Prescription opioids can be used to treat moderate-to-severe pain and are often prescribed following surgery or injury, or for health conditions such as cancer. In recent years, there has been a dramatic increase in the acceptance and use of prescription opioids for the treatment of chronic, non-cancer pain, such as back pain or osteoarthritis, despite serious risks and the lack of evidence about their long-term effectiveness.

When the Prescription Becomes the Problem

• More than 191 million opioid prescriptions were dispensed to American patients in 2017—with wide variation across states.
• There is a wide variation of opioid prescription rates across states. Health care providers in the highest prescribing state, Alabama, wrote almost three times as many of these prescriptions per person as those in the lowest prescribing state, Hawaii.
• Studies suggest that regional variation in use of prescription opioids cannot be explained by the underlying health status of the population.
• The most common drugs involved in prescription opioid overdose deaths include:
  • Methadone
  • Oxycodone (such as OxyContin®)
  • Hydrocodone (such as Vicodin®)

To reverse this epidemic, we need to improve the way we treat pain. We must prevent abuse, addiction, and overdose before they start.

Addiction and Overdose

Anyone who takes prescription opioids can become addicted to them. In fact, as many as one in four patients receiving long-term opioid therapy in a primary care setting struggles with opioid addiction.Once addicted, it can be hard to stop. In 2016, more than 11.5 million Americans reported misusing prescription opioids in the past year.

Taking too many prescription opioids can stop a person’s breathing—leading to death.

Prescription opioid overdose deaths also often involve benzodiazepines. Benzodiazepines are central nervous system depressants used to sedate, induce sleep, prevent seizures, and relieve anxiety. Examples include alprazolam (Xanax®), diazepam (Valium®), and lorazepam (Ativan®). Avoid taking benzodiazepines while taking prescription opioids whenever possible.

Side Effects

In addition to the serious risks of addiction, abuse, and overdose, the use of prescription opioids can have a number of side effects, even when taken as directed:

• Tolerance—meaning you might need to take more of the medication for the same pain relief
• Physical dependence—meaning you have symptoms of withdrawal when the medication is stopped
• Increased sensitivity to pain
• Constipation
• Nausea, vomiting, and dry mouth
• Sleepiness and dizziness
• Confusion
• Depression
• Low levels of testosterone that can result in lower sex drive, energy, and strength
• Itching and sweating

Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, and many others.

Prescription Opioids

Opioids are a class of drugs naturally found in the opium poppy plant. Some prescription opioids are made from the plant directly, and others are made by scientists in labs using the same chemical structure.

• If you take a medicine in a way that is different from what the doctor prescribed, it is called prescription drug misuse.
• Prescription opioid use, even when used as prescribed by a doctor can lead to a substance use disorder, which takes the form of addiction in severe cases.
• Research Report: Prescription Drug Misuse

Fentanyl

Fentanyl is a powerful synthetic opioid that is similar to morphine but is 50 to 100 times more potent. In its prescription form it is prescribed for pain, but fentanyl is also made illegally.

Heroin

Heroin is a highly addictive drug made from morphine, which comes from opium poppy plants. Some prescription opioid pain medicines have effects similar to heroin. Research suggests that misuse of these drugs may open the door to heroin use.

Understanding Drug Misuse, Addiction, and Overdose

When used correctly under a health care provider's direction, prescription pain medicines are helpful. However, misusing prescription opioids risks dependence, addiction, and overdose.

The best ways to prevent opioid overdose deaths are to improve safe opioid prescribing, reduce exposure to opioids, prevent misuse, and treat opioid use disorder.

Overview

Opioids are a type of medication used to relieve pain. They require a prescription from your dentist or doctor, and include drugs such as hydrocodone, oxycodone, morphine, and codeine. Opioids also include illegal drugs such as heroin.

To ease discomfort that can result from some dental procedures, such as tooth extraction, gum and other dental surgery, or placement of dental implants, dentists may prescribe medications for pain relief, including opioids. Commonly prescribed opioid medications for relief of dental pain include hydrocodone (Vicodin^®), oxycodone (Percocet^® or OxyContin^®), and acetaminophen with codeine (Tylenol^® No. 3 and Tylenol^® No. 4).

These types of medications are generally safe if they are used for a short period of time—as prescribed by a health professional—to relieve short-term oral pain that may result from injuries or some dental procedures. However, using these types of medications for a longer period of time and at a higher dose than prescribed puts you at risk for becoming dependent on opioid medications. And, when misused, opioids can lead to addiction, overdose, or death.

It is important to know there are over-the-counter, non-opioid medications—acetaminophen (Tylenol^®) and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil^®, Motrin^®)—that can be just as effective for managing most dental pain.

