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Just this morning, a primary care provider came to consult with me, looking for pain rehabilitation options for her patient with a complex set of needs. Emphasizing the legitimacy of the patient’s pain complaints, the provider detailed a long history of an active substance use disorder. The patient has had multiple urine drug screens positive for both opioids, which weren’t prescribed to the patient, and illegal substances. The provider recounts that the patient has been asked to leave multiple pain clinics for similar aberrant prescription drug use behaviors, all of which are indicative of an inability to control the use of opioids. Given the patient's history, she is at high risk of further exacerbating her addiction and/or death, if opioids continue to be prescribed. Nevertheless, the provider feels as if she has to prescribe opioids to the patient because, "she has legitimate medical conditions with real pain."

As I said, the curbside consult happened this morning, but conversations with providers like this one has happened countless times in the past. There are two essential aspects to these conversations: 1) a perceived dilemma between the use of opioids for pain in an individual with a high risk of adverse events from the use of opioids, particularly exacerbation of a substance use disorder or accidental overdose or both, and 2) the provider feeling constrained to nevertheless prescribe opioids.

Notice the relative value that treating pain has in these common scenarios. The reduction of pain with the use of opioids is more important than the risk of adverse harm in the form of exacerbating an existent addiction or death.

Why do providers feel forced to treat pain with opioids, even at the risk of high likelihood of addiction and death?

This sense of constraint comes in part from patients who commonly insist that opioids are the only therapy that Photo by Oscar Keys courtesy of Unsplashworks for them. They report histories of the use of various therapies all of which were insufficiently helpful to go without opioids. Thus, the unspoken inference is that if pain is to be treated, it must be treated with opioids. From here, we come upon the aforementioned value judgment: both untreated pain and the exacerbation of an active substance use disorder with a high risk of death are unacceptable, but it is more unacceptable to experience untreated pain.

An impetus to this common sense of constraint to treat pain with opioids is the assumption that opioids are the most effective form of pain management. It’s a commonly held view in society, but it isn’t necessarily true. In 2018 a meta-analysis (Busse, Wang, Kamaledin, et al), which is a study combining previous studies to make one big study, and typically thought of as one of the gold standards for determining scientific findings, found that opioids for pain were associated with a small, less than one point decrease in pain on the zero to ten scale when compared to a placebo. The authors noted that while the finding was statistically significant, it was not a clinically significant difference in pain reduction. Moreover, they found no difference in pain reduction when comparing opioids to non-narcotic pain medications. Also, in 2018, Krebs, et al., found that those who managed moderate to severe chronic low back, hip or knee pain with opioids had less reduction in pain than those who managed their pain with non-narcotic options. Moreover, those using opioids had significantly more adverse outcomes. In 2019, a two-year prospective study comparing matched controls between those who manage chronic pain with opioids to those who didn’t found no difference in pain, physical functioning, emotional functioning, or social functioning (Veiga, Montenero- Soares, Mendonca, et al., 2019).

In all, what these studies show is that the use of opioids for moderate to severe chronic pain does not add value over and above non-narcotic medications for managing pain. They are not more effective and they are associated with greater risks of addiction and death. As such, they also cast into doubt the benefit-risk ratio that we have tended to make – the known risks of harm in terms of addiction and death outweigh the known levels of pain reduction that the medications produce.

In addition, non-pharmacological methods to manage moderate to severe chronic pain are more effective than opioid management. Specifically, chronic pain rehabilitation programs, sometimes also referred to as functional restoration programs, have long been known to provide greater pain relief than opioids (Du, Hu, Dong, et al, 2017). Indeed, such programs are so successful that patients taking opioids are able to stop taking them and still have significantly less pain than when they were taking opioids.

One might explain to patients, such as the person in the above described consultation, that for their condition there are both pharmacological and non-pharmacological ways to manage moderate to severe chronic pain that is more effective than opioids. This discussion should come to patients as relieving – there is hope that doesn’t have to come at the risk of harm caused by taking opioids!

So, why does the insistence on treating pain with opioids continue? Why do we maintain the sentiment that pain reduction with opioids is more important than the associated risks of exacerbating an already known addiction and its likelihood of accidental death?

Stigma of Addiction

The stigma of addiction might play a role in providers feeling compelled to prescribe opioids, even when they exacerbate an existing addiction or lead to the possibility of accidental death. There are many ways to define stigma and the Institute has discussed many of them. One way to look at stigma is in the relative value that we place on health conditions when comparing them. This issue lies in the background or context of clinical decision-making, but it can subtly determine or influence clinical decision-making within a busy clinic setting. Conditions that tend to be stigmatized are those that tend to have less value than conditions that aren't stigmatized. Value itself can be defined by the degree of education providers receive in their training, or the degree of attention that is provided to it in a busy clinic setting where time is itself in high demand. Thus, stigma might underlie these value judgments in terms of how important a condition is or deserving of time and attention.

We can see such subtle influence in the practice of providers who readily prescribe opioids to those with a brain disorder of addiction Photo by Aude Andre Debleza Saturnio Courtesy of Unsplashdespite being loathe to prescribe acetaminophen to those with a renal disorder. Similarly, providers might commonly ask patients whether they have ever had a history of gastrointestinal bleeding before prescribing ibuprofen, but just as commonly refrain from asking about a history of addiction prior to prescribing opioids. What makes renal and gastrointestinal bleeding disorders more important than the brain disorder of addiction? This subtle relative value difference is typically long-standing in the careers of providers, where one commonly received more education and clinical training in the former conditions than the latter condition. As such, the typical provider simply has a greater level of expertise and comfort with renal and gastrointestinal disorders than brain disorders. This fact remains true more generally for all physical health conditions, as compared mental health conditions. This distinction of value between physical health versus mental health conditions is evident in how the provider in the above described consultation felt compelled to emphasize that the patient in question has a ‘real medical condition’, as if by affirming its reality it somehow becomes more deserving of attention and treatment than the not-so-real brain disorder of addiction that the patient also has. Thus, the reduction of pain can become more important than the reduction of addiction.

Another way stigma can influence clinical-decision making when it comes to the relative importance of reducing either pain, on the one hand, or addiction and death, on the other hand, is that pain is easier to discuss than addiction and the potential for accidental overdose. While all three topics are commonly emotional topics, addiction and accidental overdose are more emotionally sensitive topics. They take greater degrees of time, energy and emotional intelligence on the part of the clinician. In a busy clinic setting where the next patients to be seen are already awaiting their turn in the exam room next door, pain and its reduction can be the path of least resistance as opposed to the more complicated and time consuming focus of how to reduce pain, addiction and accidental overdose.

How important is pain reduction -- revisited

We started this discussion with a story about a primary care provider consulting me over a dilemma that she faced – a provider who feels constrained to treat pain with opioids despite a known opioid addiction and its risk of accidental overdose and death. However, we actually don’t have a dilemma between reducing pain and reducing addiction or death when it comes to the treatment of moderate to severe chronic pain. We don’t have to continue the practice of reducing pain with opioids at the cost of iatrogenic addiction and death. We need to dispel this sentiment, because it just isn’t true. We have multiple ways to manage moderate to severe chronic pain that are at least as effective if not more effective than opioids, all of which come with less risk of harm.

It’s a pretty good deal and it’s time that we, as healthcare providers and patients, accept that deal more often.

