What are the risks associated with long-term use of narcotics (opioids)?

From the Guidelines

Long-term narcotic use is associated with a significant increase in risk for opioid use disorder, overdose, all-cause deaths, fractures, falls, and myocardial infarction, and therefore, should be prescribed with caution and only when benefits outweigh the risks. The CDC clinical practice guideline for prescribing opioids for pain - United States, 2022, found insufficient evidence to determine long-term benefits of opioid therapy for chronic pain and found an increased risk for serious harms related to long-term opioid therapy that appears to be dose-dependent 1. Some of the risks associated with long-term narcotic use include:

• Opioid use disorder, with adjusted odds ratios of 15, 29, and 122 at low, medium, and high opioid dosages, respectively 1
• Overdose, which can be fatal
• All-cause deaths
• Fractures and falls, particularly in older adults
• Myocardial infarction
• Gastrointestinal adverse events, somnolence, dizziness, and pruritus
• Hormonal imbalances leading to reduced testosterone levels, sexual dysfunction, and irregular menstruation
• Immune system suppression, making users more susceptible to infections
• Hyperalgesia, a condition where pain sensitivity increases despite taking pain medication
• Cognitive impairment affecting memory, attention, and decision-making

When considering long-term narcotic use, healthcare providers should:

• Determine with patients how functional benefit will be evaluated and establish treatment goals 1
• Assess and follow function, pain severity, and quality of life using tools such as the three-item PEG assessment scale 1
• Discuss expected benefits, common risks, serious risks, and alternatives to opioids with patients before starting or continuing opioid therapy 1
• Involve patients in decisions about whether to start opioid therapy and ensure that patients are aware of the potential risks and benefits 1
• Regularly evaluate the benefits versus risks for patients requiring long-term therapy and consider tapering or discontinuing opioids if benefits do not outweigh risks 1

From the FDA Drug Label

Use of opioids for an extended period of time may influence the hypothalamic-pituitary-gonadal axis, leading to androgen deficiency that may manifest as low libido, impotence, erectile dysfunction, amenorrhea, or infertility

• The risk with long term narcotic use includes androgen deficiency, which may manifest as: + Low libido + Impotence + Erectile dysfunction + Amenorrhea + Infertility The causal role of opioids in the clinical syndrome of hypogonadism is unknown 2

From the Research

Risks Associated with Long-Term Narcotic Use

• Long-term use of opioids can lead to physical dependence, tolerance, and addiction 3
• Common side effects of opioid administration include sedation, dizziness, nausea, vomiting, constipation, and respiratory depression 3
• Less common side effects may include delayed gastric emptying, hyperalgesia, immunologic and hormonal dysfunction, muscle rigidity, and myoclonus 3
• The combination of opioids with non-opioids may increase analgesic potency, reduce tolerance and dependence, and minimize side effects 4

Clinical Concerns and Implications

• Prescription opioid misuse has increased to epidemic proportions, with substantial increases in prescription opioid use and corresponding increases in treatment admissions for problems related to opioid misuse 5
• The use of opioids in the treatment of pain poses a significant clinical challenge, with competing pressures to diagnose and treat pain syndromes and identify individuals at risk for addictive disorders 5
• Long-term opioid use may have significant effects on the endocrine, immune, cardiovascular, respiratory, gastrointestinal, and neural systems, increasing the risk of fractures, infections, cardiovascular complications, and mortality 6

Long-Term Course of Opioid Addiction

• Opioid addiction is associated with excess mortality, morbidities, and other adverse conditions, with a chronic disorder characterized by frequent relapses 7
• Longer treatment retention is associated with a greater likelihood of abstinence, whereas incarceration is negatively related to subsequent abstinence 7
• Maintaining opioid abstinence for at least five years substantially increases the likelihood of future stable abstinence 7