Helpful Tips

Be sure to talk with your dentist about how to manage pain after a dental procedure:

• Ask your dentist if there are other ways besides opioids to relieve your pain.
• If your dentist prescribes an opioid pain medication, you should:
  • Let your dentist know about any other medications you are currently taking, and also whether you or others in your family have had any problems with substance abuse, such as with alcohol, prescription medications, or illicit drugs.
  • Ask about the risks of taking the medication.
  • Ask how to take the medicine and how long you should take it.
  • Be sure to take the medicine according to the directions you have received.
  • Never use alcohol when taking an opioid medication.
  • Store the medication in a safe place out of sight and out of reach of children, preferably in a locked cabinet.

Dispose of any unused or expired medication as soon as possible.

What are prescription opioids?

Opioids are a class of drugs naturally found in the opium poppy plant. Some prescription opioids are made from the plant directly, and others are made by scientists in labs using the same chemical structure. Opioids are often used as medicines because they contain chemicals that relax the body and can relieve pain. Prescription opioids are used mostly to treat moderate to severe pain, though some opioids can be used to treat coughing and diarrhea. Opioids can also make people feel very relaxed and "high" - which is why they are sometimes used for non-medical reasons. This can be dangerous because opioids can be highly addictive, and overdoses and death are common. Heroin is one of the world's most dangerous opioids, and is never used as a medicine in the United States.

What are common prescription opioids?

• hydrocodone (Vicodin) oxycodone (OxyContin, Percocet)
• oxymorphone (Opana)
• morphine (Kadian, Avinza)
• codeine
• fentanyl

How do people misuse prescription opioids?

Prescription opioids used for pain relief are generally safe when taken for a short time and as prescribed by a doctor, but they can be misused. People misuse prescription opioids by:

• taking the medicine in a way or dose other than prescribed
• taking someone else's prescription medicine
• taking the medicine for the effect it causes-to get high

When misusing a prescription opioid, a person can swallow the medicine in its normal form. Sometimes people crush pills or open capsules, dissolve the powder in water, and inject the liquid into a vein. Some also snort the powder.

How do prescription opioids affect the brain?

Opioids bind to and activate opioid receptors on cells located in many areas of the brain, spinal cord, and other organs in the body, especially those involved in feelings of pain and pleasure. When opioids attach to these receptors, they block pain signals sent from the brain to the body and release large amounts of dopamine throughout the body. This release can strongly reinforce the act of taking the drug, making the user want to repeat the experience.

What are some possible effects of prescription opioids on the brain and body?

In the short term, opioids can relieve pain and make people feel relaxed and happy. However, opioids can also have harmful effects, including:

• drowsiness
• confusion
• nausea
• constipation
• euphoria
• slowed breathing

Opioid misuse can cause slowed breathing, which can cause hypoxia, a condition that results when too little oxygen reaches the brain. Hypoxia can have short- and long-term psychological and neurological effects, including coma, permanent brain damage, or death. Researchers are also investigating the long-term effects of opioid addiction on the brain, including whether damage can be reversed.

What are the other health effects of opioid medications?

Older adults are at higher risk of accidental misuse or abuse because they typically have multiple prescriptions and chronic diseases, increasing the risk of drug-drug and drug-disease interactions, as well as a slowed metabolism that affects the breakdown of drugs. Sharing drug injection equipment and having impaired judgment from drug use can increase the risk of contracting infectious diseases such as HIV and from unprotected sex.

Prescription Opioids and Heroin

Prescription opioids and heroin are chemically similar and can produce a similar high. In some places, heroin is cheaper and easier to get than prescription opioids, so some people switch to using heroin instead. Data from 2011 showed that an estimated 4 to 6 percent who misuse prescription opioids switch to heroin and about 80 percent of people who used heroin first misused prescription opioids. More recent data suggest that heroin is frequently the first opioid people use. In a study of those entering treatment for opioid use disorder, approximately one-third reported heroin as the first opioid they used regularly to get high.

This suggests that prescription opioid misuse is just one factor leading to heroin use.

Can I take prescription opioids if I'm pregnant?

If a woman uses prescription opioids when she's pregnant, the baby could develop dependence and have withdrawal symptoms after birth. This is called neonatal abstinence syndrome, which can be treated with medicines. Use during pregnancy can also lead to miscarriage and low birth weight.

It can be difficult for a person with an opioid addiction to quit, but pregnant women who seek treatment have better outcomes than those who quit abruptly. Methadone and buprenorphine are the standard of care to treat opioid-dependent pregnant women. Methadone or buprenorphine maintenance combined with prenatal care and a comprehensive drug treatment program can improve many of the adverse outcomes associated with untreated opioid addiction. If a woman is unable to quit before becoming pregnant, treatment with methadone or buprenorphine during pregnancy improves the chances of having a healthier baby at birth.