More information

For more information, please see: Is It Possible to Manage Pain Well without Opioids? and Benefits of Managing Chronic Pain without Opioids


Busse, J. W., Wang, L., Kamaleldin, M. et al. (2018). Opioids for Chronic Noncancer Pain: A systematic review and meta-analysis. JAMA, 320(23), 2448-2460. doi: 10.1001/jama.2018.18472 Video:

Du, S., Hu, L., Dong, J., et al. (2017). Self-management program for chronic low back pain: A systematic review and meta-analysis. Paient Education and Counseling, 100(1), 37-49. doi: 10.1016/j.pec.2016.07.029

Krebs, E. E., Gravely, A., Nugent, S., et al. (2018). Effect of opioid vs. non-opioid medications on pain-related function in patients with chronic back pain or hip or osteoarthritis knee pain: The SPACE randomized clinical trial. JAMA, 319(9), 872-882. doi: 10.1001/jama.2018.0899

Veiga, D. R., Montenero- Soares, M., Mendonca, L., Castro-Lopes, J. M., & Azevedo, L. F. (2019). Effectiveness of Opioids for Chronic Noncancer Pain: A two-year multicenter prospective cohort study with propensity score matching. The Journal of Pain, 20(6), 706-715.

Date of publication: October 6, 2020

Date of last modification: November 8, 2020

About the author: Dr. Murray J. McAllister is the publisher and editor at the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported and to make that empirically-supported pain management more publicly acessible. To achieve these ends, the ICP provides scientifically accurate information on pain that is approachable to patients and their families.

]]> (Murray J. McAllister, PsyD) Opioids Mon, 05 Oct 2020 18:31:48 +0000
Opioid Dependency and the Intolerability of Pain

The most vexing of all questions in the debate over long-term opioid management for pain is subtle, difficult to articulate, and rarely considered. It lies at the heart of whether and how we maintain patients with severe pain on long-term opioids or whether we help them learn to self-manage it instead.

This most vexing of questions involves how we understand the nature of pain severity and its relationship to its degree of tolerability in the long-term opioid management patient. For depending on how we understand the intolerability of severe pain, it leads to contradictory treatment considerations among well-meaning, competent patients and providers, and even within the larger society.

Succinctly put, it occurs in the following all-too-common scenario:

  • A patient on long-term opioids reports that his or her severe pain would be intolerable without the use of opioids and becomes threatened by open discussion of reducing or tapering opioids, even when the discussion proceeds in a professional manner with caring and empathy.

This all-too-common scenario leads to two contradictory treatment considerations among patients, providers and the greater society, depending on how thePhoto by Cherry Laithang courtesy of Unsplash phenomenon of intolerability of pain on long-term opioids is understood.

Some will look upon the intolerability of pain as solely a function of pain severity. In this manner of understanding, pain occurs wholly independently of the use of opioids. It’s a common sense understanding: pain is intolerable because it’s severe, and only because the pain is severe; the use of opioids is what keeps the intolerably severe pain at bay. With this understanding of the patient’s pain relative to the use of opioids, many consider the only right thing to do in terms of ethical and humane practice is to continue opioids and even increase them should the severity of pain break through the alleviating properties of the present opioid regimen.

Still others understand the intolerability of pain in the patient’s case as evidence of harm by the opioid therapy itself and thus consider cessation of opioid use as the only right thing to do. By this way of understanding, the severity of pain plays only a partial role in its intolerability. The intolerability of pain is also due to the additional long-term exposure to opioids1, 2, 3 and the likely effects of this exposure on the central nervous system,4 which changes the perceived tolerability of pain. In other words, both the patient’s belief in the intolerability of pain without opioids and the related fear-based response to the possibility of opioid reduction are functions of opioid dependency. Succinctly put, these cognitive and emotional perceptions of pain are not commensurate with solely the pain itself, free of its potential influence by opioid-induced changes to the central nervous system.

Rather, they are a function of how opioid dependency lowers pain thresholds, leaving patients increasingly vulnerable and thus fearful of pain. In this view, opioid dependency is a secondary contributor to the overall experience of pain as intolerable.

As a result, opioid tapering, when done with caring and empathy, and in an interdisciplinary fashion, is an exposure-based therapy that leads patients to overcome their perceived intolerability of severe pain and the resultant fear-based vulnerability to pain. In their stead, patients with severe pain become an empowered self-manager of their pain. In comparison to maintaining patients in a persistently dependent, fear-based state on long-term opioids, the benefits of opioid tapering make tapering the only right thing to do, in terms of ethical and humane practice, when the intolerability of severe pain is conceptualized in this manner.

Herein lies the current state of practice within the field of chronic pain management: two contradictory treatment considerations both espousing to be the most ethical, humane practice – one maintaining patients with persistent, severe pain on long-term opioids and the other tapering the very same patients.

Epistemology as ethics

The conviction that severe pain is necessarily intolerable has held a firm position over the last two decades within the movement to treat chronic pain with long-term use of opioids (and now the proponents of medical cannabis make this very same assumption as well). Indeed, it’s seems an easy viewpoint to assume: the belief that severe, persistent pain is intolerable without the use of opioids seems epistemologically self-evident. Severe pain, it seems, is synonymous with agony or suffering. Once this synonymity is assumed, it becomes an imperative to get rid of the pain by any means necessary. The only apparent alternative is to allow people with severe pain to suffer in agony, which, of course, is unacceptable. As such, treatment with opioids becomes a moral imperative.

No doubt such reasoning forms the basis for the high level of sensitivity that comes with the use of opioids, either as a patient or as a provider who espouses the use of opioids. From this perspective, it can be hard to even understand how anyone might hold a contrary perspective and advocate for the withholding of opioids. Any such advocacy brings with it an immediate rejoinder, bordering on doubt of the advocate’s sense of humanity: “What, you want people with severe pain to suffer?”

Of course, in this view, the only other possible explanation for advocating a taper or withholding of opioids is disbelief that the pain is as severe as the person says it is. Indeed, commonly, those of us who recommend self-management over opioid management for those with severe, persistent pain are accused of disbelieving patients or, worse yet, stigmatizing them as weak in their inability to tolerate pain. A common rejoinder in these cases center on something akin to “You wouldn’t be able to cope with this pain either!” Notice the operating assumptions here: it’s self-evidently true that severe pain is necessarily intolerable and to suggest otherwise is simply to engage in some type of offensively critical value judgment.

Despite its appearance as morally suspect, is it invalid to assert that it’s possible to have severe pain and tolerate it – and tolerate it so well that one can work and engage in other valued life activities, all without opioids?

Pain severity and pain tolerability: Distinct phenomena?

These arguments against the recommendation to taper or otherwise withhold opioids border on ad hominem attacks. Of course, those who advocate for tapering opioids are, or at least should be presumed to be, well-meaning. Most providers who engage in tapering opioids in the process of helping people learn to self-manage pain instead aren’t in it to make people suffer or stigmatize them.

Nonetheless, are they misguided in their belief that severe pain doesn’t have to be intolerable?

