An oft-reported reason why doctors are force-tapering chronic non-cancer pain patients off their opioid pain-relieving medications is that they are NOT safe long term. The main concerns are addiction and overdose.
This page is dealing with the evidence on overdose risk, and I’m addressing the evidence on addiction on this page.
A common reason for force-tapering patients off their pain-relieving opioid medications is the risk of overdose. Doctors and policy-makers repeatedly state that the risk of overdose is too high, and these medications are not safe.
So what does the evidence show? What is the risk of overdose? And what is the actual incidence of overdose in people prescribed long term opioid therapy for chronic pain?
The truth is that overdose is very rare. Somewhere in the order of 0.03%. Or three people in every TEN THOUSAND will experience an overdose. And at least a third of these, statistically speaking, are intentional overdoses. So two in ten thousand people will accidentally overdose on their opioid pain relieving medications. Please see the supporting evidence below.
Published: April 2022
Opioid-related overdose and chronic use following an initial prescription of hydrocodone versus oxycodone
Link to the original study: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0266561
This study was comparing oxycodone to hydrocodone to see which resulted in more overdoses and addiction (persistent use). What the study very clearly found was that overdose was very rare with either medication. In fact only 0.3% of patients, in a sample of 14, 458 patients, experienced an overdose. But they do not report this in their conclusions.
This study is a very good example of how researchers cherry-pick their own data and only report on those parts of the study that support the conclusions that they are setting out to prove. And the narrative that they are pushing.
These researchers chose, in their conclusion, to only mention which medication – oxycodone or hydrocodone resulted in more overdoses. But they did NOT mention the incredibly low overdose rate over all! Why? Because an overdose rate of 0.3% is not what they expected to find, and it was not what they wanted to find. This result did not suit the anti-opioid narrative they are promoting, therefore they had to cherry-pick their own data, and selectively report their results.
This is a deceptive practice, and any ethical researcher would have made clear in the conclusion that both overdose and addiction are very, very rare.
Their conclusion: “Among previously opioid-naïve patients, the risk of developing chronic use was slightly higher with hydrocodone, whereas the risk of overdose was higher after oxycodone, in combination with acetaminophen or monotherapy. With a goal of reducing overdose-related deaths, hydrocodone may be the favorable agent.”
March 2022 article published in the journal “Journal of Pain Research – Vol 15”
Further, this study:
Misinterpretation of the “Overdose Crisis” Continues to Fuel Misunderstanding of the Role of Prescription Opioids
This is a well-researched article by leading pain researchers and clinicians with no less than 81 references to support their assertion that opioids ARE safe for chronic pain and the overdose risk is highly inflated. The fact is that most overdoses involved polypharmacy and that an overdose on only opioid medication is vanishingly rare.
I’ve done a full write up of the article here ‘ Misinterpretation of the “Overdose Crisis” continues to fuel misunderstanding of the role of prescription opioids“
“We endorse responsible prescribing and dispensing of medications of all types, including opioids; however we do not endorse propagating hysteria, deceitful use of clinical evidence or lack thereof, nor trying to influence the current pharmaceutical market for self-gain…”
“…From an ethical perspective, we are deeply concerned that such egregious efforts are potentially damaging to vulnerable chronic pain sufferers who are already stigmatized and marginalized, thereby exacerbating their plight. Sadly, we do not believe that this analysis will serve as a catalyst for disingenuous anti-opioidists to change their ways. However, we hope that by continuing to expose the continuing falsehoods that are damaging to so many patients, the tide against opioids and those who suffer from intractable chronic pain will begin to turn in a more moderatist direction.”
Published March 2021
A far more honest study, without bias, that reported on the true safety and efficacy of opioids for chronic pain. But the media did not pick up this story. And therefore people, including doctors, continue to believe that opioids are unsafe, and that the overdose risk is high.
This next study found a slightly higher rate of overdose – 0.055%. Or 5.5 peole in ten thousand.
Initial opioid prescription patterns and the risk of the ongoing use and adverse outcomes
This study looked at patients who were prescribed an opioid for pain and examined how many people continued to take them long-term (3.17%) and how many experienced an opioid overdose (0.055%). Its clear that opioid overdose is a rare event in pain patients and the risk of overdose is highly inflated.
