Rethinking Strong Opioids for Noncancer Pain

“Getting into higher doses for any condition brings into play issues of tolerance, dependence, respiratory depression, and at very high doses, hyperalgesia,” Dr Buck pointed out.

The authors note that pain specialists in the United States have issued a petition supporting restrictions to strong opioid use in noncancer pain, limiting doses to less than 100 mg/day morphine-equivalents, for a maximum of 100 days. The action reflects the sobering statistic that opioids contribute to more than 10 000 deaths in the United States each year.1

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“The fact is that opiates are great drugs if they are used properly for acute pain, but they fail miserably when we use them as a Band-Aid. We need to realize that most of the world’s opiates are sold here in the US. If opiates were truly the painkillers we thought, we would have eliminated pain from every corner. Not only haven’t we eliminated pain, [but] the opiate epidemic has directly resulted in [an] ever-growing number of drug overdoses,” said Dr Maleki.

What About Cancer Pain?

Although the mean dose of morphine for cancer pain ranges from 100 to 250 mg/day, doses exceeding 1000 mg are not unusual and have been studied in a few placebo-controlled trials. Results tend to show  a good initial analgesic effect, especially for fentanyl, followed by decreasing efficacy and increasing toxicity over time. A Cochrane review of 62 trials involving more than 4000 patients found that adequate analgesia was only achieved in 29% of studies.1

The “war on pain” that was started 20 years ago has relied heavily on opioids. Is it time to say that opioids have lost the war on pain?

“I would not go that far,” said Dr Buck. “Opioids are still well indicated for acute and severe pain, such as in the post-op setting — but they are rarely indicated for chronic pain.”

Future Prospects and Key Takeaways

The development of new analgesics and new nonpharmacological approaches may be our best hope for future pain management, the authors write.

“There is no game changer on the horizon as far as new analgesics. I think [that] the future of pain management may lie more in nonpharmacological treatments, like spinal cord stimulation, peripheral nerve stimulation for neuropathic pain, and cognitive behavioral therapy interventions,” Dr Buck said.

“Primary care providers should be aware that the bulk of opioid prescriptions are distributed by general practitioners,” Dr Maleki said, noting that these clinicians are the first to field the acute onset of chronic pain.

“Primary care providers play a crucial role in preventing transition of acute pain into chronic pain. Patient education, lifestyle changes, proper diet, stress reduction, and adequate exercise, along with use of non-opioid medications are the primary management tools,” Dr Maleki concluded.


Berthelot JM, Darrieutort-Lafitte C, Le Goff B, Maugars Y. Strong opioids for noncancer pain due to musculoskeletal diseases: Not more effective than acetaminophen or NSAIDs. Joint Bone Spine. 2015 Dec;82(6):397-401. doi: 10.1016/j.jbspin.2015.08.003. Epub 2015 Oct 6.