Opioids are the nuclear option for pain: codeine (more readily available, mostly in small doses in Tylenol IIs and IIIs) and more serious “hillbilly heroin” (Oxycontin, Percocet, etc) are all capable of inducing deep relaxation, euphoria, and making you “not care” about pain.1 All opioids are narcotics, but in health care we like to talk about “opioids” because it sounds better than “Let’s give you some narcotics for your chronic pain.”
But there are so many problems …
- They don’t work at all on quite a few people for genetic reasons.
- They are ineffective for chronic pain (non-cancer) in particular, and can actually backfire, which is nightmare fuel.
- It’s not even clear that they are actual effective for acute pain! Fun fact.
- And, of course, they are dangerous. Extremely dangerous.
But, as with cars and mountain climbing, some risks are worthwhile, and there is a vigorous ongoing debate about how opioids should be used. For each patient, it depends, and you need to talk to your doctor about it. And some doctors are far more qualified to discuss it than others.2 This article is intended to help patients with chronic body pain prepare for that conversation.
It’s official: opioids for chronic musculoskeletal pain are a bad idea
Prescription opioid [DrugAbuse.com] abuse is causing so many deaths by overdose that, in early 2016, the American Centers for Disease Control and Prevention (CDC) decided it had to do something. (Not the FDA, but the CDC!3) They made many recommendations, including that opioids should not be considered an option for chronic musculoskeletal pain,4 which were quickly adopted by many physician colleges around the world.5 I’ll get into more of the evidence more below.
The CDC’s position is strongly opposed by pain patient advocacy groups, because opioids obviously do help many people.6 More cynically, perhaps they don’t want to lose funding from the drug companies that make prescription opioids.7
The danger can’t be overstated: it’s been called the “opioid crisis” [Google search] repeatedly in recent years, because deaths from opioid overdose have tripled (in the US).8 In fact, since 2014, more Americans have died from opioid overdoses than from car accidents9 — the first time in decades that car accidents haven’t been the number one cause of accidental death.
And a whopping 60% of opioid-related deaths are linked to a chronic pain diagnosis10 — which is a huge problem for the argument that opioids are safer when prescribed for chronic pain.
So, before you try opioids for a condition like back pain, ask yourself the reasonable question, “Do I really want to risk death? Or, if I’m “luckier,” a decade of addiction and rehab hell?”
Maybe we all need to stop thinking of opioids as “powerful” pain killers
As if all the extreme danger wasn’t bad enough, opioids just don’t work all that well for many patients. It’s not that they don’t work at all, just not nearly well enough or in the right ways for enough people. As with all drugs, the effects are unpredictable at best. Some people are actually immune to (oral) opioids: they can’t get high that way at all!11 In some people, they just straight-up backfire, a nasty fate in which opioids actually cause pain (“opioid hyperalgesia”).1213
But recent scientific literature on opioid efficacy for many kinds of musculoskeletal pain is a litany of disappointing results:
- 2015 — A review of opioids for non-cancer musculoskeletal diseases concluded that opioids were “only slightly more effective than their placebos, no more effective than acetaminophen, and somewhat less effective than nonsteroidal anti-inflammatory drugs (NSAIDs).14
- 2016 — Shaheed et al concluded that “opioid analgesics provide modest short-term pain relief but the effect is not likely to be clinically important within guideline recommended doses.”15
- 2017 — A trial showed that regular pain-killers work just as well as lower-dose opioids for severe, acute extremity pain in the emergency room: “no statistically significant or clinically important differences in pain reduction at 2 hours.”16
- 2018 — Most relevant to most people, most of the time, a trial for patients with ordinary arthritis and back pain found that “treatment with opioids was not superior to treatment with nonopioid medication.” There were no important differences except that opioids have more side effects. A lot more.17
All of this evidence suggests that opioids are surprisingly unimpressive as a pain treatment at safer dosages for many of the conditions people want them for. While they may well work better at higher dosages, then you’re flirting with greater addiction risk. The questionable efficacy should be a major point of concern when discussing the opioid option with a doctor.
Should opioids be demonized?
Demonizing an entire class of drugs is usually a bad idea. It might be justified and defensible in this case, given the serious dangers, but not everyone gets addicted and nothing is all bad. Opioids still have a vital place in pain management for some kinds of patients, especially:
- acute traumatic pain
- the terminally ill (where addiction is not a concern)
- unusually extreme pain where addiction is the lesser of evils, like some neuralgias [Wikipedia] or complex regional pain syndrome [Mayo]
But there is still intense controversy about their use for everything else,18 and how to manage the undeniable crisis. For musculoskeletal pain in particular, over the last few years, expert concensus has shifted strongly towards the belief that they should only be used with great caution and close supervision … or not at all.19
What if you’re already on opioids? Should you stop?