In general, it is important to closely monitor women who are trying to quit drug use during pregnancy and to provide treatment as needed.

Tolerance vs. Dependence vs. Addiction

Long-term use of prescription opioids, even as prescribed by a doctor, can cause some people to develop a tolerance, which means that they need higher and/or more frequent doses of the drug to get the desired effects.

Drug dependence occurs with repeated use, causing the neurons to adapt so they only function normally in the presence of the drug. The absence of the drug causes several physiological reactions, ranging from mild in the case of caffeine, to potentially life threatening, such as with heroin. Some chronic pain patients are dependent on opioids and require medical support to stop taking the drug.

Drug addiction is a chronic disease characterized by compulsive, or uncontrollable, drug seeking and use despite harmful consequences and long-lasting changes in the brain. The changes can result in harmful behaviors by those who misuse drugs, whether prescription or illicit drugs.

Can a person overdose on prescription opioids?

Yes, a person can overdose on prescription opioids. An opioid overdose occurs when a person uses enough of the drug to produce life-threatening symptoms or death. When people overdose on an opioid medication, their breathing often slows or stops. This can decrease the amount of oxygen that reaches the brain, which can result in coma, permanent brain damage, or death.

How can an opioid overdose be treated?

If you suspect someone has overdosed, the most important step to take is to call 911 so he or she can receive immediate medical attention. Once medical personnel arrive, they will administer naloxone. Naloxone is a medicine that can treat an opioid overdose when given right away. It works by rapidly binding to opioid receptors and blocking the effects of opioid drugs. Naloxone is available as an injectable (needle) solution and nasal sprays (NARCAN Nasal Spray and KLOXXADO).

Some states have passed laws that allow pharmacists to dispense naloxone without a personal prescription. Friends, family, and others in the community can use the nasal spray versions of naloxone to save someone who is overdosing.

Can use of prescription opioids lead to addiction?

Yes, repeated misuse of prescription opioids can lead to a substance use disorder (SUD), a medical illness which ranges from mild to severe and from temporary to chronic. Addiction is the most severe form of an SUD. An SUD develops when continued misuse of the drug changes the brain and causes health problems and failure to meet responsibilities at work, school, or home.

People addicted to an opioid medication who stop using the drug can have severe withdrawal symptoms that begin as early as a few hours after the drug was last taken. These symptoms include:

• muscle and bone pain
• sleep problems
• diarrhea and vomiting
• cold flashes with goose bumps
• uncontrollable leg movements
• severe cravings

These symptoms can be extremely uncomfortable and are the reason many people find it so difficult to stop using opioids. There are medicines being developed to help with the withdrawal process, including lofexidine, a non-opioid medicine designed to reduce opioid withdrawal symptoms that was approved by the U.S. Food and Drug Administration (FDA) in 2018. The FDA has also approved sale of a device, NSS-2 Bridge, that can help ease withdrawal symptoms. The NSS-2 Bridge is a small electrical nerve stimulator placed behind the person’s ear, that can be used for up to five days during the acute withdrawal phase.

What type of treatment can people get for addiction to prescription opioids?

A range of treatments including medicines and behavioral therapies are effective in helping people with opioid addiction.

Two medicines, buprenorphine and methadone, work by binding to the same opioid receptors in the brain as the opioid medicines, reducing cravings and withdrawal symptoms. Another medicine, naltrexone, blocks opioid receptors and prevents opioid drugs from having an effect.

Behavioral therapies for addiction to prescription opioids help people modify their attitudes and behaviors related to drug use, increase healthy life skills, and persist with other forms of treatment, such as medication. Some examples include, cognitive behavioral therapy which helps modify the patient's drug use expectations and behaviors, and also effectively manage triggers and stress. Multidimensional family therapy, developed for adolescents with drug use problems, addresses a range of personal and family influences on one's drug use patterns and is designed to improve overall functioning. These behavioral treatment approaches have proven effective, especially when used along with medicines.

Points to Remember

• Prescription opioids are used mostly to treat moderate to severe pain, though some opioids can be used to treat coughing and diarrhea.
• People misuse prescription opioids by taking the medicine in a way other than prescribed, taking someone else's prescription, or taking the medicine to get high. When misusing a prescription opioid, a person may swallow, inject, or snort the drug.
• Opioids bind to and activate opioid receptors on cells located in the brain, spinal cord, and other organs in the body, especially those involved in feelings of pain and pleasure, and can strongly reinforce the act of taking the drug, making the user want to repeat the experience.
• People who use prescription opioids can feel relaxed and happy, but also experience drowsiness, confusion, nausea, constipation, and slowed breathing.
• Prescription opioids have effects similar to heroin. While prescription opioid misuse is a risk factor for starting heroin use, only a small fraction of people who misuse opioid pain relievers switch to heroin.
• A person can overdose on prescription opioids. Naloxone is a medicine that can treat an opioid overdose when given right away.
• Prescription opioid use, even when used as prescribed by a doctor can lead to a substance use disorder, which takes the form of addiction in severe cases. Withdrawal symptoms include muscle and bone pain, sleep problems, diarrhea and vomiting, and severe cravings.
• A range of treatments including medicines and behavioral therapies are effective in helping people with an opioid use disorder.