The historical clinical evidence would suggest that they are not. Tapering opioids for those with persistent, severe pain has had a longstanding history within pain management. Certainly overshadowed over the years by the rise of opioid management for persistent pain, interdisciplinary chronic pain rehabilitation programs (CPRP’s) have been tapering people with severe pain from opioids for about four decades.5, 6 CPRP’s are an interdisciplinary, cognitive-behavioral and exercise-based therapy that exposes patients with persistent pain to what they have long avoided through the use of opioids (or other means, such as reduced activity). In the process, the CPRP’s show patients how to self-manage pain and increase activities in a work-like schedule of therapies. As a result, patients taper opioids and learn how to maintain a weekly schedule of activities. In learning, they moreover regain confidence that they can successfully self-manage pain and return to work at the same time. Instead of opioid management, CPRP’s, as stated previously, have been teaching patients to successfully self-manage severe pain and return to valued life activities for the last four decades. Various meta-analyses over these four decades testify to the empirical effectiveness of such programs.7, 8, 9, 10 These studies repetitively show that participation in a CPRP allows for the cessation of opioid use, while mildly reducing pain, and significantly increasing functioning.

While facing declines in numbers over the years that correspond to the rise of opioid management,11 many healthcare systems across the Western world continue to have interdisciplinary chronic pain rehabilitation programs. Some systems, such as the Veterans Affairs and the Mayo Health systems, are even expanding the number of such programs. The state of Minnesota recently moved to increase access to such programs through their Medical Assistance program.12

Patients in such programs, after having managed their pain for years on opioids, come to find that they really can learn to self-manage pain – they become empowered self-managers of their severe pain. Initially, it’s a threatening experience to let go of the opioid medications and expose themselves to pain, for the doubt lingers that they’ll experience nothing but intolerable suffering. With caring, empathy and expertise, the staff of CPRP’s coaches them to increasingly face their pain in a gradual opioid taper and learn to self-manage it instead. In so doing, patients learn how to successfully self-manage severe pain. However, just as importantly, they learn to overcome the fear of giving up their dependency on opioids in an empowering experience of taking back control of their lives. In other words, they learn that successfully self-managing severe pain is possible. Anecdotally, one of the most common comments upon discharge is “Why didn’t anyone ever refer me to this program earlier?”

In both the empirical evidence (as evident by multiple meta-analyses cited above) and the anecdotal evidence of the last four decades, CPRP’s produce successful, independent self-managers of severe and persistent pain.

It must, therefore, be possible to self-manage severe, persistent pain and do so successfully. As such, perhaps it’s not so misguided to conclude that severe pain isn’t by necessity intolerable. Suffering and agony are not the inevitable result of managing pain without opioids.

If learning to self-manage severe pain through a concerted effort of interdisciplinary training is possible, isn’t it preferable to maintaining people with severe pain in a vulnerable and fearfully dependent state on opioids? Indeed, doesn’t it become a moral imperative to alleviate such dependent vulnerability and arm patients with the health literate skill sets that allow for successful self-management of severe pain?

Population based studies of self- and opioid management of pain

Studies on the effectiveness of CPRP’s, such as those cited above, have been published for years and yet the belief that severe pain is necessarily intolerable without opioids remains widespread among patients on opioids and providers within the healthcare system. Obviously, publication of empirical evidence to the contrary is insufficient to dispel the belief that without opioids severe pain inevitably leads to suffering and agony.

Epidemiological studies of pain severity and opioid use, over the decades of the rise of opioid management, are pertinent here. What they show is that only a minority of people with chronic pain utilize long-term opioid management. In a US-based study conducted in 2000-2001, early in the era of widespread use of opioids, Hudson, et al.,13 found that, among people who had moderate to severe chronic pain, roughly 6% were engaging in the use of opioids for their pain. In a later study conducted in 2007, Toblin, et al.,14 found a modestly larger minority of people managing their pain with opioids, even though more than half of all people with pain rated their pain as moderate to severe. In a more recent study performed in 2012, Nahin15 found that about 17% of the US population reported having severe pain on some to most every day. However, estimates of the use of opioids for pain lie in the 3-4% range.16, 17 These data show that throughout the era of opioid management, even at its height, only a minority of people with severe pain manages their pain with opioids.

Data from diverse researchers have clearly shown that this minority of people with severe pain who manage it with opioids have psychosocial vulnerabilities that differentiate them from those in the majority of people with severe pain who do not manage their pain with opioids.18, 19 In a phenomenon dubbed “adverse selection”, an identified risk factor for becoming a long-term users of opioids for pain is having psychosocial vulnerabilities to dependency, with or without aberrant prescription drug use behaviors indicative of loss of control. These psychosocial vulnerabilities are pre-existing or comorbid mental health and substance use disorders,20, 21, 22, 23, 24, 25  lifestyle related medical conditions,20, 23  lower economic status,26 lower educational levels,21 and rural areas lacking access to non-opioid related therapies for pain.26

Acknowledgement of these data doesn’t entail stigmatizing judgments

The striking lesson from these data is clear: managing severe pain with opioids is not the norm. Most people in the general population with severe, persistent pain have the health literacy and psychosocial capacities to cope with pain and do so without opioids. A minority of the people with severe, persistent pain unfortunately do not have such capacities and as a result they become vulnerable to pain once onset occurs and thus susceptible to depending on opioids to manage their pain for them.

Just as we do not, or should not, stigmatize anyone with mental health and substance use disorders, we do not, or should not, stigmatize the identification of psychosocial comorbidities with persistent pain. The appropriate response for healthcare providers and society alike is not critical judgment, but caring and empathy.

From this light, we can better understand the belief that seems inevitably associated with opioid dependency: the conviction that pain is intolerable without opioids. For those who do not have the psychosocial wherewithal to self-manage severe pain, opioids must seem a Godsend. This opioid dependency becomes self-referential. Dependency on opioids fosters conviction to the false belief that it is impossible to manage pain well without opioids, thus furthering the need to depend on opioids to manage pain.

In this manner, opioid dependency is not dissimilar to dependency on other substances. Substances, like alcohol, can become the means to cope with adverse life events for those who, due to unfortunate life circumstances, do not have the psychosocial capacities to cope successfully on their own. Once having developed an alcohol use disorder, the thought of accepting ‘life on life’s terms’ without alcohol is a highly threatening experience, which simply further reinforces the need to rely on alcohol to cope with the disturbances of life.

Unlike with opioids, however, healthcare providers and the rest of society do not become susceptible to the alcoholic’s conviction that life and all its problems are intolerable without alcohol. As such, we do not feel compelled to make alcohol available to those with an alcohol use disorder.

Why might we do so with opioids?

Providers in the healthcare system can fall prey to the false belief that severe pain is intolerable without opioids. Since the majority of people with severe pain are independent self-managers of their pain, they do not present for pain management and so healthcare providers do not tend to see them in clinic or hospital. Rather, healthcare providers tend to see only those people with persistent pain who are psychosocially vulnerable to pain and who, in their opioid dependency, assert that suffering and agony is the inevitable result of severe pain. Thus, it is understandable that healthcare providers might come to mutually believe that severe pain is necessarily intolerable and so therefore assert that severe pain requires the use of opioids.

A new moral imperative?

It’s time to recognize that pain severity and one’s personal assessment of pain as intolerable or not are distinct phenomena. Just as pain severity varies across individuals along a spectrum from mild to severe, individual differences in the ability to tolerate pain occur along a related yet different spectrum, ranging from low to high pain tolerance.

The acknowledgement of these individual differences in pain tolerance is simply an observation, not a stigmatizing judgment. Of course, some people do judge, but the fact that they do only means that their judgment occurs in addition to the observation that people vary in their abilities to tolerate pain, even severe pain. Some people struggle to cope well with severe pain while others tolerate severe pain and remain engaged in valued life activities. The appropriate response to these observations is not stigma, but empathy and compassion.

