Indications for Long-Term Opioid Therapy
Indications for long-term opioid therapy are far narrower today than they were in the past. Historically, opioids were widely prescribed for chronic non-cancer pain under the assumption that they provided sustained relief with manageable risk. Given what is known today about the risks of opioid use, the decision to initiate long-term opioid therapy—typically defined as use beyond three months—requires a far more critical, evidence-based approach.1,2
The primary indication for long-term opioid therapy is not a specific diagnosis but a clinical judgment that anticipated benefits in pain relief and functional improvement outweigh known risks. While the risks of long-term opioid use—including opioid use disorder, overdose, and death—are well established, high-quality evidence demonstrating sustained long-term benefit remains limited, with few randomized trials extending beyond short-term follow-up.1 For example, for chronic non-cancer pain, including conditions like chronic low back pain, osteoarthritis, or neuropathic pain, current guidelines emphasize that opioids should only be considered as a last resort. Instead, alternative therapies are recommended to be considered first, including nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants (e.g., SNRIs), anticonvulsants (e.g., gabapentin), physical therapy, and behavioral interventions. As a result, opioids are now considered a conditional, rather than routine, option for chronic non-cancer pain.2
Despite this general lack of long-term efficacy data, there are specific clinical contexts where long-term opioid therapy remains indicated. Opioids may be appropriate when a patient has a serious illness with a poor prognosis for returning to their previous level of function, when there are specific contraindications to non-opioid therapies, or when both clinician and patient agree that the overriding goal is patient comfort.1 Certain examples of these scenarios include pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care—situations in which the unique therapeutic goals and the balance of benefits and risks can justify long-term opioid use.1
When clinicians and patients consider the indications for long-term opioid therapy, it is vital to acknowledge the harms of both the overtreatment and undertreatment of pain. While the dangers of liberal opioid prescribing are well documented, some experts argue that withholding opioids from patients with high-impact chronic pain who have exhausted other alternatives can also cause harm, potentially increasing the risk of mental health crises or suicide.2,3 Furthermore, if the clinical indication is met to initiate opioid therapy, it must be accompanied by realistic goal-setting. Before starting therapy, clinicians and patients must establish specific, measurable treatment goals for pain and function and must clearly define an exit strategy or tapering plan if the expected benefits do not materialize.1
Ultimately, the decision to prescribe opioids long-term is highly individualized. It relies not on a rigid sequential failure of other treatments but on a careful, patient-centered assessment that ensures the specific benefits of long-term opioid therapy will meaningfully outweigh the substantial risks.
References
1. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain–United States, 2022. MMWR Recomm Rep. 2022;71(3):1–95.
2. Bicket MC, Bateman BT. Long-term opioid therapy for pain: what is known about harms–and still not known about benefits. JAMA. 2025;334(12):1057–1058.
3. Webster LR. Long-term pain therapy with opioids. JAMA. 2026 Jan 27;335(4):372–373.