Many people experience pain every day. All patients with pain should receive safe and effective pain care. The objective of any pain care strategy is to safely reduce pain and increase your ability to do everyday activities.

No matter what form of treatment is used, discuss with your doctor what kind of pain relief and improvement you can expect overall and continue to follow up with your doctor on your progress.

On this page, you’ll learn about the types of pain – acute, subacute, and chronic – and options for treatment.

What are Prescription Opioids?

Opioids are natural or synthetic chemicals that bind to receptors in your brain or body to reduce the intensity of pain signals reaching the brain. Doctors sometimes prescribe opioid medications to manage pain. Common prescription opioid drugs include:

• Hydrocodone (such as Vicodin®, Norco®)
• Oxycodone (such as OxyContin®, Percocet®)
• Morphine (such as MS Contin®, Kadian®)

Acute and Subacute Pain Management

Acute pain is pain that has lasted for less than a month and has a known cause, like an injury, trauma, surgery, or infection. You may have experienced acute pain from outpatient medical procedures, like a wisdom tooth extraction, or injuries, like a broken bone. Subacute pain is pain that lasts longer than 1 month but not more than 3 months.

The goal of any pain management strategy is to safely reduce pain and increase your ability to do everyday activities.

No matter what form of treatment is used, discuss with your doctor what kind of pain relief and improvement you can expect overall and continue to follow up with your doctor on your progress.

Acute pain normally gets better as your body heals. Opioid medications are one of many ways to reduce severe acute pain, but many other options can provide relief with fewer side effects, including:

• Over-the-counter medications like acetaminophen (such as Tylenol®), ibuprofen (such as Advil®, Motrin®), and naproxen (such as Aleve®)
• Application of heat or ice
• Physical therapy, acupuncture, acupressure, massage, or spinal manipulation
• Music therapy
• Transcutaneous electrical nerve stimulation (TENS)
• Exercise

It is important to note that continuing opioid therapy during the subacute time frame might represent the start of long-term opioid therapy. Talk to your doctor about your treatment goals and the benefits and risks of different types of treatment for subacute pain.

Chronic Pain Management

Chronic pain is pain lasting three months or more.  It can be caused by a disease or condition, injury, medical treatment, inflammation, or even an unknown reason. Sometimes acute or subacute pain that is not effectively managed becomes chronic pain. Many people experience chronic pain, which can lead to impaired physical functioning, poor mental health, reduced quality of life, and contributes to substantial disability and death each year.

There are many possible options to treat your chronic pain. It is important to understand all your options and the risks and benefits of each. You and your doctor should work together to establish treatment goals for pain and function in your daily life.

Chronic pain can be managed with or without prescription opioids, but many of the nonopioid options have been shown to work better with fewer side effects. Examples include:

1. Over-the-counter medications like acetaminophen (Tylenol®), ibuprofen (Advil®, Motrin®), and naproxen (Aleve®)
2. Physical therapy and exercise
3. Cognitive behavioral therapy (CBT)
4. Certain antidepressant and antiseizure medications

Take control of how you manage your pain and ask your doctor about different options. Keep in mind that sometimes you may feel worse before you feel better when starting a new treatment program. Work with your doctor to find safe and effective care to help you reach your goals.

Patient Safety Is an Important Part of Pain Care

Before starting opioids to treat pain, you can:

• Learn about prescription opioids and know the risks.
• Consider ways to manage pain that do not include opioids. Examples include:
  • Physical therapy
  • Exercise
  • Nonopioid medications, such as acetaminophen or ibuprofen
  • Cognitive behavioral therapy (CBT)
• Make the most informed decision with your doctors.