Recognition of individual differences in the abilities to tolerate pain, even severe pain, underpins the clinical- and research-based observations that many people rate their pain as severe, yet do not manage their pain with opioids. They live and work and engage in other valued life activities even though they have severe pain and do not use opioids.

This recognition directly challenges the long-held belief that managing severe pain well is impossible without opioids. This belief has been a mainstay for those who espouse opioid management and it underlies the unrelenting fear of those who are reliant on opioids that agony and suffering will inevitably result if they do not have opioids to manage their pain. When, however, we recognize that many people with severe pain fair well without opioids, we cast the long-standing conviction that it is impossible into a new light. We come to see that as a universal statement it is false. We also come to see that the unrelenting conviction with which this false belief is held may be a function of opioid dependency.

Four decades of care from CPRP’s show that self-managing severe pain is a skill set that can be learned. Everyday, people across numerous facilities and multiple countries come to learn how to self-manage severe, persistent pain and do it successfully. Whereas they were once reliant on opioids out of a fear that suffering would inevitably result from their severe pain, they are now no longer vulnerable to their pain. They have pain, but in an important way they have moved on and are now engaged in valued life activities. In other words, they are empowered, independent self-managers of their severe pain.

From this light, a question compels us to be asked: how can we not encourage people with severe pain and reliance on opioids to follow suit? We do not help people with severe and persistent pain by maintaining them in a dependent state of vulnerability and fear that comes with long-term use of opioids for pain. When we have established, empirically-supported therapies that allow such patients to overcome their dependent state of vulnerability to pain, don’t we have a moral obligation to offer it to them and encourage them to access it?


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23. Seal, K. H., Shi, Y., Cohen, G., et al. (2012). Association of mental health disorders with prescription opioids and high-risk opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. Journal of the American Medical Association, 307(9), 940-947. doi: 10.1001/jama.2012.234

24. Singh, J & Lewallen, D. (2010). Predictors of pain and use of pain medications following primary total hip arthroplasty (THA): 5,707 THAs at 2-years and 3,289 THAs at 5-years. BMC Musculoskeletal Disorders, 11, 90. doi: 10.1186/1471-2474-11-90

25. Sullivan, M. D., Edlund, M. J., Steffick, D., & Unutzer, J. (2005). Regular use of prescribed opioids: Association with common psychiatric disordersPain, 119(1-3), 95-103. doi: 10.1016/j.pain.2005.09.020

26. Rogers, K. D., Kemp, A., McLachlan, A. J., & Blyth, F. (2013). Adverse selection? A multi-dimensional profile of people dispense opioid analgesics for persistent non-cancer pain. PlosOne, 8(12), e80095. doi: 10.1371/journal.pone.0080095

]]> (Murray J. McAllister, PsyD) Chronic Pain Rehabilitation Sat, 07 Apr 2018 15:23:13 +0000
Are Opioids the Most Powerful Pain Reliever for Low Back Pain? Are Opioids the Most Effective Pain Reliever?

Opioids, or narcotic pain medications, are commonly thought of as powerful pain relievers. Patients frequently request them and healthcare providers often prescribe them for back pain because they think that opioids are the most effective pain reliving treatment. Popular media and others in society also commonly think that without opioids patients will suffer intolerable or “intractable” back pain. The implication is that, again, opioids are the most powerful and effective pain reliever.

But are they the most effective pain relieving treatment for back pain?

 The American College of Physicians (Qaseem, et al., 2017) recently published guidelines for the treatment of acute low back pain (i.e., back pain lasting less than three months) and chronic low back pain (i.e., pain lasting longer than three months). Experts in the field of low back pain from within their group developed the guidelines. The experts reviewed all the available scientific evidence on what works and what doesn’t work for low back pain. Specifically, they reviewed the evidence for the effectiveness of medications and non-medication therapies, with the exception of surgeries and other interventional procedures, such as spinal injections.

Here’s what they found:

  • Many therapies have more evidence in support of their effectiveness than opioids
  • A number of non-medication therapies were more effective than any medication, including opioids
  • For low back pain lasting less than three months long (i.e., acute low back pain), the therapies that have more evidence to support their effectiveness are anti-inflammatory medications, heat, exercise, spinal manipulation (i.e., chiropractic) and possibly acupuncture
  • For low back pain lasting longer than three months (i.e., chronic low back pain), these therapies are largely considered to be more effective than opioid pain medications: interdisciplinary pain rehabilitation programs, cognitive behavioral therapy, exercise, mindfulness based stress reduction, and to a lesser extent acupuncture, tai chi, and yoga.
  • Of the medications used for chronic low back pain, anti-inflammatories and duloxetine have greater support for their effectiveness than opioid medications.
  • Opioid pain medications, while having less scientific evidence supporting their effectiveness, were associated with increased risk of harm, including addiction and death.

Perhaps it’s time to start dispelling the myth that opioid pain medications are always the most effective pain relieving treatment. There are conditions, like low back pain, for which other treatments are more effective. On top of it all, these more effective treatments aren’t associated with high rates of addiction and death.


Qaseem, A., Wilt, T. J., McLean, R. M., & Forciea, M. A. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(7), 514-530.

Author: Murray J. McAllister, PsyD

Date of last modification: July 5, 2017

About the author: Dr. McAllister is the editor at the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported and to make that empirically-supported pain management more publicly acessible. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families.

Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis. 

The views contained in this post are solely those of the author and do not represent Courage Kenny Rehabilitation Institute or Allina Health.

]]> (Murray J. McAllister, PsyD) Opioids Tue, 04 Jul 2017 13:14:56 +0000
Six Common Assumptions in the Opioid Management Debate Six Common Assumptions in the Opioid Management Debate

Few topics in healthcare generate more passion than the use of opioid medications for chronic, non-cancer pain. Some, in the debate, lead the charge for greater access to opioids, arguing fervently that these medications are under-prescribed, while others call for more limited access, arguing that opioids are over-prescribed. The central focus for these strong feelings is typically the issue of addiction, but other issues commonly receive attention as well, such as the effectiveness of opioids and humanitarian calls to alleviate suffering.

Within all these contentions, certain assumptions commonly remain unexamined – rarely do people stop to question whether these assumptions are justifiable by the available science. The following is a list of common assumptions within the debate about using long-term opioids for the management of chronic pain. After each assumption, a brief review of the published empirical research provides an examination of the degree to which the assumption is justifiable.

1. When used for chronic pain, addiction to opioid medications is rare.

In the late 1990’s and early 2000’s, an almost ubiquitous belief in healthcare was that addiction to opioid medications is rare. While not as widespread today, it is still commonly assumed (see, for some examples, these sites here or here).

In part, this belief was due to two studies that at one time were commonly cited -- one by Porter and Jick1and the other by Portnoy and Foley.2 The Porter and Jick study was a retrospective chart review of patients prescribed opioids in an emergency room. Published as a one-paragraph letter to the editor, the study involved the brief use of opioids (presumably a single prescription) in a sample of emergency room patients and found that rarely did the initiation of opioids in this setting lead to problems with addiction. The study was subsequently used to justify long-term use of opioids in a chronic population – despite the differences in treatment (short- versus long-term use of opioids) and patient populations (acute pain versus chronic pain). Portnoy and Foley reported on 38 cases of long-term use of opioids for chronic pain and found only two individuals who developed “management problems,” their brief description for behaviors indicative of addiction. Both studies were hailed as evidence that opioid use for chronic pain rarely results in addiction.

