Should you treat chronic pain with opioids?

Should you treat chronic pain with opioids?

As medical practice shifts away from Vicodin, Percocet and OxyContin for chronic pain, consider less-risky treatments

Last updated: June 2015


Narcotic painkillers like OxyContin, Vicodin or Percocet, also known as “opioids,” are commonly prescribed to treat moderate-to-severe pain after surgery, an injury or a kidney stone. They can also help reduce pain associated with terminal or very serious illnesses, such as cancer. But opioids are also prescribed to millions of people who have long-term, chronic pain—arthritis, lower-back pain, or nerve pain, for example. Yet there’s a surprising lack of medical evidence that supports using opioids against those types of pain. That’s according to a large systematic review published in September 2014 by the Agency for Healthcare Research and Quality. Since then, physician groups have started to change their prescribing guidelines. Instead of opioids, they suggest trying other medications and even nondrug treatments since that can provide relief with less risk.

Besides not treating long-term pain very well, opioids can cause side effects, including constipation and sedation. There’s also the risks of overdose, physical dependence, and addiction. Because of these factors, our Consumer Reports Best Buy Drugs program has not chosen any opioid as a “Best Buy.”

The dangers of pain pills - why you should take caution with these powerful drugs

Instead of opioid medications to treat chronic pain, our medical advisers recommend that people try other options first. Other, less risky pain relievers—such as acetaminophen (Tylenol and generic), ibuprofen (Advil, Motrin, and generic), or naproxen (Aleve and generic)—work well for many people with chronic pain, even when it’s moderate to severe. However, almost no studies have compared these non-opioid drugs with opioids in treating moderate to severe chronic pain over long periods of time. And, experts believe cognitive behavioral therapy, exercise, spinal manipulation, or physical rehab programs as well as behavior changes can also help ease chronic pain, either alone or in combination with drugs.

What are opioids?

Opioids are a diverse group of drugs. There are about 12 different kinds, and they work by changing the way pain is experienced and “felt” by blocking pain signals to and in the brain. They also have potent sedative effects, which can increase sleep time but reduce deep sleep. Sedation is associated with the most dangerous side effect of opioid drugs—respiratory depression and death—particularly if excessive doses are taken accidently or intentionally. 

Because of their potential for abuse and because they can be addictive, opioids are classified by the federal government as controlled substances. This means that pharmacies and government agencies monitor opioid prescriptions quite closely.

Some opioids, such as morphine and codeine, are derived from poppy plants. Others are synthetic or partly synthetic, meaning they are chemically manufactured. Some are available primarily in combination with other pain relievers, usually aspirin or acetaminophen. Others are prescribed as single-ingredient products.  

The various opioids differ in their rate of action in the body. Also, they are available in short-acting and long-acting forms. Opioids are available mostly as pills but skin patches are also an option. The type of opioid makes a difference in how frequently you take one and how quickly you get pain relief. Long-acting opioids are generally taken one to three times in 24 hours while short-acting opioids are taken more frequently—as often as every three to four hours, even at night.

What you need to know about opioids - 5 surprising facts

Here’s the list of the most commonly prescribed opioids, in both short- and long-acting forms, and versions available as single ingredient drugs and in combination with acetaminophen:

Opioid Drugs

Generic Name(s)

Brand Name(s)

Available as a Generic?


Butrans transdermal film



Generic only



Actiq, Duragesic (patch), Fentora



Lorect, Lortab, Norco, Vicodin,* Zohydro ER



Dilaudid, Exalgo



Generic only






Dolophine, Methadose



Avinza, Kadian, MS Contin CR, OraMorph SR


Morphine plus naltrexone




OxyContin, Percocet,* Roxicodone, Roxicet,* Endocet*


Oxycodone and naloxone


Targiniq ER



Opana ER



ConZip, Rybix, Ryzolt, Ultram, Ultracet*


CR=controlled release; SR=sustained release; ER=extended release

* These versions contain acetaminophen.  

