18 Nov 2025
- 8 Comments
Opioid Risk Assessment Calculator
This tool helps you calculate your morphine milligram equivalent (MME) dose and assess your risk of opioid-induced adrenal insufficiency based on your current opioid therapy. According to the article, you're at significantly higher risk when taking more than 20 MME per day for longer than 90 days.
Most people know opioids can cause constipation, drowsiness, or addiction. But few know they can quietly shut down your body’s stress response - and that could kill you.
What Exactly Is Opioid-Induced Adrenal Insufficiency?
Opioid-induced adrenal insufficiency (OIAI) happens when long-term opioid use messes with your brain’s ability to tell your adrenal glands to make cortisol. Cortisol isn’t just a stress hormone - it’s your body’s emergency fuel. It keeps your blood pressure up, your blood sugar stable, and your immune system from going haywire during illness, injury, or infection.
Unlike adrenal damage from disease, OIAI isn’t about broken glands. It’s about broken signals. Opioids bind to receptors in your hypothalamus and pituitary, the command centers that normally say, “Release ACTH - now make cortisol!” When that signal gets blocked, cortisol production drops. And if you’re on high-dose opioids for months or years, your body forgets how to make enough on its own.
It’s not common - about 5% of people on chronic opioid therapy develop it, according to a 2023 study. But here’s the catch: it’s often missed. Symptoms like fatigue, nausea, low blood pressure, and dizziness look just like the pain condition you’re being treated for. So doctors don’t test for it. And that’s dangerous.
Who’s at Risk?
You don’t need to be on heroin or oxycodone daily to be at risk. The real red flag is dose and duration. If you’re taking more than 20 morphine milligram equivalents (MME) per day for longer than 90 days, your risk jumps significantly. A 2020 study found that 22.5% of long-term opioid users failed adrenal stimulation tests - compared to 0% of people not on opioids.
It doesn’t matter if you’re taking methadone for pain after surgery, fentanyl patches for cancer, or hydrocodone for chronic back pain. The suppression happens across the board. One case study followed a 25-year-old man on methadone after a car accident. He developed high calcium levels during recovery - a sign his body was in crisis. Turns out, his cortisol was barely detectable. Once his opioids were tapered, his adrenal function returned within weeks.
Higher doses mean higher risk. Patients taking over 100 MME per day are most likely to develop full-blown adrenal insufficiency. And the longer you’re on them, the more your body loses its natural rhythm. Cortisol naturally peaks in the morning. In OIAI, that peak vanishes.
How Is It Diagnosed?
There’s no blood test you can take at your local clinic. Diagnosis requires a special stimulation test - usually an ACTH stimulation test. You get a shot of synthetic ACTH, and your cortisol levels are measured before and 30 to 60 minutes later.
Normal response: cortisol jumps above 18 mcg/dL (500 nmol/L). If it stays below that, your adrenal glands aren’t responding - even if your baseline cortisol looks “okay.” Some newer studies suggest even lower thresholds may be needed, especially in chronic users.
Baseline morning cortisol alone isn’t enough. A level of 5 mcg/dL might seem low, but if you’re stressed or sick, your body might still be trying to compensate. That’s why the stimulation test is gold standard. Without it, OIAI slips through the cracks.
And here’s the problem: most pain specialists don’t order it. Endocrinologists rarely see these patients unless they’re already in crisis. So unless someone asks - or you bring it up - it won’t be tested.
What Are the Symptoms?
They’re sneaky. Fatigue. Dizziness. Nausea. Weight loss. Low blood pressure. Muscle weakness. These look like depression, chronic pain flares, or even just “getting older.”
But there’s a dangerous twist: if you get sick, injured, or have surgery - and your cortisol is already low - your body can’t respond. That’s when an Addisonian crisis hits. Blood pressure crashes. You go into shock. You can die within hours if you don’t get IV hydrocortisone and fluids.
One patient in a 2015 case report had a severe infection after surgery. His cortisol was so low, his body couldn’t fight it. He developed hypercalcemia - calcium levels so high they caused kidney damage. Only after starting glucocorticoid replacement did he stabilize. His opioid dose was lowered, and within months, his adrenal function returned.
That’s why OIAI isn’t just a lab curiosity. It’s a silent timer. You might feel fine until the moment you need your body to save itself - and it can’t.
Can It Be Reversed?
Yes. And that’s the good news.
Unlike permanent adrenal damage from autoimmune disease, OIAI is reversible. Once opioids are tapered slowly, the brain’s signaling system usually wakes up again. Studies show cortisol levels return to normal in weeks to months after stopping or reducing opioids.