Talk To Your Doctor About What Kind of Pain Care Is Right for You

If after talking to your doctor about your pain treatment, you are prescribed opioids, be sure to ask about the risks and benefits. To help ensure your treatment is safe and effective, your doctor may:

• Prescribe the lowest effective dose of immediate-release opioids
• Check your state’s prescription drug monitoring program to check if you’ve been prescribed other controlled substances
• Test your urine for the presence of drugs during your therapy, which is increasingly becoming a routine part of care.
• Offer naloxone, which can reverse an overdose
• Follow up within the first few days after you start a new opioid or a new dose
• Follow up at least every 3 months if you are on a stable dose to ensure benefits of opioids continue to outweigh risks

If You Are Prescribed Opioids for Pain Management

• Follow up with your doctor within the first few days of starting your prescription to ensure opioids are helping.
  • You should also discuss what kind of pain relief and improvement you can expect overall. Opioids can reduce pain in the short-term but will not likely relieve all your pain.
  • Also discuss any side-effects you are experiencing.
• Develop your personal pain management plan with your doctor which may include:
  • Your personal treatment goals, which describe what you may achieve as you make progress
  • Information about treatment options
  • Referral to specialists as needed

Side Effects of Opioid Therapy

Prescription opioids carry serious risks of addiction and overdose. Opioids can slow a person’s breathing, often a sign associated with someone experiencing an opioid overdose that can cause death. The use of prescription opioids can have several side effects as well, even when taken as directed:

• Tolerance—meaning you might need to take more of a medication for the same pain relief
• Physical dependence—meaning you have symptoms of withdrawal when a medication is stopped, or you take less
• Increased sensitivity to pain
• Constipation
• Nausea and vomiting
• Dry mouth
• Sleepiness
• Dizziness
• Confusion
• Low levels of testosterone that can result in lower sex drive, energy, and strength
• Itching and sweating

Talk to your doctor about ways to manage your pain that do not involve prescription opioids. Patients with pain should receive treatment that provides the greatest benefit. Evidence suggests that some nonopioid treatments used for many types of pain, including therapies that don’t involve medications, may actually work better for some conditions and have fewer risks and side effects.

Depending on the type of pain you are experiencing, options may include:

• Acetaminophen (Tylenol®), ibuprofen (Advil®), naproxen (Aleve®)
• Cognitive behavioral therapy (CBT) – a psychological, goal-directed approach in which patients learn how to modify physical, behavioral, and emotional triggers of pain and stress
• Exercise therapy, including physical therapy
• Certain medications for depression or for seizures, some of which can also treat pain
• Interventional therapies, like injections
• Exercise and weight loss
• Other therapies such as acupuncture and massage

Opioids are just one option for treating pain. Other options work just as well or better and have fewer risks and side effects.

Every patient should ask questions when getting a new prescription. This is especially important when your doctor, dentist or other health care professional prescribes you an opioid, such as hydrocodone, oxycodone, codeine and morphine.

What should you ask?

1. Why do I need this medication — is it right for me?

This conversation could begin like this: “My condition is causing pain. How long do you expect it to last? What medication are you giving me? If it’s an opioid, are there non-opioid options that could help with pain relief while I recover?”

Opioids approved by the U.S. Food and Drug Administration (FDA) can be used to treat certain kinds of acute and chronic pain. They also can have some very serious side effects.

If your doctor thinks your pain is best managed with a prescription opioid, then ask:

2. How long should I take this medication?

Find out when and how to stop using, or taper off, opioids. Ask that your doctor prescribe the lowest dose and the smallest quantity you may need and find out when to call to follow up on how well it is working. Other questions to consider:

How can I reduce the risk of potential side effects from this medication? Take your medicine exactly as prescribed by your health care provider. If you are still feeling pain, call your health care provider; do not take an extra dose. Learn to identify serious side effects (such as excessive sleepiness or a feeling of craving more of the medication) so you and your family will know when to call a doctor or go to the hospital. Ask your pharmacist if your prescription comes with a Medication Guide (paper handouts that come with many prescription medicines) for more information.

What if I have a history of addiction? Tell your health care provider about any history you have had with substance misuse or addiction to drugs or alcohol and if you have a history of smoking cigarettes. You should also tell your health care provider if anyone in your family has had a problem with substance misuse, alcoholism or drug addiction.

What about the other medications I’m taking? It is also very important that you tell your health care provider about all of the medicines you are taking, especially those prescribed to treat anxiety, sleeping problems, or seizure. Even medicines you take only occasionally could interact with the opioid pain medicine. Ask your health care provider about possible interactions.

How should I store my opioid medicine? If you have children at home — from a toddler to a teenager — consider a lockbox for your medications. Even one accidental dose of an opioid pain medicine meant for an adult can cause a fatal overdose in a child. Also, teenagers and others in the home or who are visiting may seek out opioid pain medicines for nonmedical use. They may look in bathroom medicine cabinets for a chance to steal these medicines.

What should I do with unused opioid medicine? Don’t store it in case you have more pain later. Your leftover opioids can be targeted by people who you’d never expect to take it: friends, relatives, and even your kids and their friends. If there is no drug take-back program near you, FDA has created a list of opioid pain medicines we recommend you flush down the toilet when they’re no longer needed. This way there can be no accidental exposures or mistakes in the home.

