The World of Pain project, an investigative collaboration involving The Examination and 10 media partners, reveals that pharmaceutical companies are using tactics long discredited in the U.S. to sell opioids internationally. Here’s why doctors are moving away from recommending opioids for chronic pain.

What is chronic pain?

Medical experts define chronic pain as pain that lasts for more than 12 weeks or that persists long after recovery from an injury or an illness. The pain may be constant or may come and go, and it can affect any area of the body. Common types of chronic pain include joint pain (arthritis), back pain, neck pain, headaches and migraines, testicular pain, muscle pain (including fibromyalgia) and pain caused by cancer or by damage to the nervous system.

Chronic pain differs from acute pain, which lasts for a week or two and ends once the underlying cause — such as tissue damage, injury or illness — is resolved.

Acute pain is sometimes described as “useful pain,” because it has a clear, protective function, said Cormac Ryan, professor of rehabilitation at Teesside University. “You put your hand on a hot surface, and it makes you pull it away. If you fall over and break your leg, the pain stops you from getting up and continuing to run on it and continuing to displace the fracture. It’s a great protector,” he said.

Acute pain can become chronic if the underlying medical cause, like cancer, endometriosis or arthritis, is not managed, or if there is an ongoing injury or inflammation in the body. But for many chronic pain patients, doctors cannot find an underlying injury or illness. “That does not mean that they're faking it or that they do not have pain,” Ryan said. “They absolutely have pain that is 100% real, but it’s due to the body’s systems becoming overprotective.”

Chronic pain can affect almost every aspect of a person’s life. It can hamper physical activity and lead to depression, anxiety and insomnia, which can make the pain even worse. This often creates a cycle that is difficult to break, and patients suffering from chronic pain are at increased risk of suicidal thoughts and behaviors, studies show. 

Chronic pain can also be linked to a lack of resources and to gender difference: People who deal with chronic pain tend to live in more disadvantaged areas, and women are affected more than men. This exacerbates the existing health inequities for those marginalized and disadvantaged groups.

How common is chronic pain?

Chronic pain is estimated to affect one in four adults globally, which is higher than the number of people that develop cancer and diabetes. 

One in 14 adults in the United States experiences “high-impact” chronic pain that limits their life or work activities, according to the U.S. Centers for Disease Control and Prevention.

The condition is a major burden for the person suffering, their families, health care systems and economies worldwide. It is the biggest contributor to disability globally, and it is projected to rise in many regions of the world with increases in obesity, sedentary lifestyles and an aging population.

What are opioids and why are they not always appropriate to treat chronic pain?

Opioids are a class of drugs that block pain signals between the brain and the body. They include prescription medications like oxycodone, morphine, codeine, buprenorphine and tramadol and illicit drugs like heroin. 

They can produce feelings of euphoria, or a “high,” which is why they are misused. They also carry side effects like drowsiness, confusion, nausea, constipation and an increased sensitivity to pain. At high doses, they can slow breathing — which can lead to death. 

Most patients taking opioids long term will develop physical dependence and will suffer withdrawal symptoms if they stop taking the drugs. The withdrawal symptoms might include uncontrollable crying, diarrhea, nausea and vomiting, muscle aches, sensitivity to light, insomnia, rapid breathing, fast heart rate and sweating.

Patients develop tolerance to opioids, needing higher and higher doses to achieve the same effect. Some people will become addicted, developing “opioid use disorder” and continuing to use the drugs despite significant negative effects on their lives. 

In the 1990s and early 2000s, opioids became the mainstay for treating pain in the United States, despite very limited evidence to support their long term benefits, according to the CDC. 

Aggressive pharmaceutical marketing fueled a surge in prescriptions that led to widespread addiction and hundreds of thousands of overdose deaths in the U.S., prompting a global reassessment of prescribing practices. Opioids are still recommended for cancer and end-of-life care, but they are no longer routinely recommended for non-cancer chronic pain conditions.