No one thinks these drugs are completely useless and dangerous for everyone all the time … just for so many people that it may be unwise to try them in the first place. All medical decisions are about balancing risk and benefit, and if you’ve already opened that door and walked through it, and there seems to be some real benefit and minimal risk as far as you can tell so far… well then, phew. You’re one of the lucky ones: you’re demonstrating that opioids can be used safely.20
But please consider:
- The benefits might be a least partially illusory. Opioids have that weird knack for making pain seem more tolerable — suffering reduction — rather than actually reducing it. And suffering reduction is something that can be achieved other ways, and maybe should be.
- The risks don’t go away just because you’ve been on the drug for a while. The risk of overdose continues. People can do just fine on opioids for a long time and then still get into trouble.
If you continue on opioids, work closely with your doctor and be wary of increasing your dosage, particularly if it has been stable for some time.
The smart way to ask for a prescription
If you still want to try opioids for your pain, find a doctor who respects opioids as a powerful tool to be used with great caution, if at all.
- Volunteer to accept only a low-dose prescription for a short period.
- Show that you understand the idea of dependence and the risks of addiction and death, and make it clear that you want supervision and collaboration.
- Ask for his or her opinion of what you should do.
- And still allow yourself to be talked out of it!
Consider refusing a prescription from any doctor who does not show awareness of the risks — but those are getting rare these days, of course. If anything, the opposite problem is now looming: doctors are so aware of the problems that they don't want to deal with opioids at all.
It’s getting harder to find doctors that will help with getting off opioids
More and more chronic pain patients are “forced to navigate their transition off prescribed opioids, often with little or no assistance or guidance, with the potential for disastrous results,” explain the authors of a well-written NEJM editorial about the serious medical consequences of physicians choosing to “simplify their lives by discontinuing prescribing of opioid analgesics.”21
And why would physicians stop prescribing opioids? “The most important contributor to a desire to stop prescribing opioids is the effect of opioid prescribing on clinicians’ emotional well-being.”
Translation: dealing with opioids professionally is a huge bummer.
It’s difficult to walk into an exam room knowing that we have to significantly reduce or stop a patient’s opioid treatment — and then deal with the lengthy, emotional, possibly confrontational encounter that typically ensues.
“It’s difficult.” An understatement, I am sure.
A few notes about other pain killers, for perspective
Over-the-counter (OTC) pain killers are somewhat effective and definitely safer than opioids, but they have their own substantial risks, particularly the anti-inflammatories. Beware of taking any of them for long — risks go up over time, and they can even backfire and cause pain (rebound headaches [Mayo]).
Acetaminophen/paracetamol (Tylenol) is good for fever and pain, and is one of the safest of all drugs at recommended dosages, but overdose can badly hurt livers22 and it doesn’t work especially well for a lot of common musculoskeletal pains.23 The NSAIDs (Aspirin, ibuprofen, Advil, etc) may be a better bet …24
The NSAIDs reduce inflammation as well as pain and fever. As mentioned and referenced above, they may actually be more effective than opioids for musculoskeletal pain, or at least no less. (All the OTC meds are roughly equal for acute injury pain,25 but benefits vary between people and issues.)
Unfortunately, at any dose they can cause heart attacks and strokes26 and they are “gut burners”27 — they can badly irritate the GI tract, even taken with food, and especially with booze. Aspirin is usually best for joint and muscle pain, but it’s the most gut-burninating of them all.
Voltaren® is an ointment NSAID, generally much safer because it involves a smaller dose only where you need it. It’s by far the best option for any minor, superficial musculoskeletal pain.28 And there’s always icing, too!
Addiction versus dependence
Addiction is a loaded word, full of mischief. Like opioids themselves, it must be used with caution. It’s often used casually to refer to anything people overindulge in: chips, video games, shoes. But these terms have precise meanings that matter:
Addiction: Complex, compulsive, self-destructive behaviour driven by a craving.
Dependence: A relatively simple biological need for a drug.
And now with a little more feeling …
Physical dependence is the biological need for a drug to maintain normal function, caused by the drug itself, which does its damage only when the dosage is reduced. You can be dangerously dependent on a drug without being an “addict” at all (exactly the case for many people on opioids), and you can get addicted without dependence (gambling is the classic example). Importantly, physical dependence on a prescribed drug is always, by definition, an iatrogenic (doctor-caused) disease — doctors have an ethical responsibility to treat dependence regardless, but all the more so when they actually prescribed the drug that caused dependency.