Can I share this medication with someone else? No. Your prescription is for you. Your doctor considers many factors when prescribing opioids. What’s safe for you might lead to an overdose for someone else.

3. Can I have an Rx for naloxone?

You should discuss with your doctor whether you should also receive a prescription for naloxone, a drug that can reverse the effects of an opioid overdose and could save lives. In many cases it makes sense to be prepared for potential problems by keeping naloxone in your home.

Play it safe. It doesn’t matter who is writing the prescription, ask these questions before taking opioids.

If you are prescribed opioids for your pain, you have the following responsibilities to help ensure you are getting the safest, most effective pain management possible.

What You Can Do to Prevent Opioid Misuse

Work with Your Doctor

• Work with your doctor to create a plan on how to manage your pain.
  • Know your options and consider ways to manage your pain that do not include opioids.
  • Talk to your doctor about any and all side effects and concerns.
  • Make the most informed decision with your doctor.
• Follow up regularly with your doctor.

Take and Store Opioids Properly

• Never take prescription opioids in greater amounts or more often than prescribed.
• Always let your doctor know about any side effects or concerns you may have about using opioids.
• Avoid taking opioids with alcohol and other substances or medications. It is very dangerous to combine opioids with other drugs, especially those that cause drowsiness:
  • Benzodiazepines (such as Xanax® and Valium®)
  • Muscle relaxants (such as Soma® or Flexeril®)
  • Hypnotics (such as Ambien® or Lunesta®)
  • Other prescription opioids
• Do not share or sell your prescription opioids.
• Store prescription opioids in a secure place, out of reach of others (including children, family, friends, and visitors).
• If you have unused prescription opioids at the end of your treatment, find your community drug take-back program or your pharmacy mail-back program, or flush them down the toilet, following guidance from the Food and Drug Administration.

• Acute Pain – Pain that usually starts suddenly and has a known cause, like an injury or surgery. It normally gets better as your body heals and lasts less than three months.
• Analgesics – Pain relieving medications including over-the-counter medications like acetaminophen (Tylenol^®) or ibuprofen (Advil^®) and prescription opioids.
• Analog – Drugs that are similar in chemical structure or pharmacologic effect to another drug, but are not identical.
• Benzodiazepines – Sometimes called “benzos,” these are sedatives often used to treat anxiety, insomnia, and other conditions. Combining benzodiazepines with opioids increases a person’s risk of overdose and death.
• Chronic pain – Pain that lasts 3 months or more and can be caused by a disease or condition, injury, medical treatment, inflammation, or an unknown reason.
• Drug misuse – The use of illegal drugs and/or the use of prescription drugs in a manner other than as directed by a doctor, such as use in greater amounts, more often, or longer than told to take a drug or using someone else’s prescription.
• Drug addiction – The preferred term is substance use disorder. When referring to opioids, see the Opioid Use Disorder (OUD) definition below and text box discussing the difference between “tolerance,” “dependence,” and “addiction.”
• Extended-release/long-acting (ER/LA) opioids – Slower-acting medication with a longer duration of pain-relieving action.
• Fentanyl – Pharmaceutical fentanyl is a synthetic opioid, approved for treating severe pain, typically advanced cancer pain. It is 50 to 100 times more potent than morphine. However, illegally made fentanyl is sold through illicit drug markets for its heroin-like effect, and it is often mixed with heroin or other drugs, such as cocaine, or pressed in to counterfeit prescription pills.
• Heroin – An illegal, highly addictive opioid drug processed from morphine and extracted from certain poppy plants.
• Illicit drugs – The nonmedical use of a variety of drugs that are prohibited by law. These drugs can include: amphetamine- type stimulants, marijuana/cannabis, cocaine, heroin, other opioids, and synthetic drugs, such as illicitly manufactured fentanyl (IMF) and ecstasy (MDMA).
• Immediate-release opioids – Faster-acting medication with a shorter duration of pain-relieving action.
• Medication-assisted treatment (MAT) – Treatment for opioid use disorder combining the use of medications (methadone, buprenorphine, or naltrexone) with counseling and behavioral therapies.
• Methamphetamine – A highly addictive central nervous system stimulant that is also categorized as a psychostimulant. Methamphetamine use has been linked to mental disorders, problems with physical health, violent behavior, and overdose deaths. Methamphetamine is commonly referred to as meth, ice, speed, and crystal, among many other terms.
• Morphine milligram equivalents (MME) – The amount of milligrams of morphine an opioid dose is equal to when prescribed. Calculating MME accounts for differences in opioid drug type and strength.
• Naloxone – A drug that can reverse the effects of opioid overdose and can be life-saving if administered in time. The drug is sold under the brand name Narcan or Evzio.
• Narcotic drugs – Originally referred to any substance that dulled the senses and relieved pain. Some people use the term to refer to all illegal drugs but technically, it refers only to opioids. Opioid is now the preferred term to avoid confusion.
• Nonmedical use – Taking prescribed or diverted prescription drugs (drugs not prescribed to the person using them) not in the way, for the reasons, in the amount, or during the time-period prescribed.
• Non-opioid therapy – Methods of managing pain that does not involve opioids. These methods can include, but are not limited to, acetaminophen (Tylenol^®) or ibuprofen (Advil^®), cognitive behavioral therapy, physical therapy, acupuncture, meditation, exercise, medications for depression or for seizures, or interventional therapies (injections).
• Non-pharmacologic therapy – Treatments that do not involve medications, including physical treatments (e.g., exercise therapy, weight loss) and behavioral treatments (e.g., cognitive behavioral therapy).
• Opioid – Natural, synthetic, or semi-synthetic chemicals that interact with opioid receptors on nerve cells in the body and brain, and reduce the intensity of pain signals and feelings of pain. This class of drugs includes the illegal drug heroin, synthetic opioids such as fentanyl, and pain medications available legally by prescription, such as oxycodone, hydrocodone, codeine, morphine, and many others. Prescription opioids are generally safe when taken for a short time and as directed by a doctor, but because they produce euphoria in addition to pain relief, they can be misused and have addiction potential.
• Opioid analgesics – Commonly referred to as prescription opioids, medications that have been used to treat moderate to severe pain in some patients. Categories of opioids for mortality data include:
  • Natural opioid analgesics, including morphine and codeine;
  • Semi-synthetic opioid analgesics, including drugs such as oxycodone, hydrocodone, hydromorphone, and oxymorphone;
  • Methadone, a synthetic opioid that can be prescribed for pain reduction or for use in MAT for opioid use disorder (OUD). For MAT, methadone is used under direct supervision of a healthcare provider;
  • Synthetic opioid analgesics other than methadone, including drugs such as tramadol and fentanyl.
• Opioid use disorder (OUD) – A problematic pattern of opioid use that causes significant impairment or distress. A diagnosis is based on specific criteria such as unsuccessful efforts to cut down or control use, or use resulting in social problems and a failure to fulfill obligations at work, school, or home, among other criteria. Opioid use disorder is preferred over other terms with similar definitions, “opioid abuse or dependence” or “opioid addiction.”
• Overdose – Injury to the body (poisoning) that happens when a drug is taken in excessive amounts. An overdose can be fatal or nonfatal.
• Physical dependence – Adaptation to a drug that produces symptoms of withdrawal when the drug is stopped.
• Prescription drug monitoring programs (PDMPs) – State or territorial-run electronic databases that track controlled substance prescriptions. PDMPs help providers identify patients at risk of opioid misuse, opioid use disorder, and/or overdose due to overlapping prescriptions, high dosages, or co-prescribing of opioids with benzodiazepines.
• Tolerance – Reduced response to a drug with repeated use.