From the study: “Among the 2,021,371 individuals meeting our inclusion criteria, 1121 (or 0.055%) experienced an opioid overdose within 1 year and 64,013 (3.17%) continued treatment for at least 1 year. “
You can find more on the study here: https://painpatientadvocacy.org/initial-opioid-prescription-patterns-and-the-risk-of-ongoing-use-and-adverse-outcomes/
The following studies are older, but they show that the evidence has always been available, that opioids are safe and effective for chronic pain and the entire ‘opioid epidemic’ being caused by over-prescription of opioids for chronic pain narrative, is a lie.
Published: May 2018
Efficacy of opioids versus placebo in chronic pain: a systematic review and meta-analysis of enriched enrollment randomized withdrawal trials
This study was to evaluate the effectiveness, or otherwise, of long-term opioid therapy.
The study finds that opioids ARE effective for a period of 3 months or more. The study did not evaluate safety.
The studies conclusion: “This meta-analysis of FDA-required double-blind, randomized, placebo-controlled clinical trials of opioid analgesics for the treatment of chronic pain has shown that there is an ample evidence base supporting the efficacy of opioid analgesics for at least 3 months’ duration, a standard period for the evaluation of treatments for chronic pain and other chronic disorders.”
Published April 2018 in the journal Pain Medicine, Volume 19, Issue 4
Are Prescription Opioids Driving the Opioid Crisis? Assumptions vs Facts
This study was to examine the cause of the increased number of opioid overdoses since the early 2000s. The study found:
“Non methadone prescription opioid analgesic deaths, in the absence of co-ingested benzodiazepines, alcohol, or other central nervous system/respiratory depressants, are infrequent.”
That is, deaths that are purely caused by prescription opioids, are infrequent.
Conclusion of the study: “Many current assumptions about opioid analgesics are ill-founded. Illicit fentanyl and heroin, not opioid prescribing, now fuel the current opioid overdose epidemic. National discussion has often neglected the potentially devastating effects of uncontrolled chronic pain. Opioid analgesic prescribing and related overdoses are in decline, at great cost to patients with pain who have benefited or may benefit from, but cannot access, opioid analgesic therapy.”
Published online: 04 May 2017 Canadian Journal of Pain Vol 1, 2017
“One Size Fits All” Doesn’t Fit When It Comes to Long-Term Opioid Use for People with Chronic Pain
This is an extremely thorough study which examines the rates of overdose and finds that overdose deaths are most often related to illicit fentanyl, not prescribed opioids for chronic pain.
The study’s conclusion: “The use of opioids in chronic non-cancer pain continues to be a flashpoint in medicine. The media and others continue to cite rising deaths due to opioids without clarifying that a large percentage of the current deaths are related to illicit highly potent fentanyl and other synthetic opioids coming across our borders from China. This misunderstanding is leading to an increasingly harsh regulatory climate for physicians and many physicians are electing to avoid opioid prescribing completely. Further, in this environment of fear, there are many instances of physicians refusing to treat people with chronic pain. This is unethical and unacceptable, but one can begin to understand given the inappropriate reactions of regulators across the country.”
First published: 09 January 2012
Appropriate and responsible use of opioids in chronic non-cancer pain
In 2012 a group of distinguished pain clinicians from nine European countries got together to discuss the appropriate use of strong opioids for chronic non-cancer pain. These people are all at the top of their field and their conclusions and recommendations are drawn from vast clinical experience. That is ‘real world’ experience from caring for actual patients.
All agreed that while treating chronic noncancer pain with opioids was not without risk, some patients for whom all other therapies have failed can be safely and effectively treated with strong opioids. These patients experience reduced pain and improved quality of life where no other therapy delivers these benefits. Only a minority of patients will qualify, but strong opioids must not be denied these patients and guidelines should reflect such.
Published: May 2007
Long-term use of controlled-release oxycodone for noncancer pain: results of a 3-year registry study
This study was to evaluate the outcomes associated with the use of controlled-release (CR) oxycodone for up to 3 years in the treatment of noncancer pain. It is an older study, and a small study, with only 233 participants, It is still very important, however, because there are very few long-term studies on the effects of long-term opioid therapy on chronic non-cancer pain.
This study clearly finds that for the majority of patients in this study, long-term opioid therapy provided sustained pain relief, with little need for dose increases. There were no serious side effects and the side effects waned over time. Most importantly of all, there were NO cases of addiction or overdose, which is the reason most often used for non-prescription and/or involuntary tapering of chronic non-cancer pain patients off opioids.