Starting Opioids

Assessing benefit and harm




Potential Benefits of Opioid Therapy Potential Risks of Opioid Therapy
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  • Not all patients derive benefit

Functional status

  • Mixed evidence on improvements in functional status
  • Limitations of evidence: pharmaceutical sponsored trials, short duration, limited population without co-morbidities or oc-occurring addiction.
  • SMART Goals




Adverse Effects

  • Sedation and Respiratory Depression
    • Opioid tolerance to these side effects over time.
    • Over-sedation occurs before respiratory depression.
    • Sleep apnea increases risks of opioid therapy. Opioids worsen untreated sleep apnea.
  • Constipation
    • Tolerance does NOT occur with respect to constipation.
  • Physical dependence:
    • Withdrawal symptoms will occur if the drug is stopped or tapered too quickly in cases of daily, high dose opioids.
  • Worsening pain
    • Withdrawal-mediated pain
    • Opioid-induced hyperalgesia in some patients (mechanism unknown).
  • Allergies and organ toxicity
    • Rare but possible

Aberrant Behavior

  • Addiction
    • Unknown incidence among patients prescribed opioids.
  • Overdose
  • Collateral risks
    • Ex. ingestion and overdose by young children.




Benyamin R, et al. Opioid complications and side effects. Pain Physician 2008; 11:S105-S120.

Brush DE. Complications of long-term opioid therapy for management of chronic pain: the paradox of opioid-induced hyperalgesia. J Med Toxicol. 2012 Dec; 8 (4): 387-92.

Furlan AD, et al. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006 May 23; 174(11):1589-94.

Kalso E, et al. Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Pain. 2004 Dec; 112(3):372-80.

Lee M, et al. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011;14;145-161.

Schug SA, et al. Adverse effects of systemic opioid analgesics. Drug Saf 1992; 7(3):200-213.