Since this time, a number of studies and meta-analyses on the rates of opioid medication addiction have been published. Subsequently, a greater appreciation has emerged of the various factors that make it difficult to determine how often addiction to prescription opioids occurs. These factors are the limited generalizability for different patient populations, differences in the operational definitions of addiction, and differences in how addiction is diagnosed across providers.

In their systematic review of predominantly clinical trials of opioid medication, Fishbain, et al.3 found differences in rates of addiction between studies that excluded patients with prior histories of substance dependence and studies that included such patients. They also found differences in whether the study was a prospective clinical trial or a retrospective study. Combining all the studies, they found that the rate of addiction was 3.27%.

It might be argued that this estimate is low, relative to what we might expect in typical patients who seek opioid management in pain clinics. Clinical trial participants are dissimilar to patients seeking care in the typical pain clinic. Such study participants commonly have less comborbidity (and therefore are healthier) than typical clinic patients. Moreover, the afore-mentioned percentage represents clinician-identified addiction, but the rate of aberrant urine toxicology screens (an indicator of loss of control, or addiction) in these studies was significantly higher at 20.4%. This figure may represent an over-estimation of the rate of addiction, as one aberrant finding may not warrant an addiction diagnosis. However, the fact that the figure is so much higher than clinician-identified diagnoses suggests that the true rate may be somewhere in between 3.27 and 20.4%.

Indeed, Fishbain, et al., comment on the lack of operational definition for diagnosing addiction in their review of the published studies. Clinical judgment in the face of having no operational definition for diagnosis is apt to lead to poor inter-rater reliability, something necessary for determining rates of a diagnosis, such as addiction. In this light, the standardization of urine toxicology screens is apt to provide substantially greater reliability and therefore validity to identifying rates of addiction.

In their meta-analysis of studies on the prevalence of aberrant prescription drug use behaviors, Martel, et al.4 found a range between 5% and 24%. Of course, such behaviors alone do not constitute addiction, but rather a pattern of such behaviors is typically considered to indicate addiction. However, this range suggests that those who do exhibit a pattern would occur at a higher percentage rate than the finding established by Fishbain, et al. Indeed, Chabel, et al.5 in their study of addiction rates using an older version of DSM criteria, found a rate of 27.6%. Hojsted & Sjogren6 reviewed the literature and found a range of addiction between 0% and 50%.

In all, what these studies suggest is that rates of addiction vary for different populations. Addiction is probably rare for those who have never taken an opioid and are obtaining their first prescription of an opioid medication, particularly if they do not have a prior or concurrent history of other substance dependence. That is to say, the risk that the first prescription of an opioid will lead to addiction down the road is likely quite low for those who have no history of substance dependence. However, the rate of addiction is likely not rare for the population of patients of a pain clinic that engages in long-term opioid management. Moreover, if such patients have a prior or concurrent history of substance dependence, the risk for addiction to prescription opioids is apt to be even higher.

2. Opioid medications are effective pain relievers for patients with chronic pain.

Kroenke, et al.7 reviewed the literature on the effectiveness of short-term use of opioids. They found that opioid medications are modestly better at reducing pain than placebo. However, they found that opioid medications are slightly less effective than non-narcotic pain medications on functional outcomes. Ballantyne and Shin8 reviewed the literature on the effectiveness of long-term opioid medication use. They found that long-term use is likely ineffective.

In their meta-analysis, Martell, et al.4 found that opioid medications are in fact no better than placebo when it comes to reducing pain.

A more recent study by Chen, et al.9 showed that, among a sample of chronic pain patients obtaining opioid management over a period of seven years, the relative dose of opioids had no relationship to pain levels. That is to say, some in the sample increased their dose and some in the sample decreased their dose over the years, but neither the increases nor the decreases affected self-reported pain levels. Given these findings, the assumption that opioids are effective seems far from evident.

This lack of effectiveness also seems apparent in large-scale epidemiological studies of people with chronic pain. For instance, Eriksen, et al.10 conducted such a study and compared those who manage their pain with opioids with those who do not manage their pain with opioids. They found that use of opioids was associated with greater pain and poorer quality of life. Fredheim, et al.11 similarly found that the vast majority of patients managing pain on opioids continue to report high to very high levels of pain.

All these data indicate that we should not assume long-term opioid management is an effective treatment for chronic pain.

3. Opioid medications increase the functioning of patients with chronic pain.

Kidner, et al.12 showed in a large study that actually the opposite is true. They found that, as patients take more opioid medications, they are less likely to return to work. In the general population too, daily use of opioid medications for pain is associated not with employment but unemployment.13 In the epidemiological study cited earlier, Eriksen, et al.10 also found that the use of opioids was associated with not working.

Volinn, et al.14 studied worker’s compensation low back pain cases and compared those who received opioids with those who did not receive opioids. They found that the odds for chronic work loss were up to 14 times higher among those who obtained opioids.

In a prospective study of injured workers with chronic low back pain, Franklin, et al.15 found that, among those who remained on opioids at one year post-injury, only 26% showed improvement. Improvement was defined as a 30% reduction in pain and a 30% increase in functioning.

A similar previous study showed that the use of opioids early after onset of a low back injury is significantly associated with 69 more days of disability than those who do not obtain opioids.16 

In a primary care clinic population, Ashworth, et al.17 found in a prospective study that the use of opioids for low back pain was associated with slightly worse self-reported measures of functioning at six-month follow-up.

In all, these data indicate that short- and long-term use of opioids is associated with increasing disability, not reducing disability.

4. Opioid medications keep chronic pain patients out of the emergency room.

Wisniewski, et al.18 found that chronic pain patients who obtain long-term opioid management have greater utilization of emergency rooms, not less.

In a very large study of Arkansas Medicaid and Healthcore enrollees, Braden, et al.19 also found a similar association between long-term opioid management and increased emergency room visits.

In a sample of patients within a large health management organization, Deyo, et al.20 also found a positive relationship between the use of opioids and an increased rate of emergency room visits. The finding remained true even after controlling for health comorbidities and hospitalizations.

These findings are obviously relevant to the assumption that the use of opioids prevents the need for seeking care in emergency rooms. Indeed, the findings suggest the opposite.

5. It is unethical to withhold pain management from patients with chronic pain.

While it may in fact be unethical to withhold pain management from patients, pain management does not equate to opioid management. There are numerous conventional ways to manage chronic pain, some with better empirical outcomes, such as interdisciplinary chronic pain rehabilitation programs.21, 22, 23 Given these options, it is reasonable to acknowledge that adequate chronic pain management can be provided without resorting to the use of opioids.

One might actually argue that long-term opioid management is questionably unethical. When patients start on opioids, they generally require minimal doses. However, over time, they develop tolerance to the medication.24 In other words, as patients take opioids over time, the medications lose their effectiveness. Subsequently, patients on such medications develop the need for periodic dose increases in order to maintain the same level of pain relief. Over the years, patients commonly develop tolerance to even the highest conventionally agreed upon dosing schedules. Now, here is the rub: many patients who manage chronic pain with the use of long-term opioids are middle-aged or younger; given their relatively young age, most of these patients will still have many years left to live by the time they become tolerant to the highest doses of opioids.

