Opioids for Chronic Pain: No Easy Answers

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Opioids should only be started after a complete evaluation and pain history.
Opioids should only be started after a complete evaluation and pain history.

Federal and state laws tightly restrict opioid use in an attempt to reduce the possibility of diversion, misuse, and addiction. But millions of Americans depend on long-term opioids to manage chronic pain.1 

One recent study links opioid use in community-dwelling adults to opioid-induced hyperalgesia (OIH), adding OIH to the list of other potential complications, such as respiratory depression, dependence, and tolerance.2

What are the indications for long-term opioid use? Do the benefits outweigh the dangers? What are the alternatives? 

“Unfortunately, there are no easy answers to these questions,” said Troy Buck, MD, assistant professor of anesthesiology at the Loyola University Health System, Maywood, Illinois. 

Indications for Long-Term Opioids

According to the American Academy of Pain Medicine (AAPM), opioids should not be the first choice for chronic pain. They may be indicated for intractable chronic pain that can't be controlled with other interventions.1 

“It comes down to a judgment call. Opioids work great for acute pain. For pain that lasts more than six months, the indications and the benefits become murky. The evidence to support long-term use is not that great,” says Dr. Buck. 

How many people are being managed with opioids for long-term pain? 

“Evidence on that is hard to find,” says W. Michael Hooten, MD, associate professor of pain medicine and anesthesiology at the Mayo Clinic College of Medicine in Rochester, Minnesota. “A reasonable estimate is 3 to 5% of the population, and that number has yet to plateau.” 

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