Abstract
Opioids occupy a paradoxical position in contemporary medicine: they remain among the most effective analgesics for acute and cancer‑related pain, yet their long‑term use in chronic non‑cancer pain is associated with substantial risks, including misuse, dependence, overdose, opioid‑induced hyperalgesia, and endocrine dysfunction.1-3 Opioid‑related morbidity and mortality have risen exponentially in North America, and although the increase in Europe has been less pronounced,4-6 it has nonetheless placed internal medicine, family medicine, and pain physicians—those most involved in chronic pain care—in an increasingly difficult position. Patients with chronic pain frequently present with multimorbidity, psychological vulnerability, and social instability, further complicating opioid prescribing decisions. 1,2
This narrative review synthesizes current evidence on the limitations of traditional prescribing models, the importance of mechanism‑based pain assessment, and the influence of patient beliefs, expectations, and psychological factors on opioid outcomes.7-9 It examines epidemiological trends, the evolving understanding of opioid‑induced hyperalgesia, and the role of structured monitoring, opioid stewardship, and harm‑reduction strategies in mitigating risk.2,6 The review also outlines practical clinical recommendations for patient selection, risk stratification, informed consent, initiation, monitoring, and discontinuation.10,11
Navigating the opioid paradox requires individualized, biopsychosocial, and safety‑focused approaches that balance analgesic benefit with the potential for harm. A shift toward shared decision‑making, functional goal‑setting, and consistent monitoring is essential for safer opioid use and for the future of clinical practice in chronic pain management.