Safe and

Responsible Use

of Opioids for Chronic Pain

A Patient Information Guide

Revised October 2018 V2

IB 10-791, P96791
The healthcare providers and staff at the Department of Veterans Affairs 

(VA) are concerned about your pain. We are committed to providing you 

with the best possible care.

In this patient information guide, we review:

• Information about opioid medicines

• Your pain care plan involving specific types of treatments 

and activities

• Alternatives to opioids for pain management

• Possible side effects of opioid medicines

• How to take opioids in a safe and responsible way

Introduction
1

Opioids are medicines that may be used to treat pain. Opioids also are called “opiates” or “narcotics.” Opioids 

can be dangerous, even when prescribed and taken responsibly. Taking opioids at any dose may be harmful. 

We want to make sure you have the information and strategies to keep yourself and others safe when using 

these medicines.

Prescription Opioid Medicines Include:

• Hydrocodone (Vicodin®, Lortab®, Norco®)

• Oxycodone (OxyContin®, Percocet®, Endocet®,)

• Morphine (MS Contin®, Kadian®, Oramorph SR®)

• Hydromorphone (Dilaudid®)

• Fentanyl (Duragesic®)

• Codeine (Tylenol® with Codeine #3, Tylenol® with 

Codeine #4)

• Methadone (Dolophine HCL®, MethadoseTM)

• Tramadol (Ultram®)

• Buprenorphine (Butrans®)

• Oxymorphone (Opana®)

• Tapentadol (Nucynta®)

Opioids also can come from sources other than medicines you get from your healthcare providers. These 

include medicines not prescribed to you (e.g., from family or friends) and “street drugs.” Any medicine that 

you did not get from a pharmacy with a prescription can have extra risks. The ingredients and strength may 

not be known, for example, counterfeit pills may contain fentanyl or carfentanil (“elephant tranquilizers”). It is 

important for you to inform your provider(s) about all medicines and substances you are taking as some can 

interact to cause harm, including overdose and death.

Your healthcare team will talk to you about the best ways to treat your pain. Together, you will discuss the 

goals for your treatment and how much relief you can expect from the different options. An example of a 

goal would be to improve your ability to move, exercise, and participate in activities you enjoy.

Opioids are not the most effective treatment for long-term, non-cancer pain. In fact, opioids are no longer 

recommended for the treatment of most patients with chronic pain. If prescription opioids are used, you will 

be given information on possible side effects, other risks, and monitoring needed for your safety.

Over the past 20 years, we have learned several important things about using opioids for chronic pain.

1. Tolerance

When opioids are taken daily, your body gets used to the medication. Over time, the opioid will be less 

effective at lowering your pain. Needing higher and higher doses to achieve the desired effect is a sign that 

you may be at risk for addiction and overdose and should alert you and your team to reassess your pain 

treatment plan.

2. Risks

Opioids come with serious risks that are outlined on pages 4 and 5. The most serious risks include 

respiratory depression (stopping breathing - also known as “overdose”) resulting in death, and the risk of 

developing opioid use disorder (from moderate to severe is also known as “addiction”). Increasing the dose 

of an opioid will increase the risk of opioid use disorder, overdose, and other side effects.

3. Risk increases with other health conditions, medicines, and substances

If you have health conditions such as sleep apnea, breathing problems, liver problems, or kidney problems, 

you may have a higher risk for overdose and side effects even with low doses of opioids. Drinking alcohol, 
2

using benzodiazepines, or taking other medicines that can make you sleepy can increase your risk of side 

effects and overdose. These substances are not recommended in combination with an opioid medicine.

4. Dependence

Dependence means that your body will depend on the opioid to feel normal. If you stop the opioid 

suddenly or decrease the dose too quickly, you will feel increased pain and other symptoms of opioid 

withdrawal. This may make it hard to stop even if you want to. Dependence can happen even when low 

doses of opioids are taken for acute pain, such as dental procedures or fractures, for less than one week. 

Opioids may be needed for acute pain in some situations. To reduce the risk of dependence when treating 

acute pain, opioids should be used for five days or less.