In many countries, opioids are still overprescribed because health professionals and the public’s understanding of pain is outdated, Ryan said.

A biomedical model, which focuses on taking pills or having surgery to address health issues, can be effective against diseases such as polio, smallpox, cancer and COVID-19. For centuries, health professionals have put pain in that same category — considering it the result of injury. But, Ryan said, today’s understanding of what causes pain is different.

Pain is now considered “biopsychosocial,” which means it’s influenced by biological, psychological and social factors, according to the CDC. Thus, many chronic pain experts say, a biopsychosocial treatment model is more effective. This approach treats the issue in diverse and holistic ways, which vary according to the type of pain and its underlying cause.

Why were pharmaceutical companies blamed for the U.S. opioid addiction crisis?

Pharmaceutical companies were widely blamed for the U.S. opioid epidemic. Their aggressive marketing and misleading claims contributed to the over-prescription of opioids. In the late 1990s, Purdue Pharma marketed its new OxyContin product, a slow release form of oxycodone opioid, as less addictive than other prescription opioids. This statement was later proven to be false and the U.S. Food and Drug Administration (FDA) was criticized for its role in approving these drugs without adequately considering their potential risks.

Purdue and other companies promoted their drugs to doctors as a safe, long term solution for chronic pain, even though there was little evidence to support their long-term use outside of cancer and end-of-life care. Between 1999 and 2010, sales of opioids in the U.S. quadrupled, according to the CDC, representing a significant departure from the established medical practices before this period. 

The companies also fostered close relationships with prominent doctors, universities, patient advocacy groups, professional societies and lawmakers, which facilitated the broad promotion of opioids. Regulatory bodies, hampered by limited methods to monitor or manage risks after drugs have been approved, were often unable to mitigate the harm caused.

As prescription opioid addiction surged, heroin markets expanded, and the crisis worsened with the introduction of synthetic opioids like fentanyl. The impact of this crisis has been devastating, with more than 600,000 opioid-related deaths in the U.S. and Canada since 1999, according to the Lancet medical journal.

How can chronic pain be more effectively treated?

Guidelines from an independent public body in the U.K. call for doctors to recommend exercise, psychological therapies like cognitive behavioral therapy (CBT), acupuncture and antidepressants. Doctors should explain to patients that antidepressants can help with pain relief even in people who have not been diagnosed with depression. Patients should also be educated about chronic pain, how it might fluctuate and how there are things that can improve quality of life even if the pain doesn’t improve. Their goals and priorities should be discussed, as well as a plan for flare-ups.

The U.K. National Institute for Health and Care Excellence (NICE), which reviews evidence to produce national treatment guidelines, released in 2021 recommendations for managing chronic primary pain — persistent pain that has no underlying cause. NICE was clear that opioids, as well as a long list of other pharmaceuticals (including the addictive drugs gabapentinoids and benzodiazepines) should not be initiated for chronic pain as there was evidence that their long-term use caused harm — and there was no evidence of their effectiveness. 

Recommendations to exercise and incorporate psychological therapies can be difficult for some patients, and their doctors, to understand and accept, Ryan said. “If you have a view that your pain is due to, for example, a ruptured disc, then, understandably, the best treatments we have don't make a lot of sense. You know, you might think to yourself, well, what's cognitive behavioral strategies going to do for my ruptured disc? How is education going to make my ligaments come back together? 

“That misunderstanding or that misconception around how pain works, creates a really significant barrier to people making, and health care professionals making, the right choices for the management of their care.”

Patients should be supported to come off opioids if they were not improving their pain and were causing harmful side effects, the guidelines said. 

Multiple experts said patients often feel better after coming off opioids; they feel less “like a zombie” and like they have their life back. “It’s about asking, ‘How well are you actually doing on those tablets? Is your pain any better? Are they actually serving you?’ Often, the answer is no,” said Lee Vaughan, a chronic pain patient and founder of the U.K.-based Partnering Pain support group.

