The Smart Patient's Guide to
Chronic Pain Management

What to Expect When Starting Chronic Opioid Therapy

The idea of taking opioids may seem scary. Here’s a guide of what you can expect.

Each day brings more news reports on the epidemic of opioid abuse and the potential to become addicted to or dependent on these powerful medications. Whether you have severe arthritis, intractable back pain, or are recovering from major surgery, your doctor has decided to prescribe opioids to treat your pain, and you probably have lots of questions before starting the medication.

Determining Whether Opioids Are Right for You

Before you are prescribed opioids, your healthcare provider will assess your risk for developing addiction, says Robert Bolash, MD, an assistant professor in the Department of Pain Management at the Cleveland Clinic in Ohio. “It’s important to know in advance if you may be susceptible to developing a problem with opioids,” he explains. “Before starting treatment, you will be asked about whether people in your family have ever had a problem with substance abuse, or if you have. It’s an important conversation.”

Your doctor may use an opioid risk-assessment tool to help in this process, such as a questionnaire that you fill out, or she may choose to ask you questions, sort of like an interview, adds Harshal Kirane, MD, director of addiction services at Northwell Health Staten Island University Hospital and assistant professor of psychiatry at Hofstra Northwell School of Medicine. “You and your doctor will decide if the medicine is, in fact, essential and if you are vulnerable for misuse,” he explains. “Also, before you start treatment, the goals of treatment will be clearly defined and there will be a discussion of side effects.”

Chronic Opioid TherapyBe prepared for what comes with starting chronic opioid therapy. (Source: 123RF)

Signing an Opioid Patient Agreement Form

Before prescribing opioids, your doctor will likely ask you to sign a Patient Agreement form, acknowledging that you understand the risks of opioid therapy and how to take them safely. This agreement is standard practice and spells out everything you need to know, from your responsibilities during treatment to how to obtain refills to the conditions under which your treatment might be terminated. For example, you may be asked to use only one pharmacy to get your prescription and to notify any of your other doctors that you are on opioid therapy. In addition, the form may point out that early refills are not allowed.

One such agreement, adapted from the American Academy of Pain Medicine, includes a list of statements that the patient must sign, including a treatment statement that both the provider and patient need to sign.

Understanding the Risks

According to the CDC, more than 40 people each day die from an overdose using prescription opioids and as many as one in four individuals who receive long-term opioid therapy in a primary care setting develops opioid use disorder (OUD), also known as opioid addiction. “It is not that the person wants to be addicted, but their brain has actually been co-opted by the medication,” explains Michael Genovese, MD, JD, chief medical officer at Acadia Healthcare. He is a member of the American Academy of Addiction Psychiatry and the American Society of Addiction Medicine, among others.

There’s an important difference between being physically dependent on opioids and having OUD. In physical dependence, the person experiences symptoms and signs of withdrawal (like nausea, sweating, and diarrhea) when suddenly lowering the dose of opioids, but does not have an addiction.

OUD, on the other hand, is a chronic relapsing disease that causes impairment and distress,1 and, in some people, can even create irreversible physical changes at cellular levels in the brain. OUD is diagnosed when certain criteria are met, such as unsuccessful efforts to cut down or control use and a failure to fulfill one’s obligations at work, school, or home. Read more on this distinction.

Getting Ready for Common Side Effects of Opioids

The risk of developing any side effects while taking an opioid is as high as 78%, so it’s likely that a person will have some side effects, says Dr. Bolash. More serious side effects, however, such as a bowel blockage or severe cognitive slowing, is under 7.5%.

One of the most common side effects is constipation, which is typically treated by increasing fiber content in the diet, taking stool softeners, and being more physically active, which promotes motility in the digestive tract, Dr. Kirane says. Sedation is another common side effect, and while the fatigue may be mild and transient, your doctor may recommend that you not drive until you see how the medication affects you individually.

Itching, cognitive slowing, and sexual dysfunction are other side effects, says Dr. Bolash. “The person may not be thinking as sharply as he or she usually does.”

If the side effects don’t abate, your doctor may consider tapering (lowering) your dose, switching to an alternative opioid, or switching the route of administration. For example, “if you were getting the medication orally, you might switch to a patch, or maybe to an injection instead,” Dr. Kirane says.

If you discontinue your opioid medication, you may experience withdrawal effects in as little as three days, says Dr. Genovese. These flu-like symptoms can include body aches, nausea, diarrhea, a runny nose, sweating, and even vomiting. “It is important to have a really good dialogue with your doctor if you are stopping or tapering off of opioids for any reason,” Dr. Genovese says. “Another medication can be prescribed to address the withdrawal symptoms. Opioids are medications that you don’t want to self-manage.”

Undergoing Drug Testing and What it Means

The CDC recommends that healthcare providers who prescribe opioids for chronic pain conduct urine drug testing before a patient starts opioid therapy, and that they consider follow-up urine drug testing at least once a year. Drug testing does not imply that the doctor thinks you are addicted to or abusing your medication—it is simply the current standard of care for opioid therapy.

These screens help the doctor assess for prescribed medications and other controlled prescription drugs and illicit drugs that you may be taking, thereby helping identify any risky interactions or misuse. If you are unable to provide urine, your doctor may be able to do a blood or saliva test instead. How often you get tested will depend on your particular case and medical history. Read a patient FAQ on clinical drug monitoring.

Storing Your Opioids Safely

Keep your opioid prescriptions in a safe place, recommends Nadya Swedan, MD, FAAPMR, who works in the Department of Physical Medicine and Rehabilitation Medicine at Lenox Hill Hospital in New York City. “Opioids are commonly stolen,” she says. “You don’t want kids to have access to them.” Even if the pills are several years old, they can remain effective for at least two years after their expiration date, she explains. If you plan to discard them, take them to your police station or wait for a takeback day

Read more about proper storage and disposal of unused opioid medication.

Updated on: 12/19/19
Continue Reading:
Tapering: How to Safely Transition Off Opioid Pain Medications