5. Opioid Use Disorder

Opioid use disorder is a chronic brain disease that develops from repeated use of opioids. In its moderate 

to severe form, it is also known as addiction and can be life-threatening. The risk of death from overdose is 

6 to 20 times greater for those with opioid use disorder than for the general population. Symptoms include 

preoccupation with and craving for opioids, continued use despite significant opioid-related problems, 

often using more opioids than intended, and other signs that one has lost the ability to control the use of 

opioids. While not every patient who develops tolerance and dependence has an opioid use disorder, these 

are two signs of increased risk of opioid use disorder. When carefully assessed, 25% to 40% of patients on 

long-term opioid therapy (more than 90 days) has an opioid use disorder.

Your Pain Care Plan

Even if opioids are used to reduce pain, they will be most 

effective when combined with other safer and more effective 

strategies. You and your healthcare team will make a pain care 

plan based on your condition and specific situation. Treatments 

may include self-care activities, non-medication treatments or 

therapies, medicines that do not contain opioids and, in some 

instances, opioid-containing medicines. Here is a list of some 

commonly used options that might be included in your pain 

care plan.

1. Self-care

These activities include everything you can do on your own 

to manage your health (including pain) and live your life as 

fully as possible.

• General Health Activities

o Develop or maintain supportive relationships.

o Get a good night’s sleep every night.

o Eat healthy foods including fruits and vegetables.

o Move your body every day and do activities you enjoy.

o Stop smoking and using other tobacco products.

o Try meditation or other relaxing activities.

• Pain Management Strategies

o Improve your posture: stand or sit up straight.

o If you are overweight, lose weight. Consider enrolling in a weight management program.

o Practice yoga, exercise, stretching, and/or Tai Chi.

o Learn and practice deep breathing and relaxation exercises.

o Use heat or cold packs on the painful areas.

o Attend pain management classes and join support groups.
3

2. Non-medication Treatments

• Behavioral Therapies

o Learn to react to pain in a way that helps you function better 

and reduce your pain, for example, Cognitive Behavioral 

Therapy (CBT), Acceptance and Commitment Therapy (ACT), 

and/or mindfulness-based therapies including meditation.

• Acupuncture

• Spinal Manipulation (Chiropractic therapy)

• Physical Therapy and Occupational Therapy

• Nerve stimulation (like a Transcutaneous Electrical Nerve 

Stimulator [TENS unit])

3. Non-opioid Medication Treatments

• Topical Treatments

o Gels, creams, ointments, or patches that are applied to the skin on a painful area, for example, 

diclofenac gel, methyl salicylate cream/ointment, lidocaine patch or ointment

• Oral Treatments

o Anti-inflammatory medicines – for muscle/bone pain

- Nonsteroidal anti-inflammatory drugs (NSAIDs), for example, ibuprofen, naproxen, meloxicam, 

etodolac, celecoxib

o Antidepressant medicines – for muscle/bone and nerve pain

- Tricyclic antidepressants (TCA), for example, nortriptyline, desipramine, amitriptyline, imipramine

- Serotonin norepinephrine reuptake inhibitors (SNRI), for example, duloxetine, venlafaxine

o Anticonvulsant medicines – for nerve pain, for example, gabapentin, pregabalin

4. Opioid Medicines

• Opioids are more effective in reducing acute pain than chronic pain

o Usually only “take the edge off” chronic pain for a short time.

o Daily use of opioids can actually make your pain worse over time.

• No matter how much you take, opioids will not take the pain away.

o Any dose can be risky, even a small dose.

o Higher doses usually cause more side effects, without reducing your pain.

• All opioids can cause respiratory depression (slow or shallow breathing) and overdose death.