Change in medical practice

Prescribing opioids to treat chronic pain over long periods of time has recently raised serious concern:

  1. Studies have not proven that opioids help treat long-term, chronic pain.
  2. Opioids are potentially addictive. The longer you take one, your risk of addiction increases.
  3. Wide use of opioids by millions of people with chronic pain has become part of a public health crisis. In addition, there is substantial illicit use of opioids.
  4. Overdoses have sharply increased in the last decade.
  5. The body can build up tolerance to opioids, which make higher doses necessary over time and which can also increase the risk of side effects.
  6. The body becomes physically dependent on opioids even when addiction is not present, so that lowering the dose or stopping the drug can cause unpleasant withdrawal symptoms.

The increasing misuse of prescription opioids has led to a recent shift in medical practice. At one time, many physician specialty groups supported the use of opioids to treat chronic pain. But now, more medical societies advise against their use. For example, in September 2014—citing studies showing that 50 percent of patients taking opioids for at least three months still take them five years later, and a lack of evidence to show they help people over the long-term—the American Academy of Neurology (AAN) recommended opioids should not be used to treat chronic, non-cancer pain. That includes using the drugs to treat headache, fibromyalgia, and chronic, low-back pain. The AAN was also concerned about the risk of death, overdose, addiction, and serious side effects.

    The cultural and larger social-health problems are these:

  • Dramatic increases in opioid prescribing and use has been linked to a similar increase in overdoses and deaths over the past decade. Some of those deaths occur among people who starting taking the drugs for pain—either with a doctor’s prescription or after having obtained the drugs illicitly. 
  • In 2013, almost 17,000 people in the U.S. died of an opioid overdose. That’s an increase in opioid overdose deaths of 400 percent from 1999.
  • Nearly 500,000 people are admitted each year to the emergency room because of opioid overdoses or adverse events. And in more than half of those cases people had received a legitimate prescription from their doctor, according to the Centers for Disease Control and Prevention.

Other treatments

If you have been diagnosed with chronic pain, your first decision is whether to take a pain medicine at all. Since pain is an entirely subjective experience, only you and your doctor can reach this decision. Pain specialists now emphasize that some people with mild to moderate chronic pain can manage well without taking any pain medicines regularly—and may experience improvements in pain and ability to function with nondrug treatments, including exercise, lifestyle adjustments, behavioral therapy, acupuncture, and massage.

Many people, however, cannot tolerate persistent or intermittent pain—even if it is mild—and they choose to take a drug to help manage it. If that describes your situation, an opioid should usually not be your or your doctor’s first choice of pain reliever.

Instead, we recommend trying acetaminophen first.  This pain reliever has a long safety track record, is available without a prescription, and is inexpensive. Even at moderate doses, it can be quite effective. If you need higher doses, however, or if you find that you need to take it everyday for pain, consult with your doctor about acetaminophen’s link to liver damage and other problems. Though rare, this can be serious. The risk is greater at higher doses and also in people who drink alcohol heavily, or have existing liver damage or disease.

We also advise keeping track of how much acetaminophen (or any pain reliever) you take. Hundreds of over-the-counter medicines contain acetaminophen, including allergy, cough and cold drugs, fever reducers, and sleep aids. And while the FDA has lowered the maximum per-pill dose of acetaminophen for prescription medicines to 325 mg, unfortunately, it hasn’t taken the same step for the over-the-counter products. Extra-strength Tylenol, for example, contains 500 mg of acetaminophen.

How much acetaminophen is too much?

When an NSAID may be better

If your mild chronic pain is not sufficiently controlled by acetaminophen, talk with your doctor about trying a nonsteroidal, anti-inflammatory drug (NSAID) like naproxen (Aleve and generic) or ibuprofen (Advil, Motrin, and generic). Some people respond better to one NSAID over another, though research has found that at equivalent doses they don’t differ in effectiveness. There’s no way to know besides trying them out.

Both ibuprofen and naproxen are inexpensive, and available without a prescription. Higher dose pills require a prescription. If either of them does not work, there are other NSAIDs to try. Those include celecoxib (Celebrex and generic) and meloxicam (Mobic and generic), both of which are now available as less expensive generics but whose prices are still significantly more than over-the-counter ibuprofen.  

