Opioids and Pain Medications: What You Need to Know About Risks and Relief

Written By James Tannenbaum

Introduction

Chronic pain affects millions worldwide, and opioids remain a cornerstone of pain relief for certain conditions. Yet their use is fraught with complexity, as benefits must be weighed against risks like dependence, side effects, and overdose. This guide offers a brief overview of opioids, analgesics, safer alternatives, and emerging best practices in pain medicine.

Part of our Guide to Pain and Pain Management.

What Are Analgesics?

Analgesics are medications designed to relieve pain without affecting consciousness. They are the first line of defense for many types of pain.

Paracetamol (Acetaminophen)

  • Effective for mild to moderate pain.

  • Minimal anti-inflammatory action.

  • Safe for most people but can cause liver damage at high doses.

NSAIDs (e.g., Ibuprofen, Naproxen)

  • Treat inflammatory and musculoskeletal pain.

  • Common side effects include gastric ulcers, kidney dysfunction, and cardiovascular risks if used long-term.

Topical Agents (e.g., Lidocaine, Capsaicin)

  • Offer localised relief for neuropathic or soft tissue pain.

  • Fewer systemic side effects compared to oral medications.

Understanding Opioids

Opioids are powerful medications used for moderate to severe pain. While essential in certain contexts, they require careful monitoring due to their high risk profile.

Types of Opioids

  • Typical (morphine-like) opioids: Morphine, codeine, oxycodone, hydromorphone, pethidine, hydrocodone, methadone, fentanyl, etc.

  • Atypical opioids: Tramadol, tapentadol and buprenorphine.

How Opioids Work

Typical opioids bind to mu-opioid receptors strongly in the brain and spinal cord to:

  • Inhibit pain signaling.

  • Increase pain tolerance.

  • Create a euphoric effect that can lead to misuse (Williams et al., 2015).

In contrast, Atypical opioids have weaker or partial agonist properties at the mu-opioid receptors in addition to non-opioid effects (e.g. serotonin and/or noradrenaline reuptake inhibition in the case of tramadol and tapentadol). Consequently, compared to typical opioids, atypical opioids are associated with:

  • Lower risks of respiratory depression and overdose, including accidental overdose

  • Lower risk of constipation

  • Generally lower abuse potential

  • Increasingly preferred for chronic pain when opioids are needed, due to improved safety profile

  • Less euphoria (especially buprenorphine)

  • Seizures (specifically tramadol)

When Are Opioids Used?

  • Appropriate for: Post-surgical pain, cancer pain, palliative care.

  • Caution for: Chronic noncancer pain, where benefits are modest and side effects more severe (Busse et al., 2018).

Opioids improve chronic pain scores by only 0.79 cm on a 10-cm visual scale, but increase the risk of vomiting and other adverse effects (Busse et al., 2018).

Risks and Considerations

Dependence and Withdrawal

  • Physical dependence may occur within weeks.

  • Transdermal buprenorphine (TBP) has shown promise in managing opioid withdrawal, with 58% of patients discontinuing opioid use after 8 weeks (Lee et al., 2024).

  • Withdrawal symptoms include agitation, cravings, sweating, nausea, and insomnia.

Side Effects and Overdose

  • Common: Nausea, dizziness, constipation, fatigue.

  • Severe: Respiratory depression, overdose.

  • In 2024, synthetic opioids like fentanyl contributed to over 87,000 deaths in the U.S. (APA, 2024).

Opioid-Induced Hyperalgesia (opioid-related increased pain/pain sensitivity)

  • Opioid-induced hyperalgesia (OIH) is a paradoxical condition in which exposure to opioid medications, rather than relieving pain, causes increased sensitivity to painful stimuli and can worsen or broaden the pain experienced by patients.

  • This may present as pain that is different from the original complaint, widespread pain, or pain that intensifies despite increasing opioid doses.

  • OIH is believed to result from neuroplastic changes in both the peripheral and central nervous systems, leading to sensitization of pain pathways.

  • There are likely several mechanisms such as increased pain enhancing (pronociceptive) neurotransmitter release, glial cell activation and neuroinflammation, and altered pain modulation.

  • Clinicians suspect OIH when pain worsens or spreads in the absence of disease progression, especially in the presence of increasingly severe pain despite higher opioid doses.

  • Management strategies include reducing or discontinuing the opioid, switching to a different opioid, especially an atypical opioid (opioid rotation), and considering adjuvant therapies such as non-opioids and multimodal pain management approaches

Alternatives to Opioids

Safer Medication Options

  • NSAIDs are as effective as opioids for many conditions without the addiction risks (Busse et al., 2018).