“Opiates” vs. “opioids” Although these terms are often used interchangeably they are different:

Opiates refer to natural opioids such as heroin, morphine and codeine.

Opioids refer to all natural, semisynthetic, and synthetic opioids.

What is the difference between “tolerance,” “dependence,” and “addiction”?

Opioid tolerance occurs when a person using opioids begins to experience a reduced response to medication, requiring more opioids to experience the same effect.

Opioid dependence occurs when the body adjusts its normal functioning around regular opioid use. Unpleasant physical symptoms occur when medication is stopped.

Opioid addiction (Opioid use disorder (OUD)) occurs when attempts to cut down or control use are unsuccessful or when use results in social problems and a failure to fulfill obligations at work, school, and home. Opioid addiction often comes after the person has developed opioid tolerance and dependence, making it physically challenging to stop opioid use and increasing the risk of withdrawal.

Prescription opioids are sometimes used to treat moderate-to-severe pain. Because prescription opioids have a number of serious side effects and risks, it is important for you to ask questions, learn more about opioids, and understand their risks. Make sure you’re getting care that is safe, effective, and right for you.

What is the Difference Between Acute Pain and Chronic Pain?

Acute pain usually starts suddenly and has a known cause, like an injury or surgery. It normally gets better as your body heals. Chronic pain is pain lasting 3 months or more and can be caused by a disease or condition, injury, medical treatment, inflammation, or even an unknown reason.

What are Opioids?

Opioids are natural or synthetic chemicals that reduce feelings of pain. Common prescription opioids include:

• Hydrocodone (Vicodin®)
• Oxycodone (OxyContin®)
• Oxymorphone (Opana®)
• Codeine
• Morphine
• Methadone
• Fentanyl

Are Opioids Necessary?

