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Opioid Safety

Understanding risks and safe use for chronic pain

Key Takeaways

  • Opioids have significant risks that increase with long-term use
  • Evidence for long-term opioid benefit in chronic pain is limited
  • Non-opioid treatments should be tried first for most conditions
  • If prescribed opioids, use the lowest effective dose for shortest time

Important Notice

Never change, stop, or start opioid medications without medical supervision. Suddenly stopping opioids can cause serious withdrawal symptoms. This page is for education only—always work with your healthcare provider for medication decisions.

Understanding Opioids

Opioids are a class of medications that work on opioid receptors in the brain and body to reduce pain perception. While effective for acute pain, their role in chronic pain management has become increasingly scrutinized.1

Common Opioids

  • Short-acting: Hydrocodone (Vicodin), oxycodone (Percocet), morphine, codeine, tramadol
  • Long-acting: Extended-release morphine, oxycodone ER (OxyContin), fentanyl patch, methadone

How They Work

  • Bind to opioid receptors in the brain, spinal cord, and body
  • Reduce pain signal transmission
  • Also affect mood, reward centers, and other functions
  • Body develops tolerance over time (same dose provides less effect)

Risks of Opioid Use

Understanding risks helps inform treatment decisions:2,3

Short-Term Side Effects

  • Constipation (very common, often persistent)
  • Nausea and vomiting
  • Drowsiness and sedation
  • Confusion, "foggy thinking"
  • Itching
  • Urinary retention

Serious Risks

  • Respiratory depression: Slowed breathing, potentially fatal
  • Overdose: Risk increases with higher doses and combinations
  • Opioid use disorder: Physical dependence and addiction
  • Falls and fractures: Especially in older adults
  • Sleep apnea: Worsened or caused by opioids
  • Hormonal effects: Low testosterone, irregular periods
  • Immune suppression: Reduced immune function

Long-Term Concerns

  • Tolerance: Needing higher doses for same effect
  • Dependence: Physical need—withdrawal if stopped
  • Hyperalgesia: Opioids may actually increase pain sensitivity over time
  • Reduced effectiveness: Limited evidence they help long-term
Limited Evidence
supports long-term opioid use for most chronic pain conditions4

When Opioids May Be Considered

Current guidelines recommend opioids only in specific circumstances:5

Generally Appropriate

  • Severe acute pain (post-surgical, injury)
  • Cancer-related pain
  • End-of-life palliative care

May Be Considered for Chronic Pain If:

  • Non-opioid treatments have been tried and failed
  • Benefits outweigh risks for that individual
  • Used at lowest effective dose
  • Combined with non-drug treatments
  • Patient is monitored closely
  • Function improves (not just pain rating)

Generally Not Recommended As First-Line For:

  • Chronic low back pain
  • Fibromyalgia
  • Tension headaches
  • Most musculoskeletal conditions

Safe Use Practices

If you are prescribed opioids, follow these safety practices:5

Taking Opioids Safely

  • Take exactly as prescribed—do not take more or more often
  • Never share your medication with anyone
  • Do not combine with alcohol, benzodiazepines, or sleep medications
  • Do not crush, chew, or break extended-release formulations
  • Report side effects to your provider

Storage and Disposal

  • Store securely, away from others (especially children and teens)
  • Do not keep unused medication "just in case"
  • Dispose of unused opioids properly at drug take-back programs
  • Never flush unless specifically instructed

Monitoring

  • Attend all follow-up appointments
  • Be honest with your provider about your pain and medication use
  • Expect periodic urine drug screens
  • Prescription monitoring programs track opioid prescriptions

Dangerous Combinations

Combining opioids with benzodiazepines (Xanax, Valium, Ativan), sleep medications, or alcohol dramatically increases overdose risk. Always tell your provider about all medications you take.

Naloxone (Narcan)

Naloxone is a life-saving medication that reverses opioid overdose:6

Who Should Have Naloxone?