While still somewhat inconclusive, research on methadone maintenance patients and non-human mammals suggest that once tolerant to opioids people will remain largely tolerant for up to years after cessation of the use of opioids.25, 26, 27 The potential meaning of these findings is that stopping the use of opioid pain medications for some period of time does not necessarily resolve the problem of tolerance. Once patients become tolerant to opioids, they may remain tolerant for the foreseeable future even if they stop using the medications.

We now routinely see this presentation in the field. Beginning in the mid-1990’s, long-term opioid management became the treatment of choice for chronic pain syndromes. For the next two decades, patients were routinely managed on opioids. Now with fifteen to twenty years of such experience, we commonly see patients who have been on opioids for many years and are tolerant to the highest conventionally agreed upon doses. Many are only in their mid-life years and yet they have exhausted opioids as a treatment option.

What if, in the future, they have an altogether different and serious acute injury? What if they later in life develop cancer? What if they have a need for an unrelated surgery and need to manage their post-surgical pain? What are they going to use for pain management in these situations?

Might it not be unethical to maintain patients on long-term opioids, allowing them to become tolerant to the highest does, if they still have many years of their life yet to live?

6. Patients will suffer if long-term opioid management is withheld from them.

Proponents of opioid management are often surprised to learn that most people with chronic pain do not manage their pain with opioid medications. Breivek, et al.28 found in an epidemiological study of European countries that 19% of the general population had chronic pain. In further follow-up interviews of the those with chronic pain, they found that 5% take long-acting opioids and 23% take short-acting opioids. In a later study, Fredheim, et al.11 found that only 15% of people with chronic pain used opioids to manage their pain. Among those reporting their pain as severe or very severe, 11% used opioids. In the United States, the rate of opioid use among patients with chronic pain is similar. Toblin, et al.29 found that a quarter of the population has chronic pain. Among people with chronic pain, they found only 15% use prescription opioids to manage their pain.

Even among patients who are readily offered opioid management on a long-term basis, most of them will voluntarily stop using opioids even though they remain in pain30 (cf. also, Fredheim, et al.31).

What these studies show is that the vast majority of people with chronic pain do not take opioid medications to manage their pain. As such, a reduction in the practice of long-term opioid management would not lead all people with chronic pain to suffer. It would not even lead a majority to suffer.

Numerous studies consistently show that patients who remain on long-term opioid management are those who, on average, have significantly higher rates of mental health and substance abuse problems.32, 31, 33, 34, 35, 36, 37  These factors are also highly associated with addiction to prescription opioids.38, 39, 40 

Would a reduction in the practice of long-term opioid management lead this minority of patients to suffer? Many advocates for opioids assume that it would.

In light of the above-cited research, though, this assumption is unwarranted. As stated, multiple studies show that the long-term use of opioids does not significantly reduce pain or increase functioning. Would suffering really result if we curtailed a practice that isn’t effective?

Moreover, one might counter that it’s a questionably unethical that we relegate long-term opioid management to those with the greatest vulnerabilities – those with chronic pain and comorbid mental health and substance abuse problems. These patients are the most susceptible to dependency and addiction. And hasn’t increasing rates of abuse and addiction been what the field has witnessed over the last fifteen to twenty years?41, 42 If we, as healthcare providers, were honest with ourselves, we would have to admit that it is a commonplace to see highly distressed patients who report high levels of pain and disability despite long-term use of opioids. Worse yet, we are also witness to chronic pain patients who, because of their psychological vulnerabilities, simply lose control of their use of opioids and become addicted. And we see it too often. The research cited above simply backs up our common clinical observations.

Rather than being concerned by widespread suffering if the field stopped the practice of long-term opioid management, we should be concerned about the present realities of our field. The most vulnerable subpopulation of people with chronic pain has been exposed to opioids on a long-term basis. In turn, we have a dramatic problem of suffering in the form of opioid addiction, overdose, and diversion in our country. It is not unethical to reduce the practice of long-term opioid management for this population. Indeed, in light of the fact that we have an empirically supported treatment option that is more effective, it might just be the most ethical thing to do.


1. Porter, J., & Jick, H. (1980). Addiction is rare in patients treated with narcotics. New England Journal of Medicine, 302, 2, 123.

2. Portnoy, R. K., & Foley, K. M. (1986). Chronic use of opioid analgesics in non-malignant pain: A report of 38 cases. Pain, 25(2), 171-186.

3. Fishbain, D. A., Cole, B., Rosomoff, H. L., Rosomoff, R. S. (2008). What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug related behaviors? A structured evidence-based review. Pain Medicine, 9(4), 444-459.

4. Martell, B. A., O’Connor, P. G., Kerns, R. D., Becker, W. C., Morales, K. H., Kosten, T. R., Fiellin. D. A. (2007). Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146, 116-127.

5. Chabel, C., Erjavec, M., Jacobson, L., Mariano, A., & Chanev, E. (1997). Prescription opiate abuse in chronic pain patients: Clinical criteria, incidence and predictors. Clinical Journal of Pain, 13, 150-155.

6. Hojsted, J., & Sjogren, P. (2007). Addiction to opioids in chronic pain patients: A literature review. European Journal of Pain, 11, 490-518.

7. Kroenke, K., Krebs, E. E., & Bair, M. J. (2009). Pharmacotherapy of chronic pain: A synthesis of recommendations from systematic reviews. General Hospital Psychiatry, 31, 206-219.

8. Ballantyne, J. C. & Shin, N. S. (2008). Efficacy of opioids for chronic pain: A review of the evidence. Clinical Journal of Pain, 24, 469-478.{

9. Chen, L, Vo, T., Seefeld, L., Malarick, C., Houghton, M., Ahmed, A., Zhang, Y., Cohen, A., Retamozo, C., St. Hilaire, K., Zhang, V., & Mao, J. (2013). Lack of correlation between opioid dose adjustment and pain score change in a group of chronic pain patients. Journal of Pain, 14(4), 384-392. doi: 10.1016/j.pain.2012.12.012{

10. Eriksen, J., Sjorgen, P., Bruera, E., Ekholm, O., & Rasmussen, N. K. (2006). Critical issues on opioids in chronic non-cancer pain: An epidemiological study. Pain, 125, 172-179.

11. Fredheim, A. M., Mahic, M., Skurtveit, S., Dale, O., Romundstadt, P., & Borchgrevink, P. C. (2014). Chronic pain and use of opioids: A population-based pharmacoepidemiological study from the Norwegian Prescription Database and the Nord-Trondelag Health Study. Pain, 155, 1213-1221.

12. Kidner, C. L., Mayer, T. G., & Gatchel, R. J. (2009). Higher opioid doses predict poorer functional outcome in patients with chronic disabling occupational musculoskeletal disorders. Journal of Bone and Joint Surgery, 91, 919-927.

13. Turunen, J., Mantyselka, P., Kumpusalo, E., & Ahonen, R. (2005). Frequent analgesic use at population level: Prevalence and patterns of use. Pain, 115, 374-381.

14. Volinn, E., Fargo, J. D., & Fine, P. G. (2009). Opioid therapy for nonspecific low back pain and the outcome of chronic work loss. Pain, 142, 194-201.

15. Franklin, G. M., Rahman, E. A., Turner, J. A., Daniell, W. E., Fulton-Kehoe, D. (2009). Opioid use for chronic low back pain: A prospective, population-based study among injured workers in Washington state, 2002-2005. Clinical Journal of Pain, 25(9), 743-751. doi: 10.1097/AJP.0b013e3181b0710

16. Webster, B. S., Verma, S. K., & Gatchel, R. J. (2007). Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine, 32(19), 2127-2132.