But here’s the catch: you can’t just quit cold turkey. If you’re on high doses, sudden withdrawal can trigger adrenal crisis - because your body isn’t ready to make cortisol yet. That’s why tapering under medical supervision is non-negotiable.
During the taper, doctors often give low-dose hydrocortisone as a bridge. It’s temporary - just enough to keep you stable while your HPA axis relearns how to work. Once cortisol levels stabilize on their own, the replacement is stopped.
One study followed 12 patients who stopped opioids after years of use. All of them recovered adrenal function within 6 months. But two had adrenal crises during withdrawal because they weren’t monitored. That’s why this isn’t something to handle alone.
What Should You Do If You’re on Opioids?
If you’ve been on opioids for more than 90 days - especially at doses above 20 MME - ask your doctor this:
- Could my symptoms be linked to low cortisol?
- Should I get an ACTH stimulation test?
- What’s my current opioid dose in MME?
Don’t wait for a crisis. If you’re planning surgery, starting chemotherapy, or even just getting the flu, your body needs cortisol to handle the stress. If you’re on long-term opioids and your doctor hasn’t checked your adrenal function, it’s time to bring it up.
Also, keep a list of all your medications - including opioids - and carry it with you. In an emergency, paramedics and ER staff need to know you might be at risk for adrenal crisis. A simple note in your phone or wallet can save your life.
Why Isn’t This More Widely Known?
Because it’s been hiding in plain sight.
For decades, doctors knew opioids could suppress cortisol. But it was seen as a lab curiosity - not a clinical threat. With the opioid epidemic focused on overdose deaths, addiction, and diversion, the endocrine side effects got lost.
Plus, the symptoms are vague. Fatigue? Everyone’s tired. Nausea? Everyone gets sick. Low blood pressure? Maybe you didn’t drink enough water.
But the evidence is piling up. A 2024 review in Frontiers in Endocrinology called it an “underappreciated endocrinopathy.” A 2020 systematic review of over 16,000 patients confirmed the link. And yet, most guidelines still don’t recommend routine screening.
That’s changing. Some pain clinics in the U.S. now screen patients on long-term opioids. But it’s not standard. Until it is, patients are left vulnerable.
The Bigger Picture
Opioids aren’t going away. Millions of people rely on them for chronic pain. But we need to treat them like any other powerful drug - with awareness of all their risks.
Adrenal insufficiency is rare, but it’s serious. And it’s preventable. If you’re on opioids long-term, you deserve to know if your body can still respond to stress. No one should have to survive a heart attack or infection only to find out their body had no backup plan.
The fix isn’t more pills. It’s better questions. Better testing. Better communication between pain doctors and endocrinologists. And most of all - awareness.
If you’re on opioids, don’t assume you’re fine. Ask. Test. Protect yourself. Your adrenal glands can’t speak - but your life depends on them working.
Can opioids cause adrenal insufficiency even if I’m not addicted?
Yes. Addiction has nothing to do with it. Opioid-induced adrenal insufficiency is a physiological effect - it happens because the drugs interfere with hormone signaling in the brain. Even people taking opioids exactly as prescribed for chronic pain can develop it, especially at doses above 20 MME per day for more than 90 days.
Is adrenal insufficiency from opioids permanent?
No. Unlike autoimmune Addison’s disease, opioid-induced adrenal insufficiency is reversible. Once opioid use is reduced or stopped under medical supervision, the hypothalamic-pituitary-adrenal (HPA) axis usually regains function within weeks to months. Some patients need temporary glucocorticoid support during tapering, but full recovery is common.
What’s the difference between adrenal insufficiency and adrenal fatigue?
Adrenal fatigue is not a real medical diagnosis. It’s a term used in alternative medicine to describe general tiredness, but there’s no scientific evidence the adrenal glands become “tired” from stress. Opioid-induced adrenal insufficiency is a real, measurable condition with clear diagnostic criteria - low cortisol after ACTH stimulation, confirmed by blood tests. It’s not a buzzword - it’s a life-threatening hormone disorder.
Can I get tested for this without my doctor’s approval?
No. The ACTH stimulation test requires a prescription and must be done in a clinical setting. You can’t buy it over the counter or do it at home. If you suspect you might have opioid-induced adrenal insufficiency, talk to your doctor about your symptoms and opioid use. Bring up the specific test name - it’s the only way to get an accurate diagnosis.
Are there any opioids that don’t cause this problem?
No. All opioids - including morphine, oxycodone, hydrocodone, fentanyl, methadone, and codeine - can suppress the HPA axis. The effect is dose- and duration-dependent, not drug-specific. Even tramadol and tapentadol, which have some serotonin activity, still carry this risk. No opioid is safe from this side effect if used long-term at high doses.