Addiction is much messier. It’s a legitimate disease in its own right, but a much more complex disease of craving and self-destructively compulsive behaviour. It usually involves what most people think of as “psychological addiction.” The harm of addiction is mainly done by the behaviour, and addicts are routinely villified and personally equated with their disease.29
“Addiction” is such a powerfully stigmatizing concept that it undermines, dilutes, and distracts legitimate claims to physical dependence. When people are written-off as addicts, whether addiction is actually a factor or not, they often don’t get the medical care they obviously need for dependence. Or the damn sympathy.
- Although the book predates the recent dramatic escalation in the opioid crisis, Marni Jackson explores the controversy with style in her book, Pain: The science and culture of why we hurt — a highly recommended read for anyone with chronic pain.
- “CDC issues guidelines against opioid prescriptions to treat chronic pain,” Susan Zalkind, TheGuardian.com. An excellent summary of the controversy around the CDC’s choice to do the FDA’s job and issue guidelines for opioid prescribing.
- “Five Studies: Understanding America’s Opioid Crisis,” Livia Gershon, PSMag.com. A good data-driven review of the prescription opioid addiction and overdose disaster unfolding around the world since the early 2000s.
- How risky are NSAIDS? A detailed review of anti-inflammatory medication safety, by pharmacist Scott Gavura.
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About Paul Ingraham
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
What’s new in this article?
Eight updates have been logged for this article since publication (2016). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more
When’s the last time you read a blog post and found a list of many changes made to that page since publication? Like good footnotes, this sets PainScience.com apart from other health websites and blogs. Although footnotes are more useful, the update logs are important. They are “fine print,” but more meaningful than most of the comments that most Internet pages waste pixels on.
I log any change to articles that might be of interest to a keen reader. Complete update logging of all noteworthy improvements to all articles started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.
See the What’s New? page for updates to all recent site updates.
2018 — New section inspired by Comerci et al: “It’s getting harder to find doctors that will help with getting off opioids.”
2018 — Important new section: “Addiction versus dependence.”
2018 — Science update: updated rebooted referencing of studies comparing opioids to over-the-counter pain killers, most notably with Krebs et al.
2016 — Improved footnotes/citations regarding other pain-killers. Added key citations about opioid and NSAID efficacy for musculoskeletal pain. Added more early emphasis on the position of pain patient advocacy groups. Miscellaneous editing.
2016 — Added citation about opioid non-responders. Added a TL;DR summary.
2016 — Major update. Added disclaimer (needed more for this article than most). Edited extensively to focus the article more strongly on official guidelines and reporting exerpt opinion and official guidelines, and greater acknowledgement of controversy. Added related reading section.
2016 — Editing, added several references, and a new section about safety issues with over-the-counter medications for perspective.
2016 — Transferred and adapted content from a chapter in Trigger Points & Myofascial Pain Syndrome.
2016 — Publication.
- That is, they don’t actually treat the source of any pain: they simply make you care less about it for a while. They decrease perception of pain, reaction to pain, and increase pain tolerance (all subtly different things). BACK TO TEXT
- PS Ingraham. The Medical Blind Spot for Aches, Pains & Injuries: Most physicians are unqualified to care for many common pain and injury problems, especially the more stubborn and tricky ones. ❐ PainScience.com. 796 words. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and even the best are poor substitutes for physical therapists. This has been proven in a number of studies, like Stockard et al, who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s advice with a grain of salt.
By all means, discuss opioids with your family physician — but it’s really the domain of specialists, preferably a doctor at a pain clinic, or any specialist who deals with a lot of chronic body pain (neurologists, rheumatologists).BACK TO TEXT
- The CDC usually leaves drug regulation to the Federal Drug Administration, but chose to issue their recommendations because of the rapidly increasing number of deaths from prescription opioids. They saw a dire need, and they stepped up. It was an interesting move. BACK TO TEXT
- CDC.gov [Internet]. Centers for Disease Control and Prevention. CDC Guideline for Prescribing Opioids for Chronic Pain; 2016 Apr [cited 16 Jun 22]. “Plainly stated, the risks of opioids are addiction and death, and the benefits for chronic pain are often transient and generally unproven.” (CDC Director Tom Frieden, from March 2016 press briefing about the new guidelines). The FDA quickly responded with “enhanced warnings” about the “risks of misuse, abuse, addiction, overdose and death.” BACK TO TEXT
- For example, in Canada: “Physician regulatory colleges in four provinces, alarmed by Canada’s opioid epidemic and frustrated by a lack of federal action, are endorsing new national standards in the United States for prescribing painkillers” (Globe and Mail, May 8, 2016). In recent years, Canadian doctors have been prescribing more opioids than than doctors anywhere else in the world. BACK TO TEXT
- Some patients do benefit from opioids, of course — more about this below. It could be a disaster for those patients if opioids become heavily stigmatized and inaccessible. BACK TO TEXT
- TheGuardian.com [Internet]. Zalkind S. CDC issues guidelines against opioid prescriptions to treat chronic pain; 2016 July 27 [cited 16 Jul 29].