When are opioids okay?

The broad recommendation against opioids in the NICE guidance was qualified: If the patient reported that the drugs were helping them, were on a safe dose and experienced no side effects, they should be supported to continue taking them.

Dr. Cathy Stannard, a former consultant in pain medicine who led the creation of the NICE guideline, stressed that though there is no evidence that opioids are effective long term for chronic pain, patients that are getting benefit should not be taken off. “I think this has caused concern in patient communities,” she said. “But if somebody with chronic primary pain is already taking opioids in a safe dose, and they feel that they're helpful and don't want to stop, that's okay.” 

There is no one overarching guideline for chronic secondary pain, where an underlying cause has been found. But NICE does not recommend opioids be used long term for low back pain, osteoarthritis, nerve pain or endometriosis, though each doctor must assess the individual needs of the patient in front of them.

Dr. Benjamin Ellis, a consultant rheumatologist at Imperial College Healthcare Trust in London, said he advises some of his arthritis patients to take opioids occasionally if it enhances their quality of life and they are carefully monitored. 

“So lots of people with arthritis will say, during the week, I have a week of activities to do, which might involve on Tuesdays, I go for a swim. On Thursdays, that's my classroom day, when I am on my feet all day. And on Saturdays, the grandchildren come around, and on those days, I really need something extra to help me recover from the activity, or to take before during the activity, to get me through it.

“So it might be long term usage, but it's long term judicious usage,” he said. 

In the U.S. the CDC released a clinical practice guideline for prescribing opioids for pain in 2022. Like NICE’s guideline, it was also clear that non-opioid therapies should be the first line treatment. These included exercise, psychological interventions, complementary therapies like mindfulness and yoga, and rehabilitation centers that combine a range of treatments. 

Over the counter drugs like acetaminophen (paracetamol), ibuprofen and aspirin could be used, antidepressants for fibromyalgia, anticonvulsant drugs for nerve pain and topical creams for localized pain.

Opioids should only be considered if the benefits outweigh the risks, the CDC said.

How can opioids be used safely to treat pain?

If opioids are deemed necessary, clinicians should start with the lowest dose and increase it slowly. Immediate-release formulations, rather than extended-release formulations, should be used initially for chronic pain. Purdue Pharma’s OxyContin is one of the most notorious extended-release opioids. Extended-release opioids should be reserved for pain severe enough that it requires daily, around-the-clock, long-term opioid treatment, according to the U.S. Food and Drug Administration.

Patients should also be regularly monitored for adverse effects, and signs of misuse, the guideline said. Naloxone, which reverses the effects of opioid overdose, should be prescribed to patients at risk of overdoses, including those that are on high doses of opioids, have a history of substance abuse or that are also taking benzodiazepines.

Those experiencing more harm than benefit from opioids should be supported to come off the drugs using a slow tapering approach, reducing the dosage by 10% per month or slower to minimize withdrawal symptoms. They should be given ongoing support like counseling and alternatives to manage their pain.

The CDC acknowledged that previous guidelines, particularly one introduced in 2016, had been misapplied and led to patients being tapered off or having their opioids stopped too abruptly, causing significant harm. The unmanaged pain and withdrawal from prescription drugs sometimes drove patients to seek out illicit drugs or to become suicidal, it said.

Dr. Barry Miller, a consultant in anesthesia and pain management and dean of the U.K.’s Faculty of Pain said it was “inappropriate” that patients had their opioids forcibly reduced, leaving them in a worse situation that they might be in before “simply on the basis the fact that there was a generic worry about their use.” 

He praised the move towards more thoughtful use of opioids, but said better access to treatments was needed for chronic pain patients globally. As a patient, you “may have had a multitude of medical people giving you different answers, none of which solved your problem. And then how do you cope without your entire life imploding?” he said.

“These are people who've fallen through most of the cracks of most healthcare systems.”