17. Ashworth, J., Green, D. J., Dunn, K. M., & Jordan, K. P. (2013). Opioid use among low back pain patients in primary care: Is opioid prescription associated with disability at 6-month follow-up? Pain, 154, 1038-1044.

18. Wisniewski, A. M., Purdy, C. H., & Blondell, R. D. (2008). The epidemiologic association between opioid prescribing, non-medical use, and emergency department visits. Journal of Addictive Disorders, 27(1), 1-11.

19. Braden, J. B., Russo, J., Fan, M. Y., Edlund, M. J., Martin, B. C., DeVries, A., & Sullivan, M. D. (2010). Emergency department visits among recipients of chronic opioid therapy. Archives of Internal Medicine, 170(16), 1425-1432.

20. Deyo, R. A., Smith, D. H., Johnson, E. S., Donovan, M., Tillotson, C. J., Yang, X., Petrik, A. F., & Dobscha, S. K. (2011). Opioids for back pain patients: Primary care prescribing patterns and use of services. Journal of the American Board of Family Medicine, 24(6), 717-727. doi: 10.3122/jabfm.2011.06.100232

21. Flor, H., Fydrich, T. & Turk, D. C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 49, 221-230.

22. Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

23. Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. The Clinical Journal of Pain, 18, 355-365.

24. Savage, S. R., Joranson, D. E., Covington, E. C., Schnoll, S. H., Heit, H. A., & Gilson, A. M. (2003). Definitions related to the medical use of opioids: Evolution towards universal agreement. Journal of Pain and Symptom Management, 26(1), 655-667.

25. Chiang, Y., Hung, T., Lee, C., Yan, J., & Ho, I. (2010). Enhancement of tolerance development to morphine in rats prenatally exposed to morphine, methadone, and buprenorphine. Journal of Biomedical Science, 17, 46.

26. Lim, G., Wang, S., Zeng, Q., Sung, B., & Mao, J. (2005).Evidence for a long-term influence on morphine tolerance after previous exposure: Role of neuronal glucoticoid receptors. Pain, 114, 81-92.

27. Mao, J., Sung, B., Ji, R., & Lim, G. (2002). Neuronal apoptosis associated with morphine tolerance: Evidence for an opioid-induced neurotoxic mechanism. Journal of Neuroscience, 22, 7650-7661.

28. Breivek, H., Collett, B., Ventafridda, V., Cohen R., & Gallacher, D. (2006). Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European Journal of Pain, 10, 287-333.

29. Toblin, R. L., Mack, K. A., Perveen, G., & Paulozzi, L. J. (2011). A population-based survey of chronic pain and its treatment with prescription drugs. Pain, 152, 1249-1255.

30. Gustavsson, A., Bjorkman, J., Ljungcrantz, C., Rhodin, A., Rivano-Fischer, M., Sjolund, K.-F., & Mannheimer, C. (2012). Pharmaceutical treatment patterns for patients with a diagnosis related to chronic pain initiating a slow-release strong opioid treatment in Sweden. Pain, 153, 2325-2331.

31. Fredheim, O. M., Borchgrevink, P. C., Mahic, M., & Skurtveit, S. (2013). A pharmacoepidemiological cohort study of subjects starting strong opioids for nonmalignant pain: A study from the Norwegian Prescription Database. Pain, 154, 2487-2493.

32. Breckenridge, J. & Clark, J. D. (2003). Patient characteristics associated with opioid versus non-steroidal anti inflammatory drug management of chronic low back pain. Journal of Pain, 4(6), 344-350.

33. Hojsted, J., Ekholm, O., Kurita G. P., Juel, K., & Sjogren, P. (2013). Addictive behaviors related to opioid use for chronic pain: A population-based study. Pain, 154, 2677-2683.

34. Jensen, M. K., Thomsen, A. B., & Hojsted, J. (2006). 10-year follow-up of chronic non-malignant pain patients: Opioid use, health-related quality of life and healthcare utilization. European Journal of Pain, 10(5), 423.

35. Mallen, C. D., Peat, G., Thomas, E., Dunn, K. M., & Croft, P. R. (2007). Prognostic factors of musculoskeletal pain in primary care: A systematic review. British Journal of General Practice, 57(541), 655-661.

36. Sullivan, M. D., Edlund, M. J., Zhang, L., Unutzer, J., & Wells, K. B. (2006). Association between mental health disorders, problem drug use, and regular prescription opioid use. Archives of Internal Medicine, 166(19), 2087-2093.

37. Thomas, E., Silman, A. J., Croft, P. R., Papageorgiou, A. C., Jayson, M. I., & Macfarlane, G. J. (1999). Predicting who develops chronic low back pain in primary care: A prospective study. British Medical Journal, 318, 1662-1667.

38. Ives, T. J., Chelminski, P. R., Hammett-Stabler, C. A., Malone, R. M., Perhac, J. S., Potisek, S. M., Shilliday, B. B., DeWalt, D. A., & Pignone, P. M. (2006). Predictors of opioid misuse in patients with chronic pain: A prospective cohort study. BMC Health Services Research, 6, 46.

39. Turk, D. C., Swanson, K. S., & Gatchel, R. J. (2008). Predicting opioid misuse by chronic pain patients: A systematic review and literature synthesis. Clinical Journal of Pain, 24(6), 497-508.

40. Wasan, A. D., Butler, S. F., Budman, S. H., Benoit, C., Fernandez, K., & Jamison, R. N. (2007). Psychiatric history and psychological adjustment as risk factors for aberrant drug-related behavior among patients with chronic pain. Clinical Journal of Pain, 23, (4), 307-315.

41. Compton, W. M. & Volkow, N. D. (2006). Major increase in opioid analgesic abuse in the United States: Concerns and strategies. Drug and Alcohol Dependence, 81, 103-107.

42. Sullivan, M. D. & Howe, C. Q. (2013). Opioid therapy for chronic pain in the United States: Promises and perils. Pain, 154, S94-S100.

Date of publication: January 11, 2015

Date of last modification: October 5, 2019

]]> (Murray J. McAllister, PsyD) Providers and Payers Sun, 11 Jan 2015 17:24:44 +0000
Opioid Management

Opioid, or narcotic, pain medications are beneficial in many ways. Patients with pain from terminal cancer benefit from their use. Patients benefit from their short-term use when recovering from an acute injury or following a painful surgical procedure. However, the long-term use of opioid medications for chronic, noncancer pain remains quite controversial.

On the one hand, there are many strong proponents of their use.1, 2 They tend to argue that opioids are an effective treatment for chronic pain and that fore-going their use is inhumane. Patients too are often strong advocates for their use.

On the other hand, there are valid concerns that make their use controversial. They are the following:

The following briefly reviews these concerns about the long-term use of opioids for chronic pain.

Questionable effectiveness for long-term use

In their review of this research, Kroenke, Krebs, and Bair3 found that the use of opioid medications on a short-term basis are modestly better at reducing pain than placebo. However, they found that opioid medications were slightly less effective than non-narcotic pain medications on functional outcomes (i.e., helping patients to do more things).

There is little research on the long-term effectiveness of opioids for chronic pain.4 Ballantyne and Shin5 reviewed the literature on the effectiveness of opioid medications and found that opioids are likely ineffective when used on a long-term basis.

In their meta-analysis of the research, Martell, et al.,6 found that opioid medications are in fact no better than placebo when it comes to reducing pain.