• Methadone is an opioid that is sometimes used for chronic pain. Because it is so long-acting, the amount 

can build up, putting you at risk for overdose.

o Methadone can cause changes in your heart beat that you may not notice. Your heart beat should be 

monitored by electrocardiogram (EKG) testing.

o Many medicines interact with methadone and, in some cases, cause harm, including overdose 

and death.
4

5. Other Treatment Options

• You may benefit from more specialized treatments available in 

some primary care clinics or from some pain clinics.

o These treatments may include trigger point injections in areas 

of localized pain and muscle spasms, or steroid injections for 

joint pain.

• Pain clinics may provide epidural steroid injections and several 

types of pain blocks that can help some patients with spine 

conditions. Rarely, spinal cord stimulation devices or spine 

surgery may be considered.

o These interventional pain procedures are for pain conditions 

that have not or are not likely to respond to other treatments.

o They are often used with the treatments listed above (1–4).

Known Side Effects and Other Risks of Opioids

• Unsteady walking

• Increased risk of 

falls, broken bones, 

or concussion

Feeling tired, drowsy, 

or foggy

• Car accidents

• You can be arrested 

for Driving While 

Impaired/Driving 

Under the Influence

It is important to report any side effects to your healthcare team. Tell your healthcare team if side effects 

interfere with your daily activities. This information will help them to better manage your pain.

Side Effects and Other Risks of Opioids

Side Effect/Risk What This Might Mean

Sleepiness or Mental 

Confusion (slow thinking)

Opioid dose may be too high.

• Increases risk of falls and may cause problems with making decisions.

Bad Dreams or 

Hallucinations

Opioid dose may be too high, or the opioid may not be a good fit for you.

• May need to reduce opioid dose or change to a different medicine.

Constipation All opioids cause constipation that, if severe, can cause intestinal blockage.

• Laxatives may be needed; exercise, eating more fiber and drinking more 

water may help relieve constipation.

Sweating Not a harmful effect, but uncomfortable; wearing light clothing may 

decrease sweating.

Nausea and Vomiting Can happen when first starting opioids or later in treatment.

• Usually goes away with time; medicines to help reduce nausea may 

be needed.
5

Side Effects and Other Risks of Opioids

Side Effect/Risk What This Might Mean

Itching 

(possible allergic reaction)

Mild itching is a common side effect. More severe itching with hives is rare, 

but if it happens, it is typically soon after starting an opioid.

• If you get a rash or hives, call your healthcare team right away.

• If you have shortness of breath, throat swelling, or feel like you may pass 

out, tell someone to call 911 right away. This can be an allergic reaction 

and may be life-threatening.

Decreased Sex Hormones May cause less desire for sex as well as depression, anxiety, lack of energy, 

hot flashes, night sweats, loss of muscle mass, weakness, and loss of bone 

(osteoporosis).

• In men, may have less ability to have an erection.

• In women, may cause irregular menses or lack of menstrual cycle. 

Use of birth control is needed since opioids may harm a baby if you 

become pregnant.

Bone Loss Often occurs with taking opioids for months to years. Brittle bones 

(osteoporosis) may result in bone fractures.

Dry Mouth, Tooth Decay Dry mouth may be uncomfortable and, in some cases, cause tooth decay 

and loss of teeth.

• Chewing sugarless gum, sugarless candy, or ice chips can help.

• See your dentist regularly.

Worsening Pain For some people, opioids may increase pain. If this happens, a change in 

your pain treatment plan may be needed.

Opioid Use Disorder 

(moderate to severe is also 

known as “addiction”)

Can happen even when opioids are taken as prescribed and it can be 

life-threatening.

• Medication-assisted treatment for opioid use disorder (that is, 

medications and counseling) can relieve pain and other opioid 

withdrawal symptoms, decrease opioid craving, and reduce the risk of 

overdose and death.

• Medicines for opioid use disorder include buprenorphine, 

extended-release injectable naltrexone, and (when administered daily 

through an Opioid Treatment Program) methadone.

If you are concerned that you may have developed opioid use disorder, talk 

with your provider about getting treatment for opioid use disorder along 

with ongoing pain care.

Respiratory Depression and 

Overdose

Any opioid use increases risk for respiratory depression (slow or shallow 

breathing) and possible overdose and death.

