Detailed guides to painful problems, treatments & more

Opioids for Chronic Aches & Pains

The nuclear option: Oxycontin, codeine and other opioids for musculoskeletal problems like neck and back pain

Paul Ingraham • 20m read
Banner format image of a large opium poppy seed head, plus other foliage and flowers in the background, slightly blurry.

The notorious opioids come from the “milk of the poppy,”1 and are allegedly the most potent pain-killers short of anaesthesia drugs. They include weak opioids like codeine (mostly found in small doses in Tylenol IIs and IIIs) and more infamous strong ones: morphine derivatives and synthetics like Oxycontin, Percocet, and Fentanyl. They are all capable of inducing deep relaxation, euphoria, and making you “not care” about pain.2 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. We joke about “the good stuff” like it’s a given that it will do the job if anything will, but satisfaction is far from guaranteed.

Off-white pills spilling out of an unlabelled white bottle, and a syringe filled with clear fluid.

But, as with cars and mountain climbing, some risks are worthwhile, and there is a vigorous ongoing debate about how opioids should be used, if at all. 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.3 This article is intended to help patients with chronic body pain prepare for that conversation.

Opioids for chronic musculoskeletal pain are mostly a bad idea

Prescription opioid 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!4) They made many recommendations, including that opioids should not be considered an option for chronic musculoskeletal pain,5 which were quickly adopted by many physician colleges around the world.6 I’ll get into the evidence more below.

The CDC’s position is strongly opposed by pain patient advocacy groups, because opioids obviously do help many people.7 More cynically, perhaps they don’t want to lose funding from the drug companies that make prescription opioids.8

The danger can’t be overstated: it’s been called the “opioid crisis” repeatedly in recent years, because deaths from opioid overdose have tripled (in the US).9 In fact, since 2014, more Americans have died from opioid overdoses than from car accidents10 — 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 diagnosis11 — 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 genuinely immune to (oral) opioids: they can’t get high that way at all!12 In a few people, they just straight-up backfire, a rare but nasty fate in which opioids actually start to cause more pain (“opioid hyperalgesia,” more on this shortly).

But recent scientific literature on opioid efficacy for many kinds of musculoskeletal pain is a litany of disappointing results:

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 — and the stigma. The questionable efficacy should be a major point of concern when discussing the opioid option with a doctor.

What are the opioids? More detail

What are the opioids? Many opioids are household names, like the oxycodone brands Oxycontin and Percocet, the most popular narcotic painkillers in America for some time. Other familiar examples, some known better by the brand and others by their chemical names, are fentanyl (the drug that killed Prince), Vicodin (the one Dr. Greg House was addicted to), morphine, codeine (most widely available in Tylenol 2s and 3s), heroin and methadone, Demerol, and Darvon. And, of course, there’s actual opium! Many famous people have infamous addictions to some of these drugs, such as Rush Limbaugh’s Oxycontin addiction.

An opium poppy seed head with very blurry vegetation in the background.

Ripening seed head of an opium poppy.

“Opiate” is the older word referring specifically to poppy-derived compounds. “Opioid” refers to any drug with similar effects, opioid-ish, plus any pain-killing molecule the body produces itself. In practice, the terms are used imprecisely and opioid has been taking over. (Neither term includes the infamous benzodiazepines, like Valium.)

Weak versus strong opioids

The weak opioids are drugs like codeine, dihydrocodeine, and tramadol. The strong opioids are either morphine itself (the gold standard, the canonical opioid drug) or its derivatives and synthetic imitators like fentanyl, hydromorphone, methadone and oxycodone.

It seems like it would make sense to experiment with weak opioids before strong, but the weak ones are notoriously ineffective at lower doses, and when you increase the dose the efficacy doesn’t go up very much but you do get a lot more side effects! Bad deal. If you need any opioids, you probably need strong ones. If you don’t need strong opioids, weak ones aren’t worth it either. But that’s just an opinion, a starting place for a chat with your doctor.

Best prescription ever?

“Perco-Bull (Red Bull laced with perrcocett) [sic]… Side effects include but not limited to: Wings.” Source unknown.

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 many kinds of patients, especially:

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

How opioids can cause pain: opioid hyperalgeisa, and the insidious trap of “downregulation”

There are two distinct ways that opioids backfire:

  1. Increased pain can be direct side effect of usage, a phenomenon known as “opioid hyperalgesia,” in which certain kinds of sensitivity ramp up while still taking the drug, for unclear reasons (very complex and poorly understood biochemistry).2021 This is a bit rare and exotic, and literally no one can explain it. We just don’t know what’s going on with these cases yet.
  2. As an almost inevitable consequence of withdrawal from physiological dependence. This will happen to some degree to most people who take opioids, but you are shielded from it as long as you keep taking opioids. This phenomenon is powered by downregulation, which is a vital basic principle …

Nerves fire in response to specific chemicals. The number of receptors they have for specific chemicals is “regulated,” and they can be regulated “up” or “down.” If you flood a nerve with too much with a specific chemical, it will get “numb” to it — by downregulating the number of receptors for it. Clever system.

The opioid receptors are famous because they trigger the firing of nerves that inhibit pain. When you take opioids, you are washing those opiate receptors with many more opioid molecules than normal … and the body responds by getting rid of some receptors!