Aspirin is not a good choice for treating chronic pain since the larger doses typically needed for pain relief pose a higher risk of stomach and gastrointestinal bleeding compared to naproxen, ibuprofen, or other NSAIDs.

The Consumer Reports Best Buy Drugs report on NSAIDs discusses in detail the trade-offs with these drugs. Most notably, NSAIDs (like aspirin) pose a risk of gastrointestinal bleeding that can be serious. People who are at high risk of such internal bleeding, and those taking certain other medications, such as blood thinners, should not take an NSAID. If you take NSAIDs frequently and have stomach upset and/or blood in your stool, you should see a doctor.  

NSAIDs have also been linked to a higher risk of heart disease, heart attack, and stroke.  The available evidence suggests that for most people, this risk is very small. And periodic short-term use of relatively low doses probably does not appear to add to risk for otherwise healthy people. But for people who already have heart disease or heart disease risk factors, such as high blood pressure, diabetes, or high cholesterol, the risk is greater. Before you start taking an NSAID on a regular basis for chronic pain, and particularly if you are taking high doses, your risk for heart disease and stroke should be evaluated. This is especially true for people aged 65 and over when the risk of heart attack and stroke rises for many reasons.

Common Types of Pain and Drugs to Treat Them*

This table provides a basic overview of both acute and chronic pain treatment.

Type of pain

Best initial treatment

If that doesn’t work + comments






Acetaminophen or an NSAID1 if that does not work



See a doctor if headaches are severe, persistent, or accompanied by fever or vomiting, or you have difficulty with speech or balance. Don’t self-medicate for more than two weeks. Opioids rarely prescribed. 




Acetaminophen, NSAIDs



A triptan may be needed if the others don’t work, especially if migraines are frequent and/or severe. Opioids rarely prescribed.

Menstrual cramps


Several are marketed for cramps but you can try any of them.

Pain due to minor trauma (bruises, scrapes, minor sprains)

Acetaminophen, NSAIDs


Opioids not recommended.


Pain due to moderate or severe trauma (wounds, burns, fractures, severe sprains)

Opioids. Other drugs may be prescribed as well



Typically short-term, up to two weeks.



Post-surgical pain — minor

Acetaminophen, NSAIDs

Opioids rarely needed.

Post-surgical pain — moderate to severe


Opioids. Other drugs may be prescribed as well


Opioids likely to be prescribed




Muscle aches

Acetaminophen, NSAIDs

See a doctor if pain persists.

Muscle pulls

NSAIDs, muscle relaxants

Muscle relaxants generally used, short-term. 


Acetaminophen, NSAIDs

See a doctor if pain persists. Opioids used rarely, only for flare-ups of moderate to severe pain.



Opioids may be needed for severe sprains.

Toothaches and pain following dental procedures

Acetaminophen, NSAIDs


Short-term use of an opioid may be needed if pain is severe.


Discomfort and pain due to heartburn or GERD2

Antacids, H2 Blockers (e.g. Tagamet, Zantac), Proton Pump Inhibitors (e.g. Prilosec OTC)

Heartburn that lasts more than a week needs medical attention. Aspirin and NSAIDs should be avoided.

Chronic back pain



Acetaminophen, NSAIDs


Opioids may be necessary if other drugs do not control pain and pain is moderate to severe and persistent.

Pain from a kidney stone

Acetaminophen, NSAIDs, Opioids

Opioids almost always prescribed if pain is severe.

Nerve pain3









Acetaminophen, NSAIDs, Anticonvulsants







Opioids are sometimes used, but only if anticonvulsants or other drugs have been tried and don’t work. Antidepressants, lidocaine patches, and capsaicin cream are other options.

Pain due to fibromyalgia4

Antidepressants, Anticonvulsants

Opioids have not proven to be effective in treating fibromyalgia.