As we learn more about the impact of opioid treatments, new side effects and risks may be identified. Ask 

your healthcare team if you have questions or concerns.
6

What Can You Do to Reduce Your Risk When Taking Opioids?

A good plan starts with a conversation. Your healthcare team will 

talk with you about the risks, possible benefits, and any alternatives 

to using opioids to manage chronic pain. This will be done before 

any opioids are prescribed. After answering your questions, you will 

be asked to sign an informed consent form.

Signing this form shows that you understand and agree with your 

treatment plan that includes opioids and the possible risks when 

taking them for chronic pain. You will learn about ways to reduce 

risks and increase the chance that your plan will help you manage 

your pain.

Tips to Reduce Your Risks

Tips Reasoning

ü Take all your medicines 

as prescribed.

Taking more opioid pain medicine than you need puts you at risk for side 

effects and possible overdose and death. Talk with your healthcare team 

before making any changes involving your medications.

ü Talk to your healthcare 

team if you are having 

more pain.

Do not take extra doses of opioid medication. You may run out of pills 

early and this can cause withdrawal symptoms. Taking extra doses can also 

increase your risk of overdose and death.

ü Recognize side effects. If you are having side effects that you cannot tolerate, take a lower dose or 

stop the medication, and call your healthcare team.

ü Let all your providers 

in the VA and outside 

of the VA know you are 

taking opioids.

Tell all your providers, including dentists, surgeons and specialists, that you 

are taking opioids. Taking opioids from multiple providers may lead you to 

use more than needed which can cause an overdose.

ü Tell your VA providers 

about all medicines 

and supplements you 

are taking.

Tell them about over-the-counter medicines, herbal supplements, and if 

you take medicines or substances that are not prescribed to you. Many 

medicines and substances can interact. When your provider knows 

about what you are taking, they are better equipped to make the most 

appropriate pain plan for you. This will put you at a lower risk for side effects.

ü Do not take medicines 

prescribed for someone 

else. Do not give away or 

sell your medicines.

Taking medicines that are prescribed to someone else, including a family 

member, is illegal and can put you at risk for harmful side effects and 

possible overdose and death. Keep your medicines in a safe and secure 

location. If someone steals your opioids or your opioid prescription, 

promptly report the theft to the police. Then, speak to your healthcare team 

about your options because early refills may or may not be approved.

ü Avoid alcohol and 

street drugs.

Combining opioids with alcohol, marijuana, or using “street drugs” can cause 

severe harm or death. It is important that your provider know about all 

substances you are taking. Your provider cannot safely continue prescribing 

opioids if using these substances creates a safety concern.

ü Be informed about 

the risk of developing 

opioid dependence.

Anyone taking opioids can develop dependence. The risk goes up the 

longer you take opioids and with higher doses. Treatments are available 

for opioid dependence. Talk to your healthcare team if you feel this may be 

happening to you.
7

Tips to Reduce Your Risks

Tips Reasoning

ü Talk to your provider 

about decreasing your 

opioid medication.

If you have been taking opioids for more than a few weeks, your body has 

become used to them (tolerance). If you stop them all at once, you can have 

withdrawal symptoms. Your healthcare team will work with you on a plan to 

slowly reduce (taper) your opioid medicines. If you have any problems, let 

them know.

ü Learn how to prevent 

overdose and ask for 

naloxone. Get support 

from your family 

and friends.

Talk to your healthcare team about your overdose risk. Learn how to 

decrease your risk and what to do if you overdose. Naloxone can reverse the 

effects of opioids during an overdose. Your family members, friends, and 

roommates should all receive training on how to recognize an overdose and 

use naloxone. Keep naloxone with you at all times.

ü Use caution when driving 

or operating machinery.

Sleepiness and confusion are common side effects from opioids. Do not 

drive or operate machinery if you feel sleepy or confused. Alcohol and other 

sedating medicines can increase these symptoms. State laws may limit the 

type of work you can do if you take opioids.

ü Dispose of unused 

opioid medicines.

Ask your pharmacy for instructions for safe disposal of any unused 

opioid medicines.

