Long-Term Opioid Therapy for Chronic Pain: The Risks

Do opioids actually work for chronic non-cancer pain?

The evidence is more complicated than many people expect. For acute pain — pain following surgery or injury — opioids are often effective and appropriate for short-term use. For chronic non-cancer pain (pain lasting more than three months from causes like arthritis, fibromyalgia, or back pain), the picture is more nuanced.

Short-term trials show modest pain relief for some conditions. However, long-term evidence is limited, and several high-quality reviews have found that the benefits of opioids for chronic non-cancer pain may not outweigh the risks over months to years for many patients. Importantly, pain relief often diminishes as tolerance develops, and function and quality of life do not consistently improve with ongoing opioid therapy.

For chronic cancer pain or pain in the context of serious advanced illness, opioids remain an important tool under careful medical supervision.

What are the main risks of taking opioids long-term?

Physical dependence is an expected physiological adaptation to regular opioid use. The body adjusts to the presence of the drug, and stopping abruptly causes withdrawal symptoms (flu-like symptoms, agitation, muscle cramps, insomnia). Dependence is different from addiction but can make it very difficult to reduce or stop opioids even when desired.

Tolerance means the same dose over time produces less pain relief, leading to pressure to increase doses. Higher doses increase risks without necessarily improving function.

Opioid use disorder (OUD) is a condition in which opioid use becomes compulsive and continues despite harm. It is a medical diagnosis, not a character flaw. Among people prescribed opioids for chronic pain, the risk varies depending on dose, individual factors, and history — it is not negligible, particularly at higher doses over longer periods.

Overdose risk is real, particularly with higher doses, concurrent use of benzodiazepines or alcohol, and sleep-disordered breathing (sleep apnea). Naloxone — a medication that reverses opioid overdose — is available without a prescription in many states and should be considered for anyone on long-term opioid therapy 1Ref 1Centers for Disease Control and Prevention (2024).Reversing Opioid Overdoses with Lifesaving Naloxone.Naloxone availability and use for opioid overdose reversal; recommendation for naloxone co-prescription with opioid therapy.

Opioid-induced hyperalgesia is a paradoxical increase in pain sensitivity that can develop with long-term use, meaning the opioids themselves contribute to the pain problem.

Hormonal effects: Long-term opioid use can suppress testosterone production in men and disrupt menstrual cycles in women, contributing to fatigue, mood changes, and sexual dysfunction.

Cognitive and mental health effects: Opioids can impair memory and concentration over time. They also carry risks for depression and anxiety.

Physical function: Chronic opioid use is associated with constipation, sedation, and reduced drive to engage in rehabilitation activities like exercise — which are among the most effective treatments for many chronic pain conditions 2Ref 2Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH (2017).Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews.Exercise as one of the most consistently beneficial interventions for chronic pain, supporting its use as an alternative or complement to opioid therapy.

What do current guidelines say about opioids for chronic pain?

Clinical guidelines have become substantially more cautious over the past decade in response to the opioid epidemic. General principles from current prescribing guidance include:

• Use non-opioid pharmacologic and non-pharmacologic treatments first
• If opioids are considered, use the lowest effective dose
• Set clear goals and functional expectations before starting
• Reassess regularly — if pain and function are not improving, continuing opioids may not be justified
• Avoid prescribing opioids with benzodiazepines (the combination substantially increases overdose risk)
• Consider urine drug screening and prescription monitoring programs to reduce misuse risk
• Discuss and prescribe naloxone as a safeguard 1Ref 1Centers for Disease Control and Prevention (2024).Reversing Opioid Overdoses with Lifesaving Naloxone.Naloxone availability and use for opioid overdose reversal; recommendation for naloxone co-prescription with opioid therapy

These are general principles. Any decision about opioid therapy should involve a clinician who knows your full medical history.

What are the alternatives to opioids for chronic pain?

A pain management or primary care clinician can help identify which of the following approaches fits the type of pain you have:

Non-opioid medications: - Over-the-counter options: acetaminophen and NSAIDs (ibuprofen, naproxen) for many musculoskeletal pain conditions 3Ref 3MedlinePlus / U.S. National Library of Medicine (2024).Ibuprofen: MedlinePlus Drug Information.NSAIDs as non-opioid analgesic alternatives for musculoskeletal pain4Ref 4MedlinePlus / U.S. National Library of Medicine (2024).Acetaminophen: MedlinePlus Drug Information.Acetaminophen as a non-opioid analgesic alternative - Prescription non-opioids: certain antidepressants, anticonvulsants, and topical agents have evidence for specific pain types (for example, nerve pain)

Physical and rehabilitation approaches: - Exercise is one of the most consistently beneficial interventions across many chronic pain conditions, including back pain and fibromyalgia 2Ref 2Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH (2017).Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews.Exercise as one of the most consistently beneficial interventions for chronic pain, supporting its use as an alternative or complement to opioid therapy - Physical therapy and occupational therapy - Cognitive behavioral therapy (CBT) for pain — substantial evidence supports psychological approaches to managing chronic pain - Acupuncture has evidence for modest benefit in certain chronic pain types 5Ref 5Vickers AJ, Vertosick EA, Lewith G, MacPherson H, Foster NE, Sherman KJ, Irnich D, Witt CM, Linde K; Acupuncture Trialists' Collaboration (2018).Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis.Acupuncture as a non-opioid complementary option with evidence for modest benefit in chronic pain

Interventional options: - Nerve blocks, epidural steroid injections, or other procedures managed by a pain specialist for specific conditions

Pain management specialists are specifically trained to develop multi-modal plans that address all dimensions of pain. A referral from your primary care clinician can be a helpful step if pain is significantly affecting your life.

If I am currently taking opioids for chronic pain, what should I do?

Do not stop opioids abruptly. Sudden discontinuation can cause severe withdrawal and is unsafe without medical supervision. Instead:

• Talk honestly with your prescribing clinician about your concerns and goals
• If you would like to reduce your dose, a gradual taper planned with your clinician is the safest approach
• If you feel your pain is not well controlled despite opioids, or that the medication is causing problems, a pain management specialist evaluation can offer a fresh perspective
• If you are concerned about dependence or opioid use disorder, evidence-based treatment (including medications like buprenorphine) is effective and available — this is a medical condition with good treatments, not a failure

Claude can help you find a primary care clinician or pain specialist, and help you prepare for an open conversation with your care team.