Chronic Pain Management & Preventing Opioid Addiction

Opioid medications are used to treat acute pain and can be appropriate for management of chronic pain in certain individuals. However, long term use of opioids, no matter the reason or diagnosis, does carry some important risks that all patients should be aware of.

The definition of “chronic” pain is pain that persists for months after acute injury, even after the body’s physical tissue recovers.

Chronic pain is poorly understood and can be difficult to treat. When all else fails, sometimes physicians and patients make a shared decision to start opioid treatment. Before you use opioids long term, you should educate yourself about the risks and benefits of doing so, and have an open and honest conversation with your treating doctor about your goals.

Treatment Options for Chronic Pain

There are many types of non-pharmacological therapies that show evidence of improving chronic pain. 

1. Cognitive Behavioral Therapy (CBT)

Therapists teach patients how they can change their thoughts to change their behaviors and their responses to pain in order to ultimately improve the pain itself. This usually involves working one on one with a trained therapist, although CBT can sometimes also be provided in a group setting. 

2. Biofeedback

Electronic sensors connect to specific body areas to teach patients how to recognize physical symptoms of stress and anxiety, like increased heart rate, body temperature, and muscle tension, and learn how to respond to reduce these symptoms. Biofeedback is usually done with a therapist, although there are some electronic programs that can be done at home or online. 

3. Mindfulness

Mindfulness refers to a myriad of practices that encourage people to be present “in the moment” and slow down anxious thoughts through techniques such as body scanning, progressive muscle relaxation, and meditation. Mindfulness techniques can be learned from a therapist or meditation teacher, or taught from online resources, apps or websites.

In addition to these therapies, there are a myriad of others. Regular daily exercise has been associated with reductions in chronic pain. Physical therapy, Tai Chi, Yoga, Aquatherapy, Reiki and Acupuncture also all have a strong evidence base for a number of chronic musculoskeletal pain syndromes.

Non-Opioid Medications for Chronic Pain

Before using any opioid medications, the CDC always recommends a trial of non-opioid medication options.[1] Many medications prescribed by your primary care doctor or psychologist can improve chronic pain.

These include topical medications like these:

• Lidoderm patches which provide topical pain relief
• Diclofenac gel which is also used topically 
• Muscle relaxers (common names include cyclobenzaprine, tizanidine, baclofen or methocarbamol) 
• Steroid injections
• SNRIs (venlafaxine and duloxetine)
• TCAs (amitriptyline and nortriptyline)
• Neuropathic medications (gabapentin and pregabalin)

Should You Use Opioids?

The CDC recommends nonopioid medications as the preferred treatment for chronic pain.[1] Recent studies have shown that anti-inflammatory medications, like ibuprofen, work just as well to manage acute pain flares as opioids.[2] However, in certain types of pain, for example malignancy or cancer related pain, opioids may be appropriate for more long term use. 

Risks of Long Term Opioid Use

While long term use of opioids may be appropriate in certain situations, it also poses some serious risks, including the risk of addiction, increased risk of sedation, increased risk of falls, overdose, and even death. Additionally, long term use of opioids has also been highly associated with the phenomenon of “opioid induced hyperalgesia” where patients paradoxically experienced increased pain over time.

When taken for more than a few weeks, many people become physically dependent on opioids. This means that we will experience withdrawal symptoms upon discontinuing the opioid. Opioid withdrawal usually prevents as a flu-like illness, with individuals experience symptoms like agitation, anxiety, nausea, vomiting, diarrhea, stomach cramping, shaking/tremors, and sweating.

Can Suboxone Be Used for Chronic Pain?

Yes. Buprenorphine (a partial opioid) in the medication Suboxone has pain-relieving properties. One form of Buprenorphine, Butrans patch, is actually FDA approved solely for the purpose of treating chronic pain. Other forms of buprenorphine, such as the tablet or the strip, can also be used to treat chronic pain “off label”.

When patients develop an addiction to opioids, buprenorphine/naloxone (Suboxone) can help patients by preventing cravings, withdrawal symptoms, and overdose, while simultaneously treating their pain. It may be a particularly good option for patients who are concerned about their reliance on opioids long term but who also are afraid of being without any opioid to address their pain. 

How to Prevent OUD When Dealing With Pain & Pain Management 

About 10% of patients prescribed opioids for chronic pain develop an addiction disorder. [1] Addiction can consume their lives and cause many negative consequences personally and professionally, such as losing the trust of loved ones, losing a job, and being unable to take care of kids or fulfill daily adult responsibilities.

The decision to use opioids “long term” (for weeks, months or even years) will usually be made between a doctor and a patient after carefully considering the benefits versus the harms as well as understanding that medications are only one small part of treating chronic pain.

If prescribed opioids for chronic pain, you might have to come off other medications that interact with opioids and put you at risk for overdose and death.

You will also be monitored frequently to ensure you are taking opioids safely and not developing any signs of misuse. This often includes the following, depending on the physician and the practice that you go to for your medication:

• Pain contracts – a written agreement not to misuse your medications and steps to take if you do feel tempted to do so 
• Frequent clinical visits – usually opioids, which are regulated heavily, require an in-person or virtual visit once a month 
• Urine toxicology testing – this practice varies depending on your State and the rules at the specific practice where you receive your prescription
• Prescription monitoring programs – Most states have an online prescription monitoring program where your doctor is required to check to make sure you have not received other prescriptions from other providers. This serves as a way to ensure patients are not misusing or diverting opioid medications. 

What to Do if You Do Have Concerns about Your Use of Opioid Medications

If you are started on opioids for chronic pain and are worried that you are developing an unhealthy relationship with or reliance on your medication, you may be at risk for developing an opioid use disorder.

Talk to your doctor about your concerns – they can help you either continue therapy more safely, slowly discontinue your medication, or even substitute other medications or therapies for your chronic pain. 

Many patients do not bring up these issues with their physicians because they worry their doctor will “pull the rug out” from underneath them and immediately stop providing them with their medication should they admit