This article does a great job summarizing the controversy. Here’s a good excerpt:
For Bob Twillman, executive director for the American Academy of Pain Management … the CDC’s move is an ominous sign that state and federal lawmakers will take increasing steps to turn CDC’s suggestions to prescribing doctors into a hard and fast rule. “It reflects a lack of experience in treating people with chronic pain,” says Twillman, who also receives funding from pharmaceutical companies.
Kolodny, says the blacklash from pain advocates — many of whom are funded by pharmaceutical companies — is akin to naysayers of global warming. “It’s a manufactured controversy,” Kolodny says.
So it’s quite contentious.BACK TO TEXT
- PSMag.com [Internet]. Gershon L. Five Studies: Understanding America’s Opioid Crisis; 2016 July 27 [cited 16 Jul 29]. BACK TO TEXT
- National Safety Council: “Unintentional poisoning deaths in the adult population were not prevalent until the early 1990s. Since then this category has skyrocketed to 1st place, driven by unintentional drug overdose — predominantly from prescription painkillers.” BACK TO TEXT
- Olfson M, Wall M, Wang S, Crystal S, Blanco C. Service Use Preceding Opioid-Related Fatality. Am J Psychiatry. 2017 Nov:appiajp201717070808. PubMed #29179577. ❐ BACK TO TEXT
- Tennant F. Why oral opioids may not be effective in a subset of chronic pain patients. Postgrad Med. 2016 Jan;128(1):18–22. PubMed #26635137. ❐
We tend to think of opioids as potent drugs that are going to make pretty much anyone high, and therefore probably provide some pain relief … but there’s an incredible range of responses to drugs, even strong ones. This paper presents some specific reasons why some people just aren’t much affected by (oral) opioids: “there is a group of intractable pain patients who do not effectively metabolize oral opioids,” mainly because of gastrointestinal disorders and an inherited metabolic problem (cytochrome P450 enzymatic defects).BACK TO TEXT
- Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011;14(2):145–61. PubMed #21412369. ❐
“Opioid induced hyperalgesia” is a nasty fate in which opioids actually cause pain instead of relieving it:
Opioid-induced hyperalgesia (OIH) is defined as a state of nociceptive sensitization caused by exposure to opioids. The condition is characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to certain painful stimuli.
Clinicians should suspect OIH when opioid treatment's effect seems to wane in the absence of disease progression, particularly if found in the context of unexplained pain reports or diffuse allodynia unassociated with the original pain, and increased levels of pain with increasing dosages.”
- Grace PM, Strand KA, Galer EL, et al. Morphine paradoxically prolongs neuropathic pain in rats by amplifying spinal NLRP3 inflammasome activation. Proc Natl Acad Sci U S A. 2016 06;113(24):E3441–50. PubMed #27247388. ❐ PainSci #53712. ❐
This rat study demonstrated that opioids can actually cause chronic pain rather than treating it. In rats, anyway. Obviously replication in human studies is needed.BACK TO TEXT
- Berthelot JM, Darrieutort-Lafitte C, Le Goff B, Maugars Y. Strong opioids for noncancer pain due to musculoskeletal diseases: Not more effective than acetaminophen or NSAIDs. Joint Bone Spine. 2015 Oct. PubMed #26453108. ❐ BACK TO TEXT
- Abdel Shaheed C, Maher CG, Williams KA, Day R, McLachlan AJ. Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016 Jul;176(7):958–68. PubMed #27213267. ❐ BACK TO TEXT
- Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA. 2017 Nov;318(17):1661–1667. PubMed #29114833. ❐
This JAMA trial showed that regular pain-killers work just as well for severe, acute pain. That certainly seems newsworthy.
