Traditionally used for cancer-related pain or acute pain during post-operational recovery, opioids are increasingly recommended by pain specialists when other analgesics and therapies fail to provide adequate pain relief. Opioids are natural or synthetic drugs related to morphine, the gold standard for treating moderate to severe chronic pain. Opioids in various forms—pills, syrups, anal suppositories, injections, intravenous applications, and skin patches—make life easier for countless people who live with debilitating pain.

Opioids are not appropriate or even effective for everyone, and not all individuals with chronic pain need them. For some, they provide a level of functioning that outweighs the negative side effects and risks. They are potentially dangerous at high doses, particularly for individuals who are extremely sensitive to their effects.

Many persons who have chronic pain do very well with small doses; individuals with severe pain may not need stronger opioids or a higher dose. As is the case with all medications, the smallest dose that provides adequate pain relief with manageable side effects is the right prescription for a person who needs opioids. While some side effects can be managed, identifying just the right dose is key. Finding the right balance is part of the trial-and-error process.

The Language of Opioids

• Narcotic is a legal term for a controlled substance.
• Opium is a mind-altering powder derived from the seedpod of the Papaver somniferum poppy.
• Opiates are drugs made from opium.
• Opioids are natural or synthetic drugs that bind to opioid receptors and have qualities similar to those of morphine. The term opioids includes the opiates.

Oxycodone, the opioid most commonly prescribed for chronic pain, is more potent than morphine. Take in low doses, it is often effective against bone and nerve pain and has few unwanted side effects.

Fentanyl skin patches and lozenges use very small amounts of fentanyl, since it is 100 times as strong as morphine.

Transdermal patches containing buprenorphine (Butrans) can also be used to control moderate to severe pain and may have fewer side effects. Buprenorphine (Butrans, Subutex, Suboxone) appears to be well tolerated, with a low level of physical dependence and fewer withdrawal symptoms when it is stopped.⁴

Methadone, an inexpensive and effective opioid that reduces withdrawal symptoms in addicts, is also used for chronic pain, especially when a slow-onset, long-acting opioid is needed. As a pain treatment, methadone reduces both tolerance and nerve super-sensitivity. It blocks N-methyl-D-asparate (NMDA) receptors in the spinal cord, reducing the volume or intensity of pain signals that are transmitted by the spinal cord to the brain. Methadone must be used cautiously because its long half-life (the time it takes for the body to clear one-half of the drug out of the body) can lead to dangerously high accumulations in the blood.

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This article is an excerpt from Confronting Chronic Pain, A Pain Doctor’s Guide to Relief, by Steven H. Richeimer, MD with Kathy Steligo. Reprinted by permission of Johns Hopkins University Press. Dr. Richeimer is an associate professor in the Departments of Anesthesiology and Psychiatry and chief of the Division of Pain Medicine at the University of Southern California.

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