Downregulation of opiate receptors disables your pain inhibition system … and if you can’t inhibit pain, then you’re more sensitive to it. The trap has closed. The thing that killed pain has now made you more vulnerable to it.

The inexorable logic of downregulation applies to anything that tinkers with neurological signalling related to pain. It is a plague on the quest for a perfect pain killer, a fundamental reason why it may never happen. If you pick a pathway that inhibits pain, any pathway, give it a boost with some kind of artificial stimulation… gosh darn it if it doesn’t start downregulating and become less responsive to natural stimulation, et voila: you become either dependent on the artificial stimulation or seriously sensitized without it.

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 in your case 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.22

But please consider:

  1. The benefits might be a least partially illusory. Opioids have that weird knack for making pain seem more tolerable — suffering reduction, rather than pain reduction. And suffering can be reduced in other ways. And maybe it should be.
  2. The risks don’t go away just because you’ve been on the drug for a while and getting away with it. 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.

Best Advice for People Taking Opioid Medication  11:35

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.

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 hyper-aware of the problems (medical and legal) that they don’t want to deal with opioids at all. In many cases, their hands are actually tied by policy.

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.”23

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.

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 immediate and significant medical consequences of deprivation.

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 knowing it, 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 than dependence: it’s a legitimate disease in its own right, but also a much more complex disease of 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.24

“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, they often don’t get the medical care they obviously need for dependence. Or even just the damn sympathy.

For more information, see Is There Really a Difference Between Drug Addiction and Drug Dependence? []

Related Reading

Did you find this article useful? Interesting? Maybe notice how there’s not much content like this on the internet? That’s because it’s crazy hard to make it pay. Please support (very) independent science journalism with a donation. See the donation page for more information & options.

About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:

What’s new in this article?

Twelve updates have been logged for this article since publication (2016). All 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 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.

Sep 7, 2023 — Edited. Made several minor clarifications, most notably emphasizing that opioids are indeed effective for some kinds of chronic pain (despite being surprisingly ineffective for so many others).

2021 — Clarified the distinction between standard opioid receptor downregulation versus the stranger phenomenon of opioid hyperalgesia.

2021 — New section: “How opioids can cause pain: the insidious trap of downregulation”

2020 — Miscellaneous editing and improvements. Nost notable: a new footnote about mechanism, and a new sub-section about weak versus strong opioids.

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 expert 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 The Complete Guide to Trigger Points & Myofascial Pain.

2016 — Publication.


  1. Yes, that is a Game of Thrones reference. Throughout the books and show, the “milk of the poppy” comes up again and again, prescribed by the “maesters” of Westeros, always to horribly wounded and dying characters — of which there are quite a few, of course.
  2. “Not caring” is a highly subjective and imprecise way of explaining an extremely complex phenomenon. Opioids don’t actually stop pain at the source in any sense. That is, information about tissue damage flows normally from your tissues to your central nervous system. Opioids change how those warning signals are processed and interpreted at quite a high level. They modify/decrease perception of pain rather than the sensation of it, your pain tolerance, and your behavioural responses — all subtly different things.
  3. 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. 1387 words. Most doctors lack the skills and knowledge needed to care for common aches, pains, and injury problems, especially the chronic cases, which they tend to underestimate the complexity of. This has been shown by many 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 puzzling or stubborn pain should take their family doctor’s advice with a large grain of salt, and even lower their expectations of specialists (who tend to be too specialized).

    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).

  4. 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.
  5. [Internet]. Centers for Disease Control and Prevention. CDC Guideline for Prescribing Opioids for Chronic Pain; 2016 Apr [cited 16 Jun 22]. PainSci Bibliography 53446 ❐ “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.”
  6. 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 doctors anywhere else in the world.
  7. 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.
  8. [Internet]. Zalkind S. CDC issues guidelines against opioid prescriptions to treat chronic pain; 2016 July 27 [cited 16 Jul 29]. PainSci Bibliography 53306 ❐

    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.

  9. [Internet]. Gershon L. Five Studies: Understanding America’s Opioid Crisis; 2016 July 27 [cited 16 Jul 29]. PainSci Bibliography 53301 ❐
  10. 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.”
  11. Olfson M, Wall M, Wang S, Crystal S, Blanco C. Service Use Preceding Opioid-Related Fatality. Am J Psychiatry. 2017 Nov:appiajp201717070808. PubMed 29179577 ❐
  12. 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).

  13. 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 ❐
  14. 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 ❐
  15. 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.)

  16. 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 ❐
  17. da Costa BR, Pereira TV, Saadat P, et al. Effectiveness and safety of non-steroidal anti-inflammatory drugs and opioid treatment for knee and hip osteoarthritis: network meta-analysis. BMJ. 2021 10;375:n2321. PubMed 34642179 ❐ PainSci Bibliography 52213 ❐
  18. 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.
  19. Pro Publica [Internet]. Ornstein C, Weber T. The Champion of Painkillers; 2012 Mar 7 [cited 15 May 23]. PainSci Bibliography 54413 ❐

    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.

  20. 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.”

  21. 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 Bibliography 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.

  22. 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?’”
  23. Comerci Jr, Katzman J, Duhigg D. Controlling the Swing of the Opioid Pendulum. N Engl J Med. 2018 Feb;378(8):691–693. PubMed 29466151 ❐
  24. Rather than addiction being seen as something that they have, like an 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.


linking guide

4,750 words