full article 2750 words
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.”
Opioids 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.
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
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.7Since 2014, more Americans have died from opioid overdoses than from car accidents — the first time in decades that car accidents haven’t been the number one cause of accidental death.
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.
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?”
As if all the extreme danger wasn’t bad enough, opioids just don’t work all that well. 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. Some people are actually immune to (oral) opioids: they can’t get high that way at all!10 The scientific literature on this topic is a litany of disappointing results. For instance, in 2016, Shaheed et al concluded:11
For people with chronic low back pain who tolerate the medicine, opioid analgesics provide modest short-term pain relief but the effect is not likely to be clinically important within guideline recommended doses.
And in 2015, reviewing opioids for non-cancer musculoskeletal diseases, Berthelot et al concluded:
…morphine and other strong opioids in dosages of up to 100mg/day were only slightly more effective than their placebos, no more effective than acetaminophen, and somewhat less effective than nonsteroidal anti-inflammatory drugs (NSAIDs).
In other words, opioids are surprisingly unimpressive as a pain treatment at safer dosages. (They probably work better at higher dosages, but then you’re really dancing with the addiction risk.) The questionable efficacy should be a major point of concern when discussing the opioid option with a doctor.
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:
But there is still intense controversy about their use for everything else,12 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.13
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.14
But please consider:
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.
If you still want to try opioids for your pain, find a doctor who respects opioids as a powerful tool to be used with extreme caution, if at all, and consider refusing a prescription from any doctor who does not show awareness of the risks.
Over-the-counter (OTC) pain killers are 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]).
Acetominophen (Tylenol) is good for fever and pain, and is one of the safest of all drugs at recommended dosages, but overdose can badly hurt livers15 and it doesn’t work well16) for musculoskeletal pain.
The NSAIDs (Aspirin, ibuprofen, Advil, etc) are a better bet for common aches and pains. They reduce inflammation as well as pain and fever. As mentioned above, they may actually be more effective than opioids for musculoskeletal pain (Berthelot 2015), and they are modestly effective for sprains, strains, and repetitive strain injuries.17 Unfortunately, at any dose they can cause heart attacks and strokes18 and they are “gut burners”19 — 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. And there’s always icing, too!
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.
Five updates have been logged for this article since publication (Jul 16th, 2016). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more
Like good footnotes, update logging sets PainScience.com apart from most other health websites and blogs. It’s fine print, but important fine print, in the same spirit of transparency as the editing history available for Wikipedia pages.
I log any change to articles that might be of interest to a keen reader. Complete update logging 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.
— 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.
— Added citation about opioid non-responders. Added a TL;DR summary.
— 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.
— Editing, added several references, and a new section about safety issues with over-the-counter medications for perspective.
— Transferred and adapted content from a chapter in Trigger Points & Myofascial Pain Syndrome.
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
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
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
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
“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