What to know about safe opioid use

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Opioids are a group of drugs that bind to opioid receptors in the brain. They include natural opioids like morphine and codeine, which manufacturers make from poppy seeds. Synthetic opioids such as fentanyl mimic the chemical composition of opioids but do not come from poppy seeds.

Opioids work by changing the brain’s response to certain types of pain. They can also make a person feel high, euphoric, and disoriented. This effect may encourage some people to take more than the recommended dosage, take opioids without a prescription, or use illegal recreational opioids such as heroin.

Over time, people taking opioids can become tolerant of their effects. This means the body does not respond as strongly as it once did, so a person will need a higher dose to get the same results. This chemical tolerance can also lead to addiction, which occurs when the brain begins craving opioids to feel normal.

The combination of tolerance, which encourages a person to take higher doses of opioids, and addiction, which may cause a person to take opioids illegally or combine multiple opioids, can lead to overdose.

Opioids are the leading cause of drug overdose, accounting for about three-quarters of all drug overdoses. The opioid overdose epidemic is a public health crisis.

The CDC is the primary organization promoting guidelines for prescribing opioids. Its guidelines include the following recommendations:

• Assess when and whether opioids are appropriate. Discuss opioid alternatives, and evaluate the risks and benefits of treatment.
• Use non-opioid therapy where possible and appropriate, and consider adding nonmedication treatment even when using opioids.
• Establish treatment goals when beginning opioids, and define when treatment will discontinue.
• Prescribe immediate-release rather than extended-release opioids to new opioid users.
• Prescribe the lowest recommended effective dose, and only increase the dosage slowly and as needed.
• Do not prescribe more than the amount a person is likely to need for acute pain. This usually means 3 or fewer days and rarely means more than 7 days of treatment.
• Evaluate treatment within 1 to 4 weeks of beginning treatment, including by assessing for signs of abuse or dependency.
• Review all medications the patient takes for potential interactions and red flags that the patient may be at risk of abusing opioids or taking more than the recommended safe dose.
• Consider using urine drug screening before prescribing opioids for chronic pain and at least annually thereafter.
• Avoid prescribing opioids and benzodiazepines (a group of anti-anxiety medications) together.
• Help patients access opioid abuse treatment, including medication-assisted treatment such as buprenorphine and methadone.

Most major medical organizations support the CDC’s prescribing guidelines. Hospitals and medical clinics typically draw their guidelines from the CDC’s guidelines.

However, in 2021 the American Medical Association (AMA) urged an overhaul of the prescribing guidelines, citing concerns that the guidelines might limit access to relief for people in chronic pain.

The AMA recommends revised guidelines that:

• treat people as individuals
• encourage a multimodal approach to pain
• acknowledge that illegal use and manufacture of opioids, not legally prescribed opioids, play a critical role in the abuse epidemic
• clarify that they are clinical guidelines, not legal requirements or requirements for reimbursement from insurance or Medicare

While numerous organizations have published prescribing guidelines, individual clinics and hospitals may have additional, different, or no guidelines. There is no legal requirement that prescribers follow these guidelines, so the prescribing practices may vary widely from doctor to doctor.

Some doctors may take few or no precautions, while others may deny opioids even to those who truly need them.

A person may need to alter their approach to opioids based on their doctor’s approach. For example, a doctor may be eager to prescribe opioids without much oversight. In this case, the person taking them may need to change doctors or develop strategies for monitoring their use, such as giving the opioids to a loved one to dispense at regular intervals.

In general, doctors who follow safe prescribing guidelines may do the following:

• consider alternatives to opioids and ask what options a person has already tried
• ask a person about any family history of addiction
• ask questions about the type of pain the person has to assess whether opioids are a good fit
• schedule follow-up appointments to assess how well treatment is working
• prescribe a low dose of opioids or limit the number of opioids a person gets with each prescription

Some strategies that can help a person stay safe when taking prescription painkillers include:

• incorporating nonmedication treatments, such as psychotherapy and exercise, into the treatment regimen (Pain is both a physical and psychological phenomenon, so addressing the psychological side of pain may reduce the need for pain medication.)
• not taking more than the dose a doctor prescribes
• not self-medicating by taking someone else’s opioids or taking a drug a doctor has not prescribed
• not taking opioids more frequently than a doctor recommends
• talking with a doctor before taking opioids with other medications, including over-the-counter (OTC) drugs (Some opioids contain acetaminophen, which can increase the risk of an overdose when taken with OTC pain medicine.)
• practicing good self-care by getting enough rest, maintaining a moderate weight, and eating a balanced, nourishing diet
• asking a doctor about non-opioid pain medications
• talking with a medical professional if opioids stop working or if a person begins taking more than the recommended amount

Medication disposal programs can help ease the burden of addiction by reducing access to opioids. If there are no opioids in a home, a person is less likely to find them, take them, and become addicted.

The Drug Enforcement Agency provides a comprehensive list of drug take-back programs and locations.

Addiction is a medical condition, not a personal or moral failing. It is treatable with the right combination of support, behavioral therapy, and medication. People who think they have an addiction should talk with the doctor who prescribed the opioids and ask about a referral to an addiction specialist.

Treatment for opioid addiction may include:

• taking medications to reduce the severity of drug withdrawal
• joining support groups
• receiving psychotherapy to help cope with drug cravings and develop healthy strategies for managing pain and stress
• learning about the disease of addiction

Opioids can play an important role in managing acute pain as well as chronic pain. But improper or excessive use, unnecessary use, and recreational use of illegal opioids all play a role in addiction and abuse.

Opioid addiction can be fatal, even if people think they are being careful or have safely taken the same dose before. There is no safe way to take larger doses of opioids than a doctor prescribes. So people who find themselves tempted to do so should discuss their opioid use with a medical professional.

Opioids always carry risks and benefits. It is important to discuss both with a healthcare professional to decide whether opioid treatment is right.