  • Anyone taking opioids, especially at higher doses
  • Those combining opioids with other sedating medications
  • Those with history of overdose or substance use disorder
  • Family members of people taking opioids

How to Get Naloxone

  • Ask your prescriber for a naloxone prescription
  • Available without prescription at many pharmacies
  • Free from many harm reduction programs
  • Nasal spray (Narcan) is easy to use

Signs of Overdose

  • Slow, shallow, or stopped breathing
  • Blue lips or fingernails
  • Unresponsive, cannot be woken
  • Limp body
  • Choking or gurgling sounds

If overdose suspected: Call 911 immediately and give naloxone if available.

Alternatives to Opioids

Many treatments can be effective for chronic pain:7

Non-Opioid Medications

  • NSAIDs: Ibuprofen, naproxen (with appropriate monitoring)
  • Acetaminophen: For mild to moderate pain
  • Antidepressants: Duloxetine, amitriptyline (for neuropathic pain)
  • Anticonvulsants: Gabapentin, pregabalin (for nerve pain)
  • Topical treatments: Lidocaine patches, capsaicin, NSAIDs
  • Muscle relaxants: For short-term use in muscle spasm

Non-Drug Treatments

  • Physical therapy: Exercise, manual therapy, education
  • Cognitive behavioral therapy: Addresses thoughts and behaviors
  • Mindfulness and meditation: Pain coping skills
  • Acupuncture: May help some pain conditions
  • Massage therapy: For muscle pain
  • TENS: Electrical nerve stimulation
  • Heat and cold therapy: Simple but often helpful

Interventional Procedures

  • Nerve blocks
  • Epidural injections
  • Joint injections
  • Spinal cord stimulation

Tapering Opioids

If you and your provider decide to reduce or stop opioids:8

Important Principles

  • Never stop opioids suddenly—taper gradually
  • Work with your healthcare provider on a tapering plan
  • Slower tapers are generally more successful
  • Expect some discomfort—it usually improves
  • Add other pain management strategies

Withdrawal Symptoms

May include:

  • Anxiety, irritability
  • Sweating, chills, goosebumps
  • Muscle aches
  • Nausea, vomiting, diarrhea
  • Insomnia
  • Increased pain

These symptoms, while uncomfortable, are not dangerous when tapering is done properly under medical supervision.

Support During Tapering

  • Psychological support and counseling
  • Non-opioid medications for symptoms
  • Alternative pain treatments
  • Regular follow-up appointments
  • Support groups

Tapering Success

Many people who taper opioids find their pain does not worsen significantly—and some report pain actually improves over time. Function and quality of life often improve with successful tapering.

If You're Struggling

Help is available if you are concerned about your opioid use:

Signs You May Need Help

  • Taking more than prescribed
  • Running out of medication early
  • Getting opioids from multiple sources
  • Strong cravings for the medication
  • Opioid use causing problems in life
  • Unable to cut down despite wanting to

Resources

  • SAMHSA Helpline: 1-800-662-4357 (free, confidential, 24/7)
  • Talk to your healthcare provider
  • Medication-assisted treatment (buprenorphine, methadone) is effective
  • Support groups and counseling

Explore Non-Opioid Options

Learn about other approaches for chronic pain management.

Physical Therapy Guide

References

  1. Volkow ND, McLellan AT. Opioid abuse in chronic pain—misconceptions and mitigation strategies. N Engl J Med. 2016;374(13):1253-1263.
  2. Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015;162(4):276-286.
  3. Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med. 2003;349(20):1943-1953.
  4. 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;319(9):872-882.
  5. Dowell D, Ragan KR, Jones CM, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep. 2022;71(3):1-95.
  6. Wheeler E, Jones TS, Gilbert MK, Davidson PJ. Opioid overdose prevention programs providing naloxone to laypersons — United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(23):631-635.
  7. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-530.
  8. Frank JW, Lovejoy TI, Becker WC, et al. Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review. Ann Intern Med. 2017;167(3):181-191.

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