks of Opioids for Chronic Pain

Controversial Narcotic Pain Medications for Chronic Pain

Opioids (narcotics) are powerful analgesics (painkillers) that can be effective and safe when taken under close medical supervision. But they have side effects and can lead to addiction, so their use in the long-term treatment of chronic pain is somewhat controversial.

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What Are Opioids?

Some opioids are derived from plants, some are manufactured in a lab, and others, such as endorphins, occur naturally in the body.

Opioids are very effective in the treatment of severe pain. In fact, they are frequently used to treat acute pain, such as post-surgical pain, as well as severe pain caused by diseases such as cancer.

Types

There are several types of opioids used to treat chronic pain, and there are some differences between them.

Variations include:

  • The duration of action can vary. and includes long-acting and short-acting formulations.
  • They can be used as a patch on the skin, intravenously (IV in a vein), orally, or as a rectal suppository. Some opioids can be used in more than one way, but others are limited to only one method of delivery.
  • Opioids, such as oxycodone and hydromorphone are "straight narcotics". Tylenol #3 and Vicodin, are mixed with other pain killers such as acetaminophen.

Another class of opioids, defined as agonist/antagonist, combine medications that decrease pain with medications that decrease the potential for dependence. These include buprenorphine and butorphanol.

Side Effects and Other Complications

Many people with chronic pain can use the same opioid dosage for years without building up a drug tolerance or developing a physical dependence on the drug.

Sometimes chronic pain sufferers who take opioids may wrongly be labeled as "addicts," even if they do not meet the actual criteria for addiction. There is sometimes a certain stigma associated with taking narcotic pain medication, which can be frustrating for the person with severe chronic pain.

However, dependence and addiction are legitimate concerns, and they can interfere with a person's life in serious ways.

In addition to tolerance and physical dependence, opioids have a number of other potential side effects.

These may include:

  • Drowsiness
  • Confusion
  • Nausea
  • Constipation
  • Urinary retention
  • Difficulty breathing
  • Sexual dysfunction
  • Low blood pressure
  • Itching sensations

Often, healthcare providers will start opioid doses very low and slowly increase them until a therapeutic level is reached.

Opioids tend to affect seniors and children more than adults, so these populations must be monitored especially carefully.

Certain medications may interact negatively with opioids, so careful monitoring is required if you also take other prescriptions regularly. Be sure to inform your healthcare provider of any other medications you take, including those purchased over the counter, to avoid potential complications.

Alcohol increases the risk of confusion and sedation when used with opioids, and the combination can lead to life-threatening complications.

CDC Guidelines for Prescribing Opioids for Chronic Pain

Due to the increase in overdoses related to the use of opioids for non-cancer related pain, the Centers for Disease Control and Prevention (CDC) have issued guidelines for the safe use of opioids in people with chronic pain.

Recommendations include:

  • Opioids should not be used as "first-line" therapy for chronic pain. Other non-opioid pain medications should be used first before resorting to opioids. Non-opioid pain medications include non-steroidal anti-inflammatory drugs such as Advil (ibuprofen), tricyclic antidepressants, and anti-seizure medications (anticonvulsants) such as Neurontin (gabapentin). When opioids are needed, they should be used along with these other treatment approaches (to minimize the dose of opioids needed).
  • Goals of therapy must be established. It must be determined that adding in opioid therapy will improve function or quality of life enough to make the risk of having the possible side effects worth it.
  • A patient-healthcare provider conversation must occur in which the patient clearly understands the risks and benefits of using opioids to treat their pain.
  • Immediate-release opioids (in contrast to long-acting opioids) should be used first.
  • The lowest effective dose of the medication should be prescribed. (There are tables that compare doses of the different narcotics if you will be switching from one medication to another.)
  • A short course of narcotics can be prescribed to treat acute pain that occurs on top of chronic pain.
  • Close follow up is needed. Early on in treatment, clinic visits should take place once a week or at least several times per month. When these medications are being used long-term, their use should be evaluated at least every three months—and if the pain is not improving, the medication should be stopped.
  • Healthcare providers must use strategies to decrease misuse of the medications. This may include using a combination agonist/antagonist if the potential for abuse exists.
  • Practitioners should use prescription drug monitoring program (PDMP) data to make sure another medical professional is not prescribing opioids to the same patient.
  • Urine drug testing should be used to make sure that a person is using their prescribed medication and is not using drugs that could interfere with treatment.
  • If at all possible, opioids should not be combined with benzodiazepines.
  • If dependence on opioids occurs, healthcare providers must be ready to offer substance abuse treatment.

Why Use Opioids at All?

With so much controversy surrounding their use in chronic pain conditions, you may wonder why healthcare providers prescribe opioids at all.

Simply put, sometimes the benefits of opioids outweigh their risks. Opioids are very effective at reducing severe pain, and many people who have not gotten relief from other treatments only find relief through opioid use. For many people with chronic pain, opioids can help give them back their quality of life. Negative side effects and dependence affect some people, but these issues do not affect everyone.

Before prescribing opioids for you, your healthcare provider should do a full medical assessment, including a comprehensive medical history and physical examination. Some practitioners may begin with an opioid trial, gradually increasing your dose while observing you for potential complications. And you will have regularly scheduled follow-up appointments to monitor your condition.

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