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

When you’re in severe pain-after surgery, a broken bone, or a flare-up of arthritis-it’s tempting to reach for the strongest relief possible. Opioids can deliver that. But for millions of Americans, what starts as short-term relief turns into a long, dangerous road. The question isn’t just opioid therapy-it’s when it’s appropriate, and when the risks far outweigh the benefits.

Not All Pain Needs Opioids

The CDC’s 2022 guidelines made it clear: opioids should never be the first choice for chronic pain. That means pain lasting more than three months. For most people with back pain, osteoarthritis, or fibromyalgia, non-opioid options like physical therapy, acetaminophen, NSAIDs, or even cognitive behavioral therapy work better-and safer. Studies show opioids only reduce pain by about 0.6 to 1.8 points on a 10-point scale in the short term. That’s barely noticeable. And over time? The benefits fade. The risks? They grow.

When Opioids Might Still Make Sense

There are times when opioids are the right tool. For acute pain-like after a major surgery or a serious injury-short-term use (three to seven days) is often necessary. The Veterans Affairs and Department of Defense guidelines say opioids should be reserved for severe acute pain when other options don’t cut it. Even then, the prescription should be small: just enough to get through the worst of it. A 2020 Kaiser Permanente study found that 43% of patients given opioids for acute pain got far more pills than they needed. Those extra pills? Often end up in medicine cabinets, where kids, teens, or visitors might grab them.

For cancer patients, end-of-life care, or sickle cell crises, opioids remain essential. These cases are excluded from most general guidelines because the goal isn’t long-term function-it’s comfort. But for chronic non-cancer pain? The bar is much higher. You’ve got to try everything else first: exercise, nerve blocks, antidepressants like duloxetine, or even acupuncture. Only if those fail-and only if your pain is truly disabling-should opioids even be considered.

The Dependence Risk Isn’t Theoretical

People think addiction happens to “other people.” But the numbers don’t lie. About 8 to 12% of patients on long-term opioid therapy develop opioid use disorder. That’s roughly one in ten. And if you’re on 100 morphine milligram equivalents (MME) or more per day? That risk jumps to 26%. That’s more than one in four.

It’s not just about addiction. Dependence is different. You can be physically dependent without being addicted-meaning your body needs the drug to avoid withdrawal. But withdrawal from opioids is brutal: nausea, sweating, muscle cramps, anxiety, insomnia. And if you suddenly stop, especially after months or years, you’re at higher risk of relapse-sometimes to street drugs like heroin or fentanyl.

And it’s not just dose. Other factors stack the deck. If you’re also taking benzodiazepines-like Xanax or Valium-for anxiety or sleep, your overdose risk triples. If you’re over 65, your body clears opioids slower. If you’ve had a past substance use disorder? Your risk is 3.5 times higher. These aren’t hypotheticals. They’re clinical red flags built into every major guideline.

Dosing Isn’t Arbitrary

The CDC doesn’t set hard limits, but it does give clear thresholds. Most patients should stay under 50 MME per day. That’s about 10 tablets of 5 mg oxycodone. If you’re over 90 MME? You need a serious risk assessment. Why? Because each extra 10 MME increases overdose risk by 11% between 50 and 100 MME. That’s not a small jump. It’s a steep cliff.

And here’s something many don’t realize: you don’t have to be taking high doses to be at risk. Even at 20 MME per day, your overdose risk is already 8% higher for every additional 10 MME. That’s why doctors are now trained to start low and go slow-if they go at all.

Monitoring Isn’t Optional

If you’re on opioids long-term, you’re not just getting prescriptions. You’re in a monitoring program. The VA/DoD guidelines say you should be checked at least every three months. For high-risk patients? Monthly. What do they check?

• Pain level on a 0-10 scale
• How well you’re functioning-can you walk, work, sleep?
• Urine drug tests to make sure you’re taking what’s prescribed
• Screening tools like the Current Opioid Misuse Measure (COMM) to spot red flags: doctor shopping, lost prescriptions, mood swings

If you’re not being monitored like this, you’re not getting safe care. And if your doctor isn’t using tools like the Opioid Risk Tool (ORT) before prescribing? That’s a problem. A 2021 study found only 37% of primary care providers consistently used these tools-even though 92% of guidelines recommend them.

Tapering Off Is a Skill, Not a Punishment

Too many people have been told to stop opioids cold turkey. That’s dangerous. Abrupt discontinuation can trigger severe withdrawal, depression, and even suicide. It can also push people back to illegal opioids.

The right way to taper? Slowly. For stable patients, reduce by 2-5% every 4 to 8 weeks. If you’re not improving? Increase the taper to 5-10%. Only in cases of extreme risk-like doses over 90 MME or signs of misuse-should you go faster, like 10% per week. But even then, it’s done with support: counseling, access to naloxone, and alternative pain treatments.

And here’s the truth: if you’ve been on opioids for years and they’re not helping your function, continuing them isn’t kindness-it’s harm.

What’s Changing in 2026

Opioid prescribing has dropped 42.5% since 2012. That’s progress. But overdose deaths? They’re still high-over 80,000 in 2021. Why? Because the problem shifted. More deaths now come from illicit fentanyl, not prescriptions. But that doesn’t mean we got it right. Many patients who were stable on low-dose opioids were forced off too quickly, with no plan. That’s why the American Medical Association and other groups pushed back on rigid policies.

Now, the focus is on balance. Prescription Drug Monitoring Programs (PDMPs) are live in 49 states. Doctors check them before writing a script. Naloxone-the overdose reversal drug-is now available in 51% of U.S. hospitals as a standing order for at-risk patients. That’s up from 18% in 2016.

And research is moving fast. The NIH’s HEAL Initiative has poured $1.5 billion into non-addictive pain treatments. Right now, 37 new pain drugs are in late-stage trials. None are opioids. They’re targeting nerve pain, inflammation, and brain pathways differently. That’s the future.

What You Should Do

If you’re on opioids:

• Ask: Is this helping me move, sleep, or work better-or just dulling the pain?
• Ask: Have I tried physical therapy, exercise, or other non-drug options?
• Ask: Am I on more than 50 MME per day? If yes, why?
• Ask: Do I have naloxone on hand? Does my family know how to use it?
• Ask: Can we make a plan to reduce this safely?

If you’re a provider:

• Don’t default to opioids. Use the CDC’s guidelines as a checklist, not a ceiling.
• Check the PDMP before every script.
• Prescribe naloxone if the patient is on 50+ MME, uses benzodiazepines, or has a history of substance use.
• Don’t rush tapers. Work with the patient. Make it a partnership.

Frequently Asked Questions

What Comes Next

If you’re on opioids and wondering if you should stop-don’t quit cold. Talk to your doctor. Ask for a taper plan. Ask for a referral to a pain specialist or addiction counselor. If you’re not getting the answers you need, go to a clinic that specializes in chronic pain management. You deserve care that doesn’t trade one problem for another.

The goal isn’t to eliminate opioids entirely. It’s to use them wisely-only when they truly help, and never without a plan to get off them safely. Pain matters. But so does your life beyond it.