Doctors prescribe opioids because they remain the most effective medications available for treating severe pain, particularly when other options have failed or aren’t strong enough. That said, the decision to write an opioid prescription is far more cautious and structured than it was a decade ago. The national opioid dispensing rate dropped from 46.8 prescriptions per 100 people in 2019 to 35.4 per 100 in 2024, reflecting a significant shift in how physicians weigh the benefits against the risks.
The Main Reasons Opioids Are Prescribed
The most straightforward reason is pain that’s too severe for over-the-counter medications or other treatments to control. This includes pain after major surgery, serious traumatic injuries like broken bones, and severe burns. In these situations, opioids are typically prescribed at the lowest effective dose for the shortest time needed, often just a few days.
Cancer pain is another major indication. Up to two-thirds of people with cancer experience pain severe enough to need a strong opioid. The World Health Organization uses a three-step “pain ladder” for cancer treatment: mild pain gets basic painkillers, moderate pain gets weaker opioids, and severe pain gets strong opioids like morphine. For patients with advanced or progressive disease, oral morphine is recommended as the first-line treatment, with additional fast-acting doses available for breakthrough pain episodes.
Palliative and end-of-life care represents a category where the risk calculus changes entirely. When someone is dying and in significant pain, the long-term risks of opioid dependence are no longer the primary concern. Comfort becomes the goal, and opioids are often the most humane option available.
Chronic non-cancer pain, things like severe arthritis, nerve damage, or back injuries, is the most debated category. Current CDC guidelines state that opioids should only be considered here when the expected benefits for both pain relief and physical function outweigh the risks, and only after non-opioid options have been tried first.
How Opioids Actually Block Pain
Your body has its own pain-management system built on natural opioid-like chemicals, including endorphins. Prescription opioids work by hijacking this system. They bind to the same receptors your endorphins use, located throughout your brain, spinal cord, and the pathways that carry pain signals between them.
When an opioid molecule locks onto one of these receptors, it triggers a chain reaction inside the nerve cell. The cell becomes less excitable by changing how it handles potassium and calcium, two minerals that control electrical signaling in nerves. Potassium flows increase, which quiets the cell down. Calcium flows decrease, which prevents the cell from passing pain signals along to the next neuron. The net effect is that pain messages get muted before they reach your conscious awareness.
This mechanism is also why opioids produce side effects like drowsiness, slowed breathing, and euphoria. Those same receptors exist in brain areas that control alertness, respiration, and reward, so the drug doesn’t just target pain in isolation.
Why Not Just Use Non-Opioid Painkillers?
For many types of pain, non-opioid alternatives work just as well. The CDC’s 2022 guidelines state plainly that nonopioid therapies are at least as effective as opioids for many common types of acute pain. Research on post-surgical dental pain, for example, has found that a combination of ibuprofen and acetaminophen performs comparably to hydrocodone (a common prescription opioid) combined with acetaminophen, and that the ibuprofen-acetaminophen combination is actually more effective than either drug alone.
The problem is that these alternatives have a ceiling. Anti-inflammatory drugs like ibuprofen can cause stomach bleeding and kidney problems at high doses. Acetaminophen can damage the liver. Neither class of drug is strong enough to manage the kind of pain that follows open-heart surgery, a severe fracture, or advanced cancer spreading into bone. In those situations, opioids fill a gap that no other available medication can.
How Doctors Assess Risk Before Prescribing
Prescribing an opioid today involves more screening than most patients realize. Before writing a prescription, clinicians are expected to review the patient’s history in a Prescription Drug Monitoring Program, a state-run database that tracks every controlled substance prescription a person has received. This lets the doctor see whether the patient is already getting opioids from another provider, whether they’re on benzodiazepines (which dangerously amplify opioid effects), and what their total daily opioid dose looks like across all prescriptions. Every state maintains one of these databases, and the CDC recommends checking it before initiating opioid therapy.
Many doctors also use formal risk-screening questionnaires. The most common is the Opioid Risk Tool, a brief self-report form that takes less than a minute to complete. It scores patients based on factors like family history of substance abuse, personal history of alcohol or drug use, age (people between 16 and 45 are at higher risk), history of certain psychological conditions like bipolar disorder or ADHD, and history of preadolescent sexual abuse. A score of 3 or below suggests low risk. A score of 4 to 7 is moderate risk. Eight or higher flags a patient as high risk for developing problematic opioid use. Other screening tools exist as well, including longer questionnaires that assess current misuse patterns in patients already taking opioids.
These tools don’t determine whether someone gets a prescription or not. A high-risk patient with a shattered femur still needs pain management. But the score shapes how the doctor structures the prescription: shorter supply, more frequent follow-ups, closer monitoring, and a faster transition to non-opioid alternatives.
What Current Guidelines Say
The CDC’s 2022 Clinical Practice Guideline, which most U.S. prescribers follow, lays out several key principles. Doctors should maximize non-drug treatments (physical therapy, nerve blocks, cognitive behavioral therapy) and non-opioid medications before turning to opioids. When opioids are needed for acute pain, the prescription should cover only the expected duration of severe pain, not a generous “just in case” supply. For patients who have never taken opioids before, the starting dose should be the lowest effective amount.
Before prescribing, doctors are expected to have a direct conversation with the patient about realistic benefits and known risks. This is a shift from earlier decades when opioids were sometimes handed out with little discussion. The guidelines also emphasize that the decision should weigh both pain relief and functional improvement. If an opioid reduces pain scores but doesn’t help a patient move better, sleep better, or return to daily activities, the benefit may not justify the risk.
Geographic Variation in Prescribing
Where you live significantly affects how likely you are to receive an opioid prescription. In 2024, Arkansas and Alabama had the highest dispensing rates at roughly 68 to 69 prescriptions per 100 people. Hawaii had the lowest at 21 per 100, followed by California at about 22 per 100. That means a resident of Arkansas is more than three times as likely to fill an opioid prescription as someone in Hawaii. These differences reflect variations in local prescribing culture, state regulations, access to alternative pain treatments, and the demographics and health profiles of different populations.