Depending on who you ask, opioids are anywhere from the worst drug you could possible prescribe, to a necessary evil, to the best shot at treating a lot of suffering patients.
Opioid addictions are, sadly, quite common. They're also quite dangerous, with opioid-related deaths on the rise. They have some nasty side-effects. They're also becoming a mainstay of low-level criminal activity.
And worst of all, they don't seem to be all that effective. Perhaps there's a selection bias, but I haven't met too many patients who had good pain control on large doses of narcotics - a few who seem to do alright on small amounts, usually low-intensity narcotics like Tramadol. Undoubtedly there's some sampling bias there, plus those with greater pain may require stronger opioids. However, I've yet to really see strong opioids as being a satisfying answer to chronic pain.
At this stage in my career, I've seen a few different attitudes towards narcotic prescription, underlining the fact that there really is no established standard for their use, and highlighting that I may have a lot of leeway to dictate my own prescribing tendencies when I eventually have to make these calls myself. I'm nowhere near a finalized or even satisfying answer to the question "when should I prescribe opioids, and how?", but here are my initial thoughts.
1) Have an exit strategy
I've yet to see a glaring example of someone callously giving a patient an opioid addiction, but plenty of examples of a physician setting a patient to develop one incidentally. Narcotics are insidious in the way they trap patients and providers - a short run of narcotics gets extended, or a small dose gets increased, over and over again, until the patient is on long-term, high-dose opioids. It's far too easy for patients to believe that they need a higher dose and for physicians to see no good alternative to providing it.
Therefore, I think it's essential to have an endgame in mind when starting or increasing narcotics. If there's no timeline to how or when an opioid prescription will be ceased, then the snowball towards higher doses seems to be pretty difficult to avoid. In some cases, the "how and when" narcotic use is ceased will come with the death of the patient. That can absolutely be a valid exit strategy. However, for the large number of individuals who aren't meant to die on these medications, I'd like to have a plan to stop the medications
2) Use concurrent therapy
Opioids aren't a long-term solution to most pain. They certainly don't do anything to cure pain, only to (temporarily) mask it. However, they can relieve it for a time while other factors play out, so they do have a role. In many cases, time itself is a cure. In others, a more active approach is necessary. Even when there aren't treatable physical symptoms, mental health is an important component to address. Pain can practically go away when patients are happy and have a positive attitude. It can become crippling when despair sets in. Mental health issues might not cause pain (with some exceptions...) but it can be a meaningful modifier. At this point, I don't see much value in starting opioids if there aren't other avenues being actively explored.
3) Consider weening patients off opioids
In the simple case of one patient with one provider, opioid prescribing seems very straight-forward. However, medicine's a team sport and that means not everyone plays the same way. It's very common for patients to get started on opioids by a provider they'll never see again, or who will pass on responsibility for pain management before it's properly managed. Presumably, that initiator of the opioid didn't have an exit strategy or sufficient concurrent therapy, but that shouldn't excuse inaction on your part as the now-responsible prescriber.
Opioids don't have a good evidence-base behind their long-term usage. If a patient is on opioids for an extended period already, without sufficient response, doubling-down by increasing or even maintaining their opioid dose isn't likely to help. It's worth a trial ween. It's not going to help their pain - and will increase it in the short term - but it could save them from a number of side-effects and allow the patient (and you) to focus on more effective interventions.
Anyway, opioid use in medicine in a deep, complex problem without an easy solution. You'll find similar opinions from many individuals and groups in medicine. You'll also find many opposing views from individuals and groups in medicine. I don't claim to have any novel insight into this problem. However, these decisions will be my responsibility reasonably soon, so it's time to start forming a practical approach.
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