But nuance! Dosage matters, and this was a low dosage. Opioid effectiveness is strongly dependent on previous exposure, psychosocial factors, and genetics (see Tennant). These factors need to be considered. It’s likely that opioids are more effective for acute pain than this study suggests, for the right people with the right dose. (Hat tip to @DrJimEubanks for raising my awareness on this point.)BACK TO TEXT
- Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018 Mar;319(9):872–882. PubMed #29509867. ❐ BACK TO TEXT
- Many doctors now believe that the risk of addiction and other severe complications is just too great. Others — including many chronic pain specialists and patient advocacy groups like the American Pain foundation — believe that the risks of opioid addiction are exaggerated and the benefits of properly prescribed and monitored opioids are vital to many chronic pain patients. Some even argue that there’s essentially a tragic epidemic of treatable chronic pain going untreated because of ignorant prejudice against opioids. BACK TO TEXT
- Pro Publica [Internet]. Ornstein C, Weber T. The Champion of Painkillers; 2012 Mar 7 [cited 15 May 23].
For years I assumed that narcotic pain killers are effective, and I took at face value the American Pain Foundation’s position that the risks of addiction are overblown, and the drugs are stigmatized and underused, resulting in a tragic lack of relief for many patients. This article casts reasonable doubt on all of that, and on the credibility of the APF, who may be serving the interests of pharmaceutical companies better than patients. In the spirit of Dr. Harriet Hall’s skeptical rule of thumb — “Who disagrees and why?” — it is clear that there is a problem here. Politics aside, I am most perturbed by the idea that opiates may not be all that effective in the first place. There is little doubt that these powerful drugs are valuable for some kinds of pain — just try passing a kidney stone without them! — but they may be surprisingly powerless against other kinds.BACK TO TEXT
- Huber E, Robinson RC, Noe CE, Van Ness O. Who Benefits from Chronic Opioid Therapy? Rethinking the Question of Opioid Misuse Risk. Healthcare (Basel). 2016;4(2). PubMed #27417617. ❐ “Harmful, dose-dependent deleterious effects have become clearer,” and yet “many individuals on low doses of opioids for long periods of time appear to have good pain control and retain social and occupational functioning. Therefore, we propose that the question, ‘Who is at risk of opioid misuse?’ should evolve to, ‘Who may benefit from chronic opioid therapy?’” BACK TO TEXT
- Comerci J, Katzman J, Duhigg D. Controlling the Swing of the Opioid Pendulum. N Engl J Med. 2018 Feb;378(8):691–693. PubMed #29466151. ❐ BACK TO TEXT
- FDA.gov [Internet]. Acetaminophen and Liver Injury: Q & A for Consumers; 2009 Jun 4 [cited 16 Aug 31].
“This drug is generally considered safe when used according to the directions on its labeling. But taking more than the recommended amount can cause liver damage, ranging from abnormalities in liver function blood tests, to acute liver failure, and even death.”BACK TO TEXT
- Machado GC, Maher CG, Ferreira PH, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ. 2015;350:h1225. PubMed #25828856. ❐ PainSci #54220. ❐ BACK TO TEXT
- Derry S, Moore RA, Gaskell H, McIntyre M, Wiffen PJ. Topical NSAIDs for acute musculoskeletal pain in adults. Cochrane Database Syst Rev. 2015;6:CD007402. PubMed #26068955. ❐ BACK TO TEXT
- Hung KK, Graham CA, Lo RS, et al. Oral paracetamol and/or ibuprofen for treating pain after soft tissue injuries: Single centre double-blind, randomised controlled clinical trial. PLoS One. 2018;13(2):e0192043. PubMed #29408866. ❐
In a test of ibuprofen vs paracetamol for hundreds of soft tissue injuries, there was no significant difference in the modest benefits or side effects, contrary to some past evidence and the widely held medical belief that ibuprofen is better for injuries (inflammation). It’s possible that placebo is powering the effects of both medications, and that's why they were equal, but it's impossible to know without a control group for this study. Note that the superiority of these medications is probably variable and not as clearly established as you might think.BACK TO TEXT
- FDA.gov [Internet]. FDA Strengthens Warning of Heart Attack and Stroke Risk for Non-Steroidal Anti-Inflammatory Drugs; 2015 Jul 9 [cited 18 Dec 7]. BACK TO TEXT
- Science Based Pharmacy [Internet]. Gavura S. How risky are NSAIDS?; 2015 Jul 25 [cited 16 Aug 18]. BACK TO TEXT
- Derry S, Moore RA, Gaskell H, McIntyre M, Wiffen PJ. Topical NSAIDs for acute musculoskeletal pain in adults. Cochrane Database Syst Rev. 2015;6:CD007402. PubMed #26068955. ❐ BACK TO TEXT
- Rather than addiction being seen as something that they have, like a illness, they “are” addicts — and addicts are bad people, failed people. In other words, they are blamed for it. It’s an understandable mistake, but a mistake nevertheless, and a tragic one. BACK TO TEXT