Few topics in medicine generate more emotion than opioid medications.
As an interventional pain management physician, I understand why.
Every day I meet people living with severe pain. Many have exhausted countless treatments before arriving in my office. Some have undergone multiple surgeries. Others have tried years of physical therapy, injections, medications, chiropractic care, acupuncture, and nearly everything else imaginable.
Many simply want relief.
So when patients discover that I generally discourage long-term opioid therapy, they often wonder why.
The answer has nothing to do with judgment.
It has everything to do with what I have witnessed during my career and what decades of scientific research have taught us about chronic pain.
This Isn’t About Addiction
Whenever opioid medications are discussed, addiction quickly becomes part of the conversation.
Unfortunately, this often creates anxiety.
Patients worry they are being labeled as addicts simply because they need pain medication.
That is not how I approach my patients.
Substance use disorder is a medical condition deserving of compassion, dignity, and specialized treatment. People struggling with addiction deserve care—not judgment.
But addiction is actually not the primary reason I hesitate to prescribe opioids for chronic pain.
The reason is something many patients have never heard explained.
The Problem Is That Opioids Can Increase Pain Over Time
This seems completely backwards.
How could a medication that relieves pain eventually make pain worse?
The answer lies in how our nervous system adapts.
Our bodies naturally produce chemicals called endorphins that bind to opioid receptors throughout the brain and spinal cord. These natural pain-relieving chemicals help us cope with injury and recover from physical stress.
Prescription opioids—such as oxycodone, hydrocodone, morphine, and fentanyl—work on these very same receptors.
In fact, they are extraordinarily effective.
I often tell my patients something that surprises them:
Opioids are among the most powerful pain medications ever developed.
Anyone who says otherwise is simply not being honest.
For acute pain—a broken bone, major surgery, severe trauma—they are remarkable medications.
The problem begins when they are used every day for months or years.
Over time, the nervous system becomes less responsive. Higher doses become necessary to achieve the same level of relief. At the same time, many patients develop a phenomenon known as opioid-induced hyperalgesia, in which the nervous system actually becomes more sensitive to pain.
Ironically, the medication intended to decrease pain may eventually amplify it.
Why This Makes Treating Chronic Pain So Difficult
One of the most challenging conversations I have is with someone who has been taking opioid medications for ten or fifteen years.
They often tell me:
“Doctor, these medications help me every day. How can they possibly be making me worse?”
It’s a completely reasonable question.
After all, if a medication provides several hours of relief multiple times a day, it naturally feels helpful.
But chronic pain is different from temporary pain.
The goal is not simply getting through today.
The goal is improving function, restoring movement, and maximizing health over the coming years.
Those are two very different objectives.
My Goal Isn’t Simply Less Pain
My philosophy has always been simple.
Pain relief is important.
Quality of life is even more important.
If a treatment decreases pain today but gradually increases disability, dependence, inactivity, hormonal dysfunction, constipation, sleep disruption, falls, cognitive impairment, and overall pain sensitivity, then we have to ask an uncomfortable question:
Is this truly helping the patient?
In many cases, I believe the answer is no.
I Believe in Treating Pain at Its Source
Rather than relying primarily on medications, my practice focuses on identifying the underlying generators of pain whenever possible.
That may involve:
- Epidural steroid injections
- Radiofrequency ablation
- Peripheral nerve stimulation
- Spinal cord stimulation
- Minimally invasive lumbar decompression
- Physical rehabilitation
- Strength restoration
- Improving movement patterns
- Lifestyle interventions
None of these therapies are perfect.
But they share an important goal:
Helping patients become healthier instead of becoming increasingly dependent on medication.
Every Patient Is Different
Medicine is rarely black and white.
There are patients with severe cancer pain who absolutely benefit from long-term opioid therapy.
There are patients receiving palliative or hospice care whose comfort should always come first.
There are rare chronic pain conditions where opioids may still have an appropriate role.
Good medicine recognizes exceptions.
My philosophy is not that opioids should never be prescribed.
My philosophy is that they should be prescribed thoughtfully, cautiously, and only when the expected long-term benefits clearly outweigh the long-term risks.
Walking the Middle Path
One of the hardest realities of pain medicine is balancing compassion with good judgment.
When someone’s pain increases, the natural instinct is to increase the medication.
Sometimes that is appropriate.
Often it becomes the first step toward a cycle of escalating doses with diminishing benefit.
Instead of continually asking, “How do we increase the medication?”
I prefer asking:
“How do we improve the person?”
Can we strengthen muscles?
Can we improve mobility?
Can we calm irritated nerves?
Can we reduce inflammation?
Can we improve sleep?
Can we restore confidence in movement?
Can we identify a procedure that addresses the true source of pain?
Those questions often produce better long-term outcomes.
Compassion Comes Before Prescription
Perhaps the biggest misconception about physicians who prescribe opioids cautiously is that we don’t understand pain.
Nothing could be further from the truth.
The reason I set boundaries is not because I care less.
It’s because I care about where my patients will be five years from now—not just five hours from now.
Every recommendation I make is guided by the same question:
What gives this person the greatest opportunity to regain function, independence, and long-term health?
Sometimes that includes medication.
Sometimes it includes procedures.
Sometimes it includes rehabilitation.
Most often, it includes a personalized combination of all three.
My goal has never been to simply prescribe less medication.
My goal has always been to help people live better lives.