* Important Note: The information in this table is not comprehensive. It is meant as general guidance and reflects typical medical practice. It should not substitute for a doctor’s advice. If you have pain that lasts for more than 10 days, see a doctor. The table is based on numerous sources and does not reflect analysis or input from the Drug Effectiveness Review Project. Always follow the labeling or package insert information on nonprescription and prescription drugs you use to treat pain.

1. Includes aspirin and aspirin-like drugs such as ibuprofen (Advil, Motrin, and generic) and naproxen (Aleve and generic).

2. GERD=Gastroesophageal Reflux Disease, also referred to as stomach acid reflux.

3. Associated with diabetic neuropathy, shingles, injury-related nerve damage, compression of nerves in the spine, and nerve damage associated with cancer or HIV infection.

4. Fibromyalgia is a condition marked by muscle and joint tenderness and pain. Fatigue can also be present. The cause is unknown. The symptoms it produces and their severity vary widely from person to person.

The evidence

Very little research exists that compares how well one opioid works against another to treat people with chronic pain. So we do not know if one opioid may be better than another—either overall, or in treating certain types of pain, or treating certain people.

That said, studies do clearly suggest that when a person is given similar doses of any of the opioids, the relief a person experiences from pain is about the same. Opioids also appear to produce similar results when a person’s “quality of life” is measured.

In addition, there are few studies that compare opioids with non-opioid drugs, and none that compare the two over a long period of time.

Here are some additional important points about opioid effectiveness, use, and safety from the research literature:

  • Most people who take opioids find that the drugs don’t relieve all of their pain. For example, a person who has a pain score of seven on a zero-to-10 scale could have a score of only four or five after taking an opioid.
  • Some people may have to take doses so large to get adequate pain relief that risk of side effects outweighs any benefit.
  • Some people are so bothered by the side effects, even at lower doses, that they stop taking the drug. 
  • Over time, some people with chronic pain build up a "tolerance" to an opioid. That means they have to take more of it to get the same pain relief. Most doctors are uncomfortable increasing doses past a certain point because the risks of side effects and other problems increase with higher doses.
  • Most studies on opioids have lasted less than three months. And while there is no evidence that opioids adversely affect the brain, kidneys, liver or other organs when taken long-term, there is evidence that they do affect the production of certain hormones, including testosterone, and can lead to impaired sexual function. This effect is not permanent. Opioids have also been shown to adversely affect the immune system in people with HIV infection and AIDS.
  • Long-term opioid use can actually increase the body’s sensitivity to pain; this is called "opioid-induced hyperalgesia." Although the problem is well-documented, it’s still poorly understood and worries many doctors. To avoid this, doctors may try to stabilize you on a certain dose of an opioid, but still not increase it, even if full pain relief is not achieved.  

If tolerance does occur, many doctors believe that switching you to another opioid is an option. There’s little evidence on this, unfortunately, but it can work for some patients.

Also, even when tolerance is not a factor, if you are not responding well to one opioid and a dosage increase fails to control your pain, your doctor may choose to try another opioid. Some people simply respond better to one opioid than another, and trial and error is the only way to find that out.

Short acting vs. long-acting

Studies indicate no difference between similar doses of long-acting opioids and short-acting opioids in pain relief achieved. In practice, most doctors today prescribe long-acting (extended-release) opioids for people with chronic pain. They are more convenient, avoid “breakthrough” pain, and might have less addiction potential. On the other hand, long-acting medications mean that your body is continuously being exposed to opioids, which may promote the development of tolerance and physical dependence.

Side effects

One reason for a cautious approach toward opioids is that they cause side effects, and most people who take an opioid will experience at least one effect. The most common ones include dry mouth and constipation—which can be severe and require other drugs to relieve—nausea, dizziness, lack of energy, urine retention, slowed respiration, or excessive sedation. In studies, about one in five people stopped taking an opioid because of side effects.

Drinking alcohol worsens some of the opioid side effects, especially sedation and dizziness. So do some other drugs, especially tranquilizers, such as diazepam, sedatives (barbiturates), and antihistamines. Many accidental overdoses involve the use of opioids in combination with benzodiazepines like alprazolam (Xanax).

Some side effects can ease over time—nausea, for example. While others, such as constipation, can be reduced with laxatives and stool softeners. Others, like drowsiness and sedation may persist, and can make many daily activities difficult like driving or even simply concentrating on a task. This can be especially true if you take larger doses.

That’s why many chronic pain patients complain that while opioids help them cope with the pain, they don’t always improve their quality of life. Indeed, it’s why opioids can become “part of the problem” for many people with chronic pain, who previously led, or want to lead, active lives. 

The box below lists common opioid side effects and adverse events.   

Opioid Side Effects

Some decline over time and/or can be alleviated with other drugs. 

  • Accidental overdose
  • Agitation
  • Constipation
  • Decreased testosterone, sex drive, and impaired sexual function
  • Depression
  • Dizziness
  • Drowsiness, sedation
  • Increased pain sensitivity
  • Irregular menstruation
  • Itching
  • Memory impairment
  • Nausea and vomiting
  • Slowed breathing
  • Suppressed immune system function

Risk of addiction

The most worrisome risk with taking opioids is the risk of addiction. Opioid addiction has increased substantially in the last decade as more people take opioids and as recreational use of the drugs has increased.

But what’s the risk you’ll get hooked if you start taking an opioid for chronic pain?  Can you be said to be “addicted” if you need the drug? 

Although studies have not precisely defined the risk of addiction when opioids are used intermittently and for short periods to treat breakthrough pain or pain flare-ups, research does indicate that even when used appropriately for patients with severe pain, addiction and physical dependence occur more frequently than previously thought. Experts distinguish between addiction, physical dependence, and tolerance.

  • Physical dependence occurs when the body becomes accustomed to a drug. This happens with all opioids and to all people who take them for more than a week or so. It does not mean you are “addicted.” In practical terms, it means when you stop taking the drug, your body will have to adjust. You will likely have some “withdrawal” symptoms, such as sweating, shakiness, irritability, restlessness, jitteriness, insomnia, cold flashes, and involuntary muscle movements.
  • Tolerance occurs when the drugs have decreasing effects over time. With opioids, this is both good and bad. Good because you may have fewer side effects as your body adjusts to the drug; bad because the amount of pain relief you experience decreases. To sustain the pain relief, a higher dose is needed. Becoming tolerant to the drug complicates both physical dependence and the risk of addiction. Higher doses lead to more physical dependence, tougher withdrawal, and a greater risk of addiction.
  • Addiction occurs when you become psychologically dependent on a drug. It involves elements of physical dependence, but goes beyond that. You lose the ability to control the amount of drug you take, and your ability to make judgments about that. For example, you might take the drug independent of the level of your pain and even if it’s causing problems with your work or life.

Who becomes addicted?

Experts believe some people are genetically susceptible to becoming addicted to opioids. But there’s no test for that. Having a family history of alcohol and drug abuse is also a risk factor.

All these problems make it essential to take opioids with great care and under the watchful eye of a doctor who knows how to tell when you may be getting addicted. The signs of addiction include:

• Craving the drug;

• Asking for more of it than you really need for pain relief;

• Taking more doses than prescribed and running out of a month’s supply in two to three weeks;

• Not being able to function well, and experiencing increased sedation and sleepiness;

Treatments for opioid addiction exist. We don’t evaluate or compare them here, but they include counseling and support groups as well as medications such as buprenorphine, methadone, and naltrexone that can help reduce cravings and wean you off of drugs.

If you take an opioid

If your chronic pain is severe, and not well controlled with other drugs or nondrug treatment, opioids are an option your doctor will probably consider. But before prescribing one, he or she will likely require some information and simple tests.

For example, you may be asked to keep a pain diary for a few weeks, rating how severe your pain is and how often you experience it. Keeping track will give your doctor more detailed information on your pain “patterns.” He or she may also give you one or more quality-of-life scale tests. This helps clarify how pain is affecting your life. Your doctor is also likely to ask you about past and present drug or alcohol use, whether there is a family history of such problems, whether you are depressed or have anxiety, and may ask you to submit a urine specimen to test for drug abuse.

Your doctor is trying to determine whether the benefits of an opioid outweigh the risks. In fact, it’s your doctor’s responsibility to determine if you are at high risk of abusing opioids before prescribing them.  

Your doctor is also likely to follow a general rule of opioid prescribing, at least initially: prescribe the lowest possible dose for the shortest possible time to see if it works.

Your doctor may also ask you to sign an opioid “contract” in which you pledge to abide by certain rules when taking the drugs. 

Choosing which one

Opioids vary widely in price but most short-acting forms are now available as generics and cost $100 or less for a month’s supply of common doses. Extended release forms are generally two to three times more expensive and can range up to $500 for some brand-name formulations. Opioid skin patches are also more expensive. 

Unlike with many other categories of drugs we have evaluated, we have not chosen a Best Buy opioid for the treatment of chronic pain. That’s because there’s no good evidence showing that opioids are effective in treating long-term chronic pain, or that any one opioid is any better than another for that purpose. And, the risk of addiction and even overdose is too high. Indeed, our medical consultants suggest people should, in consultation with their doctors, try other pain relievers and nondrug treatments first.  

That said, if you and your doctor decide you need an opioid to relieve chronic pain or a pain flare-up, we recommend generic versions of hydrocodone/acetaminophen, oxycodone, or tramadol. Our recommendations aren’t based on any evidence that these opioids are better than others. Instead, they are based on cost; these generic versions cost less than $100 a month, on average, compared to $300 or more a month for many brand-name opioids, with no proof those brands work better.

Safe opioid use checklist 

✔ Read the label and take the drug exactly as directed. Never take more than advised, don’t take it with alcohol, and don’t combine it with any other drug without your doctor’s OK. Most opioid deaths involve alcohol or sleeping pills.

✔ Get tested for sleep apnea. If you snore loudly, get checked for the condition, because opioids can make it worse or even fatal.

✔ Watch out if you have a respiratory problem. Opioids can interfere with breathing if you have a cold, an asthma flare-up, or bronchitis. So let your doctor know right away, and see whether you need a lower dose until you recover.

✔ Don’t drive or do anything that requires you to be fully alert. That’s especially important when you first start taking an opioid or whenever you change the type or dosage.

✔ Put opioids in a locked drawer or cabinet to prevent children from taking them or others from using them for recreational purposes.

✔ Expect regular monitoring. If you are taking opioids,  your doctor should assess you at regular visits. If pain and function do not improve at least 30 percent after starting the drugs, then they probably are not working well enough to justify the risks. 

✔ Discard unused pills. You may be able to give them back to your pharmacy. If you can’t, the FDA says, unlike other drugs, opioids are so risky excess pills should be flushed down the toilet.

Our methodology

Our evaluation of opioids in the treatment of chronic pain is based primarily on an analysis from an independent, scientific review of the evidence on the effectiveness, safety, and adverse effects of opioids. The review was conducted by a team of 10 researchers based at the Pacific Northwest Evidence-based Practice Center at the Oregon Health and Science University in Portland and at the University of Washington in Seattle. It was funded by the Agency for Healthcare Research and Quality (AHRQ), published in October 2014 and is available here.

One of the researchers who co-authored the AHRQ report was a consultant to Best Buy Drugs in updating this report. A physician and specialist in evidence-based research and analysis who is a consultant to Consumer Reports Best Buy Drugs reviewed the AHRQ report and the initial draft of this Best Buy Drugs report and made additional suggestions for revisions. We also contracted with three additional physicians who specialize in pain care to review our report, one of whom served a peer reviewer of the AHRQ report. We thank all these contributors for their valuable assistance and attention to detail.

The AHRQ review probed in detail the findings of 39 studies that evaluated opioids in the treatment of chronic pain. But the review drew on a range of other literature. A list of references appears at the end of the AHRQ paper.  

Editor's Note:

These materials are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multi-state settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).

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