Report highlights the dangers of opioid painkillers

Daniel Pendick
Daniel Pendick, Former Executive Editor, Harvard Men's Health Watch

Whenever I read or write about the overuse of so-called opioid painkillers it is with mixed feelings. As a lifelong back-pain patient who once depended on them for pain relief, I appreciate the challenge posed by opioids to people in pain and their doctors. People in agonizing pain want it to stop, but opioids are often a poor long-term solution. Doctors want to help their patients, so they may prescribe opioids for extended periods despite well-founded reservations.

At the same time, the epidemic of abuse of these painkillers has led to numerous deaths. Like many Americans, I know people whose lives were destroyed—who ended up in rehab, the legal system, or the grave—because of prescription painkiller abuse. An article this week in the New England Journal of Medicine pegs the toll at nearly 17,000 fatalities in 2010.

Hydrocodone (Vicodin) and oxycodone (Oxycontin, Percocet, Percodan) are the most widely used and abused of the opioids. Others in this family of drugs are codeine, fentanyl (Duragesic patch), hydromorphone (Dilaudid), meperidine (Demerol), morphine (MS Contin), and tramadol (Ultram). These drugs block pain perception in the brain.

Doctors are learning to say no to opioids, but at the same time have limited scientific guidance on when and how to best use opioids for chronic pain, according to a report published online in the Annals of Internal Medicine this week by a National Institute of Health expert panel. It follows on the heels of a position statement published in September 2014 by the American Academy of Neurology, stating that the harms of opioids often outweigh the benefits for treating chronic noncancer pain.

Dr. James Rathmell, the Henry Knowles Beecher Professor of Anesthesia at Harvard-affiliated Massachusetts General Hospital, sums up the doctor’s dilemma this way: “The patient is in terrible pain and wants to try it. Who am I to say no?”

At the same time, Dr. Rathmell emphasizes that whenever opioids are prescribed, the focus needs to be on limits. “We should never use these drugs unless they’re the only thing that will be effective,” he says, “and then when we use them we should prescribe them for the shortest possible time.”

More isn’t better

How much of an opioid is needed to block pain perception in the brain is a moving target—and the trajectory is always upward. After a brief honeymoon of profound pain relief when you first start taking opioids, their pain-numbing effect fades and the dose escalates rapidly. In months, you can end up taking dangerously high doses just to maintain the same level of relief.

“This isn’t a good long-term solution—but not because it doesn’t work today or tomorrow,” Dr. Rathmell says. “What do we do when it’s not working as well next month? The knee jerk response is to raise the dose, but where do we stop? Do we stop when you are falling asleep in your soup every night at dinner? Do we stop when you fall down and break your hip?”

In my case, the dose I needed to quell my severe back pain kept getting higher. I vividly remember the daily clock-watching between doses and the embarrassing pleading for more refills. Fortunately, surgery to repair a herniated disc worked. I successfully tapered off the drugs. Since then, regular exercise and stretching, plus good sitting and working habits, have reduced my back pain flare-ups to one or two a year. They last a week or two and require no more than hefty doses of ibuprofen and hot baths.

When opioids help (for a while)

No one is proposing to withhold opioids during the “acute” phase of a pain condition that would be relieved by these drugs. This means the hours, days, and weeks it takes your body to heal from an injury or surgery.

The general rule of thumb is to use them for four to six weeks, then taper off and switch to other options. People recovering from a flare-up of back pain, a severely injured joint, or surgery can often transition to acetaminophen (Tylenol) or a nonsteroidal anti-inflammatory drug (NSAIDs) like ibuprofen (Advil, Motrin) or naproxen (Aleve).

What’s at issue is treating chronic pain—pain that just won’t go away, doesn’t get better, or worsens. For the more common pain conditions—like back pain, chronic headache, and fibromyalgia—opioids may at some point offer little or no relief but cause side effects. Opioids can cause severe constipation as well as dangerous sedation. A person who takes an opioid can become cognitively impaired and confused. Accidental overdose can happen if someone hoards a few extra pills to pop in hope of a good night’s sleep, or if opioids are combined with other prescription drugs that sedate. Opioids and alcohol are notoriously deadly mix.

The rules are different for long-term pain from cancer. Carefully managed but increasing doses of opioids may be the best option.

Get extra help

So what should you do if you have chronic pain and start to hit the limits of opioids? “If there has been no benefit from other approaches and you have moderate to severe pain that is ongoing, you may want to see a pain specialist and talk about the various options,” Dr. Rathmell says. Pain specialists are often anesthesiologists by training, and have special expertise in the safe use of opioids and deploying other options for long-term pain control.

What may be needed is not a single pill, but a portfolio of tools. For example, certain antidepressants and antiseizure drugs can help control chronic pain from injured nerves. Specialized psychological counseling as well as complementary and alternative treatments, like acupuncture and meditation, can also help people with unremitting pain cope better.


  1. Inez Deborah Emilia Altar

    I am against the use of painkillers as a curative system, but not in trauma medicine such as war medicine, but depending on which cases such as some broken bones, and minor injuries, I am not sure if an academic professional is in trouble here in the Assacaias and Lezíria region.

    • Inez Deborah Emilia Altar

      I wonder if a woman right now is in urgent trauma need she could have a big piece of brain tissue from my mother Leni Ingegerd Sjoegren who is a Swedish citizen and or from me it would be in the Alviela, Assacaias, Lezíria, fields or in Sweden perhaps at some visiting nuns.´or the PSP.

  2. klaus

    This Doctor does not understand pain what so ever. Only chronic pain individuals understand what truly works. Always lousy anti depressants. They never mention all the individuals that go off on killing spree’s are taking some form of anti depressant. They want to be selective and discriminate which pain can be treated. Cancer pain is ok but other pain people must suffer it out. As far as individuals dying ever year what they fail to mention is the mix of alcohol and opiates. The combination is deadly. I have had 4 back surgeries and take 40mg of percocet a day. It works for me. Personally This Doctor needs some pain inflicted on him and see how he feels. Then let him take some anti depressants .

  3. Inez Deborah Emilia Altar

    I am being persecuted by obscene medical professional molestations not from the European Union who do not understand I follow a system of health which rejects painkillers but do think I can appeal for donations to Kobane survivor Christian Mongol descendants Christian since the Middle Ages and Assyrian Christians and their People´s Protection Force of morphine to be able to fight off ISIS which intends to kill all including women and babies, the sick, pregnant women and the old, and wounded and have paid for the donation of a token startoff donation to a Portuguese online pharmacy entitling the donation for the purpose and stipulating delivery via a Portuguese Ministry competent for this purpose in charity and also please ask if an international emergency association could be contacted immediately to help the severely clinically depressed and injured at a plot of land next to my home southern side fenced all around Assacaias, Santarém district Portugal European Union

  4. dr0p3rz

    In my case, the dose I needed to quell my severe back pain kept getting higher.

  5. adamjacksonsky

    Great piece! wow that is good describe all about the opioid painkiller and I am fully agreed with the point of view of this writer and think all man and women should read food and health article

  6. aryan khan

    It starts with drugs such as OxyContin, Percocet, and Vicodin—prescription narcotics that can make days bearable if you are recovering from surgery or suffering from cancer. But they can be as addictive as heroin and are rife with deadly side effects.
    High-strength painkillers known as opioids represent the most widely prescribed class of medications in the United States. And over the last decade, the number of prescriptions for the strongest opioids has increased nearly fourfold, with only limited evidence of their long-term effectiveness or risks, federal data shows.

    “Doctors are prescribing like crazy,” said Dr. C. Richard Chapman, the director of the Pain Research Center at the University of Utah.

    Medical professionals have long been on high alert about powerful painkillers like OxyContin because of their widespread abuse by teenagers and others for recreational purposes.

  7. Megan

    Great piece! The information provided here is pertinent in examining the dangers of opioid-prescribing methods. Dr. Rathmell is quoted as bringing up an important component of this dilemma in stating that this option should only be used short-term and only if no other alternative is available. People are accustomed to wanting quick treatment methods, and likely due to unbearable pain, yet every other option should be explored fully before resorting to a life-long dependence on opioids, be it physically, behaviorally, or otherwise. I personally am a firm believer in holistic methods, simply because I have seen them work. It never hurts to try. Doctors have no problem over-prescribing these meds and then cutting them off abruptly, leaving the patient physically ill, withdrawing, and panic-striken with desperation because the question then becomes “now what?” Ironically enough, a side effect of pain medication is that your are in more physical pain when you immediately stop than you were before starting! If only the consumers were educated on the dangers of these drugs and possessed the knowledge to question the decisions made by their doctors…

    The widespread abuse of narcotic pain medication and illicit opiates in the Boston area and is astronomical and is of major concern. I would say it’s highly alarming when in the last 11 years, I personally have had more than 15 friends/acquaintances pass away from opiate-related deaths. We must educate ourselves on the dangers of this type of treatment option and decide if the pros outweigh the cons. Are you willing to take the risk? We as patients should never be afraid to question the advice of our doctors and choose what is the best option for us.

  8. Good piece. A diverse set of tools to fight the addictive disorders is certainly valuable, especially when uniquely integrated per patients needs. It’s important to consider that physicians can be limited (and legally responsible for big medicine care) with effective alternatives as far as opiate treatments go. Patients with chronic pain need relief and are stuck in the middle. Dialogues are increasing, hopefully legit headway can be made quickly.

  9. Judy

    My primary care doctor has no problem with prescribing oxycodone (low dose). Contrary to the above comment, I know I am addicted- everyone is I think. However, my only noticeable symptom is sleeplessness if I miss a dosage. I can’t undestand why it is acceptable for cancer patients but not for those in so much chronic pain they want to die. I am a 2 x cancer survivor and went through hell but not the hell of 24/7 chronic back pain and osteoarthritis. The drug is on my formulary but my plan is denying coverage. I think decision makers are making patients pay for mistakes made by prescribers and those using drugs illegally. I’ve had FBS and cannot take most antinflamitory drugs due to a brain bleed. Narcotics help me to a large degree and it is my hope the authorities will catch and punish those for giving them a terrible name. The side effects are no worse than the anti-seizure drugs I take and have caused me numerous consequences.

  10. I have lower back Stenious and on cummadin. Those spinal shots I had before cummadin didnot help so Im on Ms C for 5 yrs low dose 30mg I feel at that dose it helps me. Im not addicted to it and I have tried PT hot rock ice nothing works. I believe if they give you low dose and you take it as prescribed then its not addicting. If America in states ok medical Marijuanna I smoke that instead iof pills.