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The Opioid Pendulum Balancing Its Risks & Benefits

The Bottom Line

Appropriate use of opioids for pain relief requires delicately balancing risks and benefits. Too much of an opioid can be dangerous or even deadly, but too little leaves the patient in pain. Listen to our podcast, Poison!, to learn more.

The Full Story

VITAL SIGNS are four medical measurements that are used by healthcare providers to assess a patient's essential bodily functions. These measurements are blood pressure, heart rate, breathing rate, and temperature. The idea of pain as the 5th vital sign was first proposed in 1995, and it is now common for healthcare providers to include it as part of their initial evaluations. The sensation of pain is unique to every person, and pain tolerance can vary even within the same person depending on the situation. Genetic, environmental, psychological, and cognitive differences all affect the way in which we deal with pain, making it unlikely that two people will experience the same level of pain given the same pain stimulus. This makes it very difficult for healthcare providers to accurately assess pain, but at least pain is being more frequently addressed and treated.

Actively assessing patients' pain has helped to reduce the undertreatment of pain, but it might have led to overuse of opioids and contributed to the present opioid epidemic. Currently, we are at a point where opioid prescribing is being discouraged. This oscillation between overprescribing and underprescribing is known as the opioid pendulum.

The opioid pendulum presents a dilemma. Concerns about overuse of opioids are valid. According to the US Centers for Disease Control and Prevention (CDC), unintentional poisoning is the leading cause of death due to injury for all age groups. It has surpassed motor vehicle traffic fatalities as the leading cause of injury death in the US. About two-thirds of the 64,070 drug overdose deaths in 2016 involved an opioid. While limiting access to opioids might seem like an appropriate reaction, it could leave people with legitimate pain or those with altered pain tolerance without adequate relief. Lack of access to opioids could cause these people to self-treat their pain through illegal and unsafe options.

A good example of the swing of the opioid pendulum comes from the Veterans Administration (VA) healthcare system. From 2001 to 2009, the percentage of veterans receiving an opioid prescription increased from 17% of veterans to 24% of veterans. Further, the number of pain medication prescriptions written by military physicians quadrupled during that same time period. Veterans with mental health disorders like posttraumatic stress disorder were more likely to be prescribed an opioid. In response, the VA cut opioid prescribing by 41% from 2012 to 2017. The VA's Opioid Safety Initiative resulted in mixed responses from advocacy groups and patients. While some have hailed the movement as a step in the right direction, others are concerned that the VA might have gone too far. The US Pain Foundation's national director of policy advocacy stated that the new recommendations put veterans at risk for unnecessary harm if they are withdrawn from therapies that have proven effective in managing their pain. This issue is further discussed in our podcast, Poison!.

Patients who have pain that has been adequately controlled by opioid medications can face suspicion, accusations, and push-back when asking their providers for opioids. Some patients suffering from chronic, painful diseases like sickle cell disease have few pain relieving options other than opioids. Because these patients can require frequent pain medication, they are often assumed to be drug abusers and are undertreated as a result.

Data have shown that many patients with severe pain can be adequately managed on non-opioid medications, and this led to the treatment recommendations by the CDC in their 2016 guidelines. Additionally, a study published in 2017 found no difference in arm and leg pain relief when comparing the effect of single doses of opioids to a combination ibuprofen/acetaminophen dose.

If the opioid pendulum swings too far in one direction, we have overprescribing and the potential for developing opioid dependence with each new prescription. If it swings too far in the other direction, data favoring non-opioid pain treatment might be used to justify aggressive tapering or immediately discontinuing opioids, resulting in inadequate pain control or withdrawal symptoms. In patients who have been taking opioids for long-term conditions, gradual tapering under healthcare provider supervision should reduce the risk of withdrawal while adequately managing symptoms of pain.

For More Information

Hoffman J. Medicare is cracking down on opioids. Doctors fear pain patients will suffer. The New York Times; 27 Mar 2018.


Annual Surveillance Report of Drug-Related Risks and Outcomes: United States, 2017. Atlanta: Centers for Disease Control and Prevention, US Department of Health and Human Services; 31 Aug 2017 [accessed 2 Jun 2018].

Bohnert AS, Ilgen MA, Trafton, et al. Trends and regional variation in opioid overdose mortality among Veterans Health Administration patients, fiscal year 2001 to 2009. Clin J Pain 2014;30:605-12.

Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial. JAMA 2017;318:1661-7.

Coghill RC. Individual differences in the subjective experience of pain: new insights into mechanisms and models. Headache 2010;50:1531-5.

Committee on Prevention, Diagnosis, Treatment, and Management of Substance Use Disorders in the U.S. Armed Forces. Substance use disorders in the U.S. Armed Forces. Washington: National Academies Press; 21 Feb 2013.

Drug overdose death data. Atlanta: Centers for Disease Control and Prevention; 19 Dec 2017 [accessed 2 Jun 2018].

Glassberg JA, Tanabe P, Chow A, et al. Emergency provider analgesic practices and attitudes toward patients with sickle cell disease. Ann Emerg Med 2013;62:293-302.

Morone NE, Weiner DK. Pain as the 5th vital sign: exposing the vital need for pain education. Clin Ther 2013;35:1728-32.

VA becomes first hospital system to release opioid prescribing rates. Washington: US Department of Veterans Affairs; 11 Jan 2018 [accessed 1 Jun 2018].


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Prevention Tips

  • Before receiving a prescription for an opioid drug, ask the prescriber if there are effective non-opioid treatments.
  • Follow medication instructions carefully.
  • Store medications in a safe and secure location away from children, pets, and those who might abuse them.
  • Do not take opioid medications with alcohol, illegal drugs, or other medications that could affect breathing.
  • Learn more about the opioid epidemic on our podcast.

This Really Happened

A 29-year-old woman went to an ER seeking treatment for opioid addiction. She had been buying Percocet (10 mg of oxycodone and 325 mg acetaminophen) on the street and said she had been taking 30 tablets daily for about a year. In the last 3 days she took 61 tablets, and in the past 24 hours she took 20. The last dose was about 5 hours before arriving at the ER. She was uncomfortable, sweaty, and had diarrhea.

Because of the acetaminophen content, there was worry about liver damage. Poison Control recommended that her liver function be evaluated and that she should receive clonidine for withdrawal symptoms. The clonidine helped, and all of her lab tests were normal. She was discharged with a referral to a drug treatment center for management of her drug use and withdrawal. Her family promised to take her there the next day.