Tolerance is when the body becomes adjusted to the use of opioid medications and as a result the medications lose their effectiveness over time. In short, the longer a patient takes opioid medications for pain the less effective the medications become. In actual practice, what this means is that, over time, patients commonly need periodic increases in their dose of opioids in order to get the same level of pain relief.

Tolerance is a significant problem. For most patients, it is not feasible to use opioid medications for pain on an indefinite basis. Assuming a normal lifespan, most patients eventually get so tolerant to opioids that the medications become ineffective. After five, ten, or fifteen years of use, the highest doses of opioids are no longer helpful. As such, when taking opioid medications on a long-term basis, patients buy pain relief today at the cost of their future well-being. Once having become tolerant to the highest doses of opioids, the medications will be ineffective down the road should there be a need for their use, like an altogether different injury or recovering from a surgery.

Opioid-induced hyperalgesia

Another significant problem associated with the long-term use of opioid medications is that opioid medications, when used over time, can actually come to increase pain rather than decrease pain. Patients often find it hard to believe. But, it is true. It’s called opioid-induced hyperalgesia.7, 8, 9, 10 "Algesia" means sensitivity to pain and "hyper" is a prefix meaning above, beyond or excessive. What happens is that, when taking opioids over a long period of time, the nervous systems become more and more sensitive to pain and so patients subsequently experience more pain. Over time, patients complain that their pain is worsening even though tests or other evaluations show no overall change in the underlying medical problem that causes the pain.

The physical basis of opioid-induced hyperalgesia is not well understood. It is thought that changes occur in the brain or the dorsal horn of the spinal cord or both. In actual practice, it is often difficult to differentiate opioid-induced hyperalgesia from increasing levels of tolerance to medications. In most situations, patients and their providers will simply think that they are becoming increasingly tolerant to opioid medications and will increase their dose. It is hard to know whether the pain is worsening because of opioid-induced hyperalgesia or whether the medications are losing their effectiveness because of tolerance. Now, it may in fact be true that both are occurring. But opioid-induced hyperalgesia becomes evident when patients begin to taper off of their opioid medications. Their pain lessens!

Hormonal changes

Another issue is that chronic use of opioids can lead to changes in the levels of important hormones in the body. In both men and women, long-term use of opioids leads to low levels of testosterone11 as well as other hormones.12 These side-effects can then cause a number of other problems such as loss of sexual desire, reduced fertility, fatigue, depression, and osteoporosis.

Mental cloudiness

A common complaint of patients on long-term opioid management is that mentally they are not as sharp as they used to be. Cognitively, they are dulled. They say that their focus and concentration is limited. Healthcare providers use the term ‘mental cloudiness’ to refer to this sense of mental dulling.

Research shows that when using opioids on a long-term basis patients tend to have significantly lower scores on measures of concentration, short-term memory, timed performance and multi-tasking.13, 14, 15 

Physiological dependence

When taking opioid medications over a long period of time, patients become physiologically dependent. The body becomes adjusted to having the medication in its system. As a result, patients become tolerant to the medication and will experience withdrawal symptoms if the medication is abruptly stopped. All patients develop physiological dependence when taking opioid medications over time.

Physiological dependence is different than addiction.addiction. The American Academy of Pain Medicine and the American Pain Society define addiction to opioid medications as a loss of control over the use of the medication or continued use of the medication despite real or potential harm to oneself.16 Even if patients never engage in any behaviors that are indicative of addiction, and take their medications only as prescribed, their bodies will develop physiological dependence.

Physiological dependence is also a concern. Many patients simply don’t like their dependency on the medication. There might be many situations in which patients inadvertently do not have access to their medication or to their provider. As a consequence, they go into withdrawal. This dependency produces a sense of vulnerability and fear. One might argue that the minimal effectiveness of opioid medications is not worth the dependent state of vulnerability and fear with which patients must live when taking such medications.

Psychological dependence

When patients use opioid pain medications on a long-term basis, they tend to develop subtle yet strongly held beliefs that lead to a loss of confidence in their own abilities to cope with pain. As such, they come to believe that it is impossible to successfully manage pain without the use of opioid medications. Moreover, they become unwilling to entertain alternatives to their use. As a consequence, patients come to overly rely on the medications long after they are no longer helpful. In other words, opioid medications foster psychological dependence.

This issue is difficult to talk about. It’s difficult because these beliefs are subtle and don’t really come to the foreground unless actually named. It’s also difficult to talk about because it’s a sensitive issue. It can evoke strong emotional reactions. Patients who are psychologically dependent on opioids view the notion that it is possible to manage pain well without opioids as ridiculous. When a healthcare provider raises the notion, they take it that the healthcare provider is incompetent. At other times, patients see it as evidence that the healthcare provider doesn’t understand what it’s like to have chronic pain. They can also see the notion that it is possible to manage pain well without opioids as invalidating the legitimacy of their pain. In any of these ways, patients can get angry. As described, it is a sensitive issue. However, the sensitivity is also indicative of psychological dependence.

Patients who are psychologically dependent on opioids rely on the medications long after they cease to be helpful. They tend to demonstrate tolerance to the medication, describing their pain as severe despite taking high doses of opioids. They may also remain disabled by pain, despite the use of opioid medications. Nonetheless, they swear that the medications are helpful. This disconnect between their subjective belief that the medications are helpful and the objective evidence of their reports of continued high levels of pain and disability is an indication of psychological dependence.

It bears remembering that most people with chronic pain do not manage their pain with opioid medications. In an epidemiological study, Toblin, et al., found that a quarter of the population has chronic pain; but among people with chronic pain, they found only 15% using prescription opioids to manage their pain.17 Now, it might be argued that the majority of people with chronic pain should be on opioids and that in fact it’s inhumane that in this day and age the majority of people with chronic pain are still being denied the use of such medications. But, that’s not what these researchers found when they asked people with chronic pain in the study. They found that the vast majority – 80% of them – were satisfied with their pain management. So, it’s true that the majority of patients with chronic pain manage their pain without opioid medications.

Patients who are psychologically dependent on opioid medications tend to believe that it is impossible. They are sensitive to the notion that it is possible and can get emotional when it is brought up. They lack an openness to any alternative to opioid medications. Lastly, they maintain the belief that the medications are helpful and necessary despite their continued reports of high levels of pain and despite the fact that they remain disabled.


Addiction, of course, is also a significant problem. As earlier described, the pain management field defines addiction as a loss of control over the use of opioid medications or continued use of the medications despite harm. In the meta-analysis cited above, Martell, et al.,6 found that upwards of 20% of patients on opioid pain medications demonstrate problematic behaviors that are suggestive of addiction.


Opioid medications are helpful pain relievers for many purposes. Patients with terminal cancer pain use them with great benefit. Patients benefit from their short-term use when recovering from an acute injury or following a painful surgical procedure. However, the long-term use of opioid medications for chronic, noncancer pain remains controversial. While many advocate for their use as beneficial and humane, there are valid concerns about their long-term use. These are their questionable effectiveness when used on a long-term basis, tolerance, opioid-induced hyperalgesia, hormonal changes, mental cloudiness, physiological dependence, psychological dependence, and addiction.


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Date of publication: April 27, 2012

Date of last modification: October 5, 2019

]]> (Murray J. McAllister, PsyD) Chronic Pain Rehabilitation Fri, 27 Apr 2012 14:02:41 +0000