Stopping Opioid Therapy Through Tapering

You or your provider may decide that opioid therapy is not right for you and that the dose of the opioid 

should be reduced (tapered) and eventually stopped.

If you and your provider decide to reduce your opioids, your provider will try to prevent or lessen any 

withdrawal symptoms. Decreasing slowly makes it easier to stop opioid medicines. Unless there are urgent 

safety concerns, a gradual reduction helps you to avoid withdrawal symptoms.

Your provider will explain how to slowly lower the dosage of your opioid medication. Your provider will 

discuss other methods to help reduce your pain and include these in your new pain care plan.

When slowly reducing your opioid medication, do not increase your dose or take extra doses. Your body is 

no longer used to higher doses and you may overdose. Follow the plan and discuss what you are feeling 

with your healthcare team.

If you have extra opioids left over from your prescription, ask your pharmacy for instructions about safe 

disposal of any unused opioid medicines.
8

Working Together with Your Healthcare Team

Communication is key! You are a respected member of your healthcare team. Honest communication will 

help you achieve your healthcare goals.

Be honest when you give your health, drug, and alcohol history. Let your provider know about drug or 

alcohol use in your family.

Ask your provider about any questions or concerns you have about your pain care plan.

Tell your VA providers about opioid prescriptions from other providers and the pharmacies you use if you 

are not getting all prescriptions filled by the VA.

Emergency rooms and urgent care clinics are not good places to get treatment for chronic pain. If you 

must go to an emergency room, tell the provider about your pain care plan.

Follow your pain care plan.

When you start taking opioids, you may see or talk to your provider or members of your healthcare team 

more frequently—in some cases, once per week. Once the opioid dose is stable, you will need to connect 

with your healthcare team at least every three months.

Try to keep all your pain care and other clinic appointments. Please update your contact information at 

every visit so your healthcare team can stay in contact with you.

Urine drug testing is part of the pain care plan when opioids are prescribed. These urine drug tests will 

show which substances and medicines you have been taking. This can help determine if there are added 

risks for side effects or overdose from opioids when they are used with other medicines or substances 

(e.g., marijuana, street drugs, and alcohol). The VA does not use these tests for law enforcement or 

employment purposes. Some urine test results may require your healthcare provider to change your pain 

care plan based on concerns for your safety.

Your provider, nurse, and pharmacist are required to track when you renew and refill opioids—both within 

and outside the VA—as part of the prescription drug monitoring program (PDMP). Laws are established in 

each state about how often providers are required to check the PDMP. VA and other healthcare providers 

may get and share information about your opioid prescriptions without your specific consent.
9

Filling Opioid Prescriptions

Ask your healthcare team how to renew your 

opioid prescriptions.

If there is a problem getting your opioids by mail at your 

address, you may have to fill your opioid prescriptions 

in person according to the plan you make with your 

healthcare team.

When ordering by mail:

• Contact your healthcare team or pharmacy at least 10 

business days before it is due.

• Make sure that you or someone you trust gets the 

package when it is delivered.

Plan ahead! The pharmacy may be closed on weekends, 

holidays, and after regular clinic hours.

Protect Your Opioids from Damage, Loss, or Theft

Keep your opioids in a safe, locked place, out of reach of family, children, visitors, and pets.

Always keep your opioids in their original labeled container.

If you travel, carry your current labeled container of opioids with you in case you are asked questions by 

airport security or law enforcement.

If you are concerned about the safety of storing medicines in your home, talk to your healthcare team.

If someone steals your opioids or your opioid prescription, promptly report the theft to the police. Then, 

speak to your healthcare team about your options because early refills may or may not be approved.

At the VA, we are committed to helping you achieve the goals of your pain care 

treatment plan in a way that keeps you and your friends and family safe. If you have 

any questions, please contact your VA healthcare team.

Please call ________________ with any questions or concerns.

Veterans Crisis Line

1-800-273-TALK (8255) or Text - 838255
Revised October 2018 V2 IB 10-791, P96791