Opioid medications are one of many ways to treat pain. It may be helpful to know that:

• Acute pain: usually starts suddenly and has a known cause, like an injury or surgery. It normally gets better as your body heals.
• Chronic pain: pain lasts 3 months or more and can be caused by a disease or condition, injury, medical treatment, inflammation, or even an unknown reason.

Prescription opioids can be used to treat severe acute pain, but there is no evidence that they are as effective for long-term use. If you’re prescribed an opioid, the best approach is to try the lowest possible dose in the smallest quantity. Opioids should only be used when necessary and only for as long as necessary. Generally, for acute pain this is often 3 days or less; more than 7 days is rarely needed.

Before taking opioid medication for chronic pain:

• Discuss with your doctor pain treatment options, including ones that do not involve prescription drugs.
• Tell your doctor about your medical history and if you or anyone in your family has a history of substance misuse or addiction to drugs or alcohol.
• Discuss all of the risks and benefits of taking prescription opioids.

Talking openly with your healthcare provider will help to make sure you’re getting care that is safe, effective, and right for you. Set up a follow-up appointment with your doctor to reevaluate your pain and, if you have been taking opioids for more than a few days, give you guidance on the best way to cope with possible withdrawal symptoms when you stop.

Will I Get Addicted to Opioids?

Anyone who takes prescription opioids can become addicted to them. You may also develop tolerance—meaning that over time you might need higher doses to relieve your pain, putting you at higher risk for a potentially fatal overdose. You can also develop physical dependence—meaning you have withdrawal symptoms when the medication is stopped.

Tell your doctor about your medical history and if you or anyone in your family has a history of substance misuse or addiction to drugs or alcohol. Also, never take opioids in higher amounts or more often than prescribed.

Can I Avoid Side Effects and Risks?

No. Opioids pose a risk to all patients. Anyone taking prescription opioids is at risk for unintentional overdose or death and can become addicted. From 1999 to 2020, more than 263,000 people died from overdose involving prescription opioids in the United States. Up to 1 out of 4 people receiving long-term opioid therapy in a primary care setting struggles with opioid use disorder.

In addition to the serious risks of opioid use disorder and overdose, the use of prescription opioids can have a number of side effects, even when taken as directed. Review these with your doctor, so you know what you may expect:

• Tolerance—needing to take more of the medication over time for the same pain relief
• Physical dependence—experiencing symptoms of withdrawal when the medication is stopped
• Increased sensitivity to pain
• Constipation
• Nausea and vomiting
• Dry mouth
• Sleepiness and dizziness
• Confusion
• Depression
• Low levels of testosterone that can result in lower sex drive, energy, and strength
• Itching
• Sweating

Remember, your doctor is a partner in your pain treatment plan. It’s important to talk about any and all side effects and concerns to make sure you’re getting the safest and most effective care.

Drug Misuse and Opioid Use Disorder

Drug Misuse: The use of prescription drugs without a prescription, or in a different way than prescribed.

Opioid Use Disorder (OUD): sometimes referred to as “opioid abuse or dependence,” or “opioid addiction.” OUD is a problematic pattern of opioid use that causes significant impairments at work, school, or home, among other criteria or distress, such as unsuccessful efforts to cut down or control use, social problems, and a failure to fulfill obligations.

What Increases My Risk of Overdose from This Medication?

It is very dangerous to combine opioids with other drugs, especially those that cause drowsiness. Risk of opioid overdose and death increases at higher dosages, and when taken for longer periods of time or more often than prescribed.

Talk to your doctor about any other medications you are using. Work out a plan to call your doctor if you continue to experience pain. Also ask about the serious side effects (like excessive sleepiness or craving more of the medication) so you and your family know when to call a doctor or go to the hospital.

Combinations that Increase Risk

Overdose risk increases when your opioid medication is combined with:

• Alcohol
• Benzodiazepines (also known as “benzos,” including diazepam and alprazolam)
• Other sedatives
• Other opioids (prescription or illicit, including heroin)

What is the Opioid Prescribing Guideline and How Does it Affect Me?

CDC developed the Guideline for Prescribing Opioids for Chronic Pain to help primary care providers make informed prescribing decisions and improve patient care for those who suffer from chronic pain (pain lasting more than 3 months) in outpatient settings. The guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.

If you have chronic pain and are prescribed opioids as part of your treatment, your doctor should monitor you regularly. This might include extra assessments, a pain treatment plan, more frequent office visits, and urine testing. Prescription opioids can be very dangerous if not used properly. Make sure to follow all of your doctor’s recommendations.

Does CDC Require My Doctor to Follow the Opioid Prescribing Guideline?

No. The Guideline helps providers make informed decisions about pain treatment for patients 18 and older in primary care settings (not active cancer treatment, palliative care, or end-of-life care). The Guideline offers 12 recommendations for opioid prescribing based on research.