What should I do if I’m on opioids and feel dizzy or fatigued?
Don’t assume it’s just pain or aging. Write down your symptoms, your opioid dose (in MME), and how long you’ve been taking it. Schedule a visit with your doctor and ask: “Could this be adrenal insufficiency?” Request an ACTH stimulation test. If your doctor dismisses it, ask for a referral to an endocrinologist. Early detection can prevent a life-threatening crisis.
Is it safe to stop opioids suddenly if I think I have adrenal insufficiency?
No. Stopping opioids abruptly while your adrenal glands are suppressed can trigger an Addisonian crisis - a medical emergency with dangerously low blood pressure, shock, and potential death. Always taper opioids under medical supervision. Your doctor may prescribe short-term hydrocortisone during the taper to keep you stable while your body readjusts.
seamus moginie
November 20, 2025Opioids suppressing cortisol? That’s not some fringe theory-it’s in the literature. I’ve seen patients crash post-surgery because no one checked their adrenal function. If you’re on more than 20 MME for over 90 days, you’re playing Russian roulette with your endocrine system. Stop normalizing this. Get tested.
river weiss
November 22, 2025This is one of the most critical yet overlooked aspects of long-term opioid therapy. The HPA axis suppression is well-documented, yet screening remains inconsistent across pain clinics. The ACTH stimulation test is simple, low-risk, and life-saving. Every patient on chronic opioids should have a baseline cortisol evaluation-especially before elective procedures. I’ve had three patients in the last year who were misdiagnosed with ‘chronic fatigue’-all had undiagnosed OIAI. Early detection saves lives.
Andrew Montandon
November 22, 2025I’m a physical therapist who’s seen this firsthand. One guy I worked with-on fentanyl patches for 3 years-kept collapsing during rehab. We thought it was pain flares. Turned out his cortisol was below 3 mcg/dL. He didn’t even know what ACTH was. Once they started him on a slow taper with hydrocortisone bridge, he went from wheelchair to walking without help in 6 weeks. This isn’t just medical jargon-it’s real people getting sidelined because no one connects the dots. If you’re on opioids long-term, ask for the test. Don’t wait until you’re in the ER gasping for air.
Sam Reicks
November 23, 2025so like... the government is hiding this? because why else would no one talk about it? they want us addicted so we keep paying for pills and then die quietly so they can shut down the clinics and blame the addicts. cortisol? sounds like a pharma word to distract from the real issue-corporate greed. i bet they dont test for it in prisons either. #opiodsareabusiness
Michael Salmon
November 24, 2025Let’s be real-this is just another fear-mongering piece from the anti-opioid crowd. Most people on long-term opioids are functional. Fatigue? That’s called life. Low blood pressure? Maybe you’re dehydrated. This article reads like a medical pamphlet from a rehab center trying to scare people off pain meds. The real crisis is doctors overprescribing, not under-testing. And no, I don’t need a blood test just because I take hydrocodone for back pain.
Joe Durham
November 25, 2025I get why this is scary, but I also get why doctors don’t test routinely-it’s not cost-effective, and most patients don’t have symptoms. But if you’re feeling off, especially if you’re planning surgery or getting sick, it’s worth asking. I had a cousin on methadone for years after a work injury. He never complained, but when he got pneumonia, he almost didn’t make it. Turns out his cortisol was zero. They gave him steroids, he recovered, and now he’s on a slow taper. No drama. Just quiet, smart medicine. If you’re worried, bring it up. No shame.
Derron Vanderpoel
November 26, 2025My dad was on 120 MME for 7 years after his accident. He was always tired, always dizzy… we thought it was the pain. Then he got the flu and ended up in ICU with shock. They found his cortisol was undetectable. They gave him IV steroids and he cried-said he felt like a person again for the first time in years. I didn’t even know cortisol was a thing. Now I carry a card in my wallet that says ‘Opioid user-risk of adrenal crisis.’ If you’re on opioids, do this. It’s not paranoia. It’s protection.
Timothy Reed
November 28, 2025Thank you for sharing this. It’s a sobering reminder that even well-intentioned treatments carry hidden risks. The reversibility of OIAI is one of the most hopeful parts-if we catch it early. I’d encourage anyone on long-term opioids to keep a symptom journal and track their MME. Bring it to your provider with specific questions: ‘Could this be adrenal suppression?’ ‘Can we run an ACTH test?’ Don’t let the stigma of pain medication keep you silent. Your body deserves to be heard.