In the thick of the opioid epidemic, there is this widespread fear called “opiophobia,” which basically means people, including patients and doctors, are scared to use opioids even when they are really needed for serious medical issues. This fear comes from the idea that even a short stint on opioids for acute pain, like after surgery, often leads to addiction or worse. John A. Bumpus’s 2025 review in ACS Pharmacology & Translational Science pushes back on this, showing that the evidence supports smart use of opioids. He points out misrepresentations, potential downsides, and the importance of balanced pain relief. Bumpus calls out extreme pushes to cut out opioids entirely, stressing that the real culprits behind overdoses are illicit drugs like fentanyl, not prescriptions from doctors.
The role of ERAS programs and opioid-sparing strategies
Enhanced Recovery After Surgery (ERAS) programs, started by Henrik Kehlet back in 1997, are all about improving how patients do around surgery by making lots of small tweaks to care. Things like opioid-sparing pain management are part of that. On average, these programs cut hospital stays by about 2.35 days and save around $639 per patient. Places like the University of Iowa Hospitals and Clinics have been using them successfully since at least 2018, with detailed guides for stuff like colorectal surgery that aim to ease pain while keeping opioid use in check.
That said, Bumpus draws a line between sensible opioid-sparing and going overboard to eliminate them. Perioperative opioid stewardship, or POS, is about using opioids wisely to handle surgical pain and get the best outcomes for patients, balancing the risks of using too much or too little, not just avoiding them altogether. Multimodal analgesia mixes things like opioids, NSAIDs, acetaminophen, and local anesthetics, taking advantage of how they work together, for example, oxycodone and acetaminophen, to use lower doses and stop pain before it spikes.
He critiques opioid-free approaches that rely on high doses of non-opioids, say 1,000 mg of acetaminophen every six hours, because they ditch that teamwork and might increase the chance of breakthrough pain. Plus, those high doses come with their own risks: Acetaminophen leads to over 56,000 ER visits a year and is the number one cause of acute liver failure in the U.S., and NSAIDs can mess with your stomach, kidneys, and heart.
Low risk of OUD from short-term medical opioids
One big myth is that 6 percent to 30 percent of surgery patients end up with opioid use disorder from short-term prescriptions. Bumpus pulls from 11 reviews between 2017 and 2024 showing the actual risk in people new to opioids is super low, like 0.09 percent to 1.41 percent. Here is a quick look at key studies in a table:
| Reference | n | Risk of OUD/Overdose/Chronic Use |
|---|---|---|
| Brat et al. (2018) | 1,015,116 | 0.6 percent (opioid abuse over 2.5 years) |
| Sun et al. (2016) | 641,941 | 0.09 percent to 1.41 percent (chronic use within 1 year) |
| Shah et al. (2017) | 675,527 | 0.09 percent (dependence/overdose within 1 year) |
These huge studies knock down the “gateway” idea, saying short-term use for pain is rarely a problem. Overblown numbers often come from loose definitions of “chronic use,” like just one refill months later being called dependency. Actually, OUD covers a range, and mild cases might involve using them responsibly for something like depression, where low-dose opioids can act as quick antidepressants.
When people keep filling scripts after surgery, about 1.2 percent in new users per one big analysis, it is usually for new pain (51 percent), another surgery (40 percent), or other reasons, not addiction. Even in dental cases, real abuse is around 0.34 percent, not the hyped-up 5.8 percent.
Declining prescriptions amid rising illicit overdoses
From 2010 to 2022, opioid prescriptions in the U.S. dropped by 48.6 percent to 51.7 percent, and those from surgeons fell 58.2 percent, from 282 mg to 164 mg. For tough surgeries like knee replacements, daily morphine equivalents went down 65.3 percent, from 43.2 to 15.0. But prescription opioid deaths stayed flat, while synthetic ones, mostly illicit fentanyl, exploded.
This shows cutting prescriptions more will not fix the illicit drug problem. In Iowa, scripts dropped 60.5 percent from 2012 to 2022, but overdoses jumped 35 percent in 2019-2020, with fentanyl in 87 percent of 2021 deaths.
Unintended consequences and the need for balance
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Pushing too hard to reduce opioids can lead to people hoarding leftovers, which happens with 20 percent to 58 percent of patients, out of fear they will not get more later. Diverted scripts are rare, 0.07 percent to 0.08 percent, and might even be a safer option than street drugs laced with fentanyl.
Worse, undertreating pain affects 20 percent to 58 percent after discharge and for chronic pain, it raises suicide risks. Opiophobia, amped up by media, rules, and legal fears, makes doctors hesitate, with some states punishing legit prescribing.
Bumpus urges balance: Use evidence-based mixes with low-dose opioids, involve patients in choices, and focus on harm reduction. The goal should be good pain control, not wiping out opioids, to avoid overreacting to the crisis.
Conclusion
Opiophobia, fueled by bad info, blows up the risks of short-term medical opioids and ignores the illicit side of the epidemic. ERAS and POS can spare opioids without banning them, but extremes risk poor pain relief and other harms. Everyone involved, from patients to policymakers, needs the real facts, so opioids stay an option for kind, effective care. As Bumpus puts it, addiction from doctor-prescribed use is rare, and smart management can make lives better without the scare.
Kayvan Haddadan is a physiatrist and pain management physician, and president and medical director of Advanced Pain Diagnostic & Solutions, a multidisciplinary pain management practice in California that he founded in 2012. A physician and surgeon licensed by the Medical Board of California, he is double board-certified in pain medicine and physical medicine and rehabilitation. He is also certified in controlled substance registration through the DEA and serves as a qualified medical examiner through California’s Department of Industrial Relations Division of Workers’ Compensation.
Dr. Haddadan earned his Bachelor of Science degree from the College of Alborz in Tehran, Iran, and his medical degree from Shahid Beheshti University of Medical Sciences. He later received his Educational Commission for Foreign Medical Graduates certification in Philadelphia, completed an internship in medical surgery at Loyola University Medical Center’s Stritch School of Medicine in Illinois, and finished his residency in physical medicine and rehabilitation at the same institution. He completed his fellowship in pain medicine at California Pacific Medical Center’s Pacific Pain Treatment Center and also trained in medical acupuncture for physicians at the University of California, Los Angeles David Geffen School of Medicine.
Dr. Haddadan has contributed to 29 research publications across multiple specialties, including pain management, cardiology, pulmonology, endocrinology, gastroenterology, and infectious disease. His work has examined topics such as hyperlipidemia in high cardiovascular risk patients, hyperuricemia and gout management, type 2 diabetes and hypertension, chronic obstructive pulmonary disease and asthma therapies, influenza treatment, irritable bowel syndrome, and opioid related complications in chronic pain care. His research has also included clinical outcome studies in spinal cord stimulation and award-winning presentations on neuropathic pain management and neuromuscular disorders.