  • Adjuvant meds such as antidepressants and anticonvulsants target neuropathic pain.

Non-Pharmacological Treatments

  • Physical therapy and interventional pain treatments are valuable opioid-sparing strategies.

  • Cognitive-behavioral therapy (CBT), acupuncture, and pacing techniques can reduce reliance on medication.

Combining Medication with Mental Health Support

Psychological therapies enhance medication outcomes by addressing underlying fear, catastrophizing, and anxiety.
See our guide on chronic pain and mental health for detailed strategies.

Patient Questions and Misconceptions

❌ Myth: Opioids are the strongest and safest option

✅ Reality: NSAIDs often offer similar pain relief for acute musculoskeletal pain with fewer side effects (Busse et al., 2018).

❌ Myth: Prescription opioids are low risk

✅ Reality: Even prescription opioids can lead to addiction. Illicit fentanyl, often combined with other drugs like xylazine, is driving the current overdose crisis in the US (APA, 2024).

✅ In Australia, opioids are present in 70% of drug-induced deaths. 80% of drug-induced deaths in Australia are accidental (AIHW, 2025).

Conclusion

Opioids remain essential for specific conditions, but must be used with caution. Safer alternatives, non-drug therapies, and integrated mental health support offer effective ways to reduce risk and improve quality of life.

For most chronic pain sufferers, a multimodal plan combining physical, psychological, and pharmacological strategies—guided by a health professional—is the safest and most effective approach.

Related Reading:

  • Pain and Pain Management: A Complete Guide

  • Physical & Interventional Pain Treatments

  • Mental Health Support for Chronic Pain

References

Busse, J. W., et al. (2018). Opioids for chronic noncancer pain: A systematic review and meta-analysis. JAMA, 320(23), 2448–2460.
https://jamanetwork.com/journals/jama/fullarticle/2718795

Els, C., et al. (2020). Less well-known consequences of long-term opioid use. Drug Design, Development and Therapy, 14, 327–333.
https://doi.org/10.2147/DDDT.S243418

Williams, J. T., et al. (2015). Opioid receptors. BJA Education, 15(5), 219–224.
https://doi.org/10.1093/bjaed/mku050

Lee, Y., et al. (2024). Transdermal buprenorphine for opioid dependence in cancer survivors. The Oncologist, 29(11), e1593–e1600.
https://doi.org/10.1093/oncolo/oead087

American Psychiatric Association. (2024). Opioid use disorder.
https://www.psychiatry.org/patients-families/opioid-use-disorder

Stein, C., & Clark, J. D. (2005). Opioid receptors. BJA Education, 5(1), 22–25.
https://doi.org/10.1093/bjaed/mki008

Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA, 315(15), 1624–1645. https://doi.org/10.1001/jama.2016.1464

Pergolizzi, J. V., Raffa, R. B., & Varrassi, G. (2020). Atypical opioids: Novel approaches to chronic pain. Expert Review of Clinical Pharmacology, 13(3), 279–286. https://doi.org/10.1080/17512433.2020.1730647

Häuser, W., Morlion, B., Vowles, K. E., Bannister, K., Buchser, E., Casale, R., ... & Cohen, S. P. (2021). European clinical practice recommendations on opioids for chronic noncancer pain—Part 1: Role of opioids in the management of chronic noncancer pain. European Journal of Pain, 25(5), 949–968. https://doi.org/10.1002/ejp.1736

Tompkins DA, Campbell CM. Opioid-Induced Hyperalgesia: Clinically Relevant or Extraneous Research Phenomenon? Curr Pain Headache Rep. 2011. https://link.springer.com/article/10.1007/s11916-010-0171-1
Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011. https://www.painphysicianjournal.com/linkout?issn=&vol=14&page=145
Chu LF, Angst MS, Clark D. Opioid-induced hyperalgesia in humans: molecular mechanisms and clinical considerations. Clin J Pain. 2008. https://journals.lww.com/clinicalpain/abstract/2008/07000/opioid_induced_hyperalgesia_in_humans__molecular.3.aspx
BMJ Support Palliat Care. 2020. Management of opioid induced hyperalgesia. https://spcare.bmj.com/content/10/Suppl_1/A7.3
Mitra S. Opioid-induced hyperalgesia: Pathophysiology and clinical implications. J Opioid Manag. 2018. https://wmpllc.org/ojs/index.php/jom/article/view/981/0

Australian Institute of Health and Welfare. (2025). Alcohol, tobacco & other drugs in Australia. Retrieved from https://www.aihw.gov.au/reports/alcohol/alcohol-tobacco-other-drugs-australia

James Tannenbaum
Previous

Pain and Pain Management: A Brief Guide to Chronic and Acute Pain Relief