Opioid Therapy: When It’s Right and When It’s Dangerous

For many people, opioids are a last-resort tool for managing severe pain. But for others, they become a trap. The line between relief and dependence isn’t always clear-and getting it wrong can cost lives.

When Opioids Are Actually Needed

Opioids aren’t meant for everyday aches. They’re not the first thing you reach for when your back hurts or your knee flares up. The CDC’s 2022 guidelines make this clear: non-opioid treatments like physical therapy, NSAIDs, or even cognitive behavioral therapy should come first. Opioids are reserved for cases where pain is severe, sudden, and expected to be short-lived-like after major surgery, a broken bone, or serious trauma.

Even then, the goal isn’t to keep you on them long. A typical prescription for acute pain should last no more than a few days. Studies show most people don’t need more than three to seven days of opioids after surgery. Yet, in 2020, nearly half of all opioid prescriptions for acute pain were for more than 10 days. That’s not just unnecessary-it’s risky.

For chronic pain-pain lasting longer than three months-the threshold is even higher. Opioids are only considered if every other option has failed. That means trying exercise, acupuncture, nerve blocks, antidepressants, or anticonvulsants first. If none of those help enough, and your pain is still disabling, then opioids might be tried as a short-term experiment. But even then, doctors should be watching closely.

How Much Is Too Much?

Dose matters. A lot. The risk of overdose doesn’t creep up slowly-it jumps. For every extra 10 morphine milligram equivalents (MME) you take per day between 20 and 50 MME, your chance of overdose goes up by 8%. Between 50 and 100 MME, it jumps to 11% per 10 MME. That’s not a small increase. It’s a warning sign.

Most guidelines agree: 50 MME per day is the upper limit for most patients. Anything above that requires strong justification. At 90 MME or higher, the risk of addiction and overdose rises sharply. The VA/DoD guidelines say that patients on doses over 100 MME per day have a 26% chance of developing opioid use disorder. That’s more than one in four.

And it’s not just about the number on the bottle. Mixing opioids with other depressants-like benzodiazepines for anxiety or sleep-multiplies the danger. The CDC found that people taking both have 3.8 times the risk of overdose compared to those on opioids alone. In some cases, that risk jumps to over 10 times higher.

Who’s Most at Risk?

Not everyone who takes opioids ends up dependent. But some people are far more vulnerable. History matters. If you’ve struggled with substance use before-even alcohol or nicotine-your risk of opioid use disorder doubles or triples. Age plays a role too. People over 65 metabolize drugs slower, so even standard doses can build up and cause breathing problems.

Genetics also play a part. Studies show 40 to 60% of vulnerability to addiction is inherited. That means if someone in your family has had a problem with drugs or alcohol, you might be at higher risk, even if you’ve never used opioids before.

Other red flags include untreated depression, anxiety, or trauma. Pain and mental health are deeply linked. When both are untreated, opioids can become a crutch-not a cure. That’s why doctors are now trained to screen for mental health conditions before prescribing.

How Doctors Monitor You

If you’re on opioids long-term, your doctor shouldn’t just write a prescription and forget about you. Regular check-ins are required. The VA/DoD guidelines say stable patients should be seen at least every three months. High-risk patients-those on higher doses, with a history of addiction, or taking other sedatives-need monthly visits.

What happens in those visits? It’s not just about asking, “Does the pain feel better?” Doctors use tools like the Pain Disability Index to measure how much pain is affecting your daily life. They check urine samples to make sure you’re taking what’s prescribed and nothing else. They use the Current Opioid Misuse Measure to spot warning signs: hoarding pills, running out early, doctor shopping, or using them for anything other than pain.

If you’re not improving-if your pain hasn’t gone down, or your ability to work, walk, or sleep hasn’t gotten better-then continuing opioids doesn’t make sense. That’s when tapering starts.

Tapering Off: Slow and Safe

Stopping opioids cold turkey is dangerous. It can trigger severe withdrawal: nausea, shaking, insomnia, anxiety, even seizures. Worse, it can push people back to street drugs like heroin or fentanyl because the pain returns and they’re desperate.

Tapering isn’t one-size-fits-all. For someone who’s been on opioids for years with no side effects and some benefit, a slow taper-reducing by 2% to 5% every four to eight weeks-is safest. If you’re not improving, or you’re developing tolerance, a moderate taper of 5% to 10% every four to eight weeks is common. If you’re on over 90 MME per day or having serious side effects, a faster taper of 10% per week may be needed.

The key is collaboration. You and your doctor should make this decision together. If you feel rushed or forced off opioids without a plan, that’s not care-that’s abandonment.

What’s Being Done to Fix This

The good news? Prescribing has dropped. In 2012, doctors wrote 81.3 opioid prescriptions for every 100 people in the U.S. By 2020, that number had fallen to 46.7. That’s a 42.5% drop. More doctors are checking prescription drug monitoring programs (PDMPs) before writing a script. Forty-nine states now have real-time PDMPs, and 87% of prescriptions are checked against them.

Naloxone, the drug that reverses overdoses, is now available in 51% of U.S. hospitals as a standing order for at-risk patients. That’s up from 18% in 2016. More pharmacies offer it without a prescription. More first responders carry it.

Research is moving fast too. The NIH’s HEAL Initiative has poured $1.5 billion into finding non-addictive pain treatments. As of late 2023, 37 new pain drugs-none opioids-are in late-stage clinical trials. Some target nerve pain differently. Others use the body’s own pain-blocking systems. These could change everything.

What You Can Do

If you’re on opioids:

• Ask: Is this still helping me function? Not just reduce pain, but let me sleep, move, work, or play with my kids?
• Ask: Am I taking more than I need? Keep track of how many pills you use each day. If you’re not using them all, talk to your doctor about reducing the dose.
• Ask: Do I have naloxone? If you’re on 50 MME or more, or take benzodiazepines, you should have it. Keep it at home. Teach someone how to use it.
• Ask: Have I tried everything else? If you haven’t done physical therapy, acupuncture, or counseling, ask if those could help before increasing your dose.

If you’re worried about someone else:

• Don’t ignore signs: hoarding pills, mood swings, secrecy, or missing prescriptions.
• Don’t shame. Offer support. Say: “I care about you. Let’s talk to your doctor.”
• Know where to turn. The SAMHSA National Helpline (1-800-662-HELP) is free, confidential, and available 24/7.

It’s Not About Fear-It’s About Balance

Opioids aren’t evil. They’ve helped people with cancer, end-of-life pain, and traumatic injuries live with dignity. But they’re powerful tools that demand respect. The goal isn’t to cut everyone off. It’s to make sure no one is left on them longer than needed, and no one is left without help when things go wrong.

The science is clear: for most chronic pain, opioids don’t work well long-term-and the risks grow fast. But for the right person, at the right time, with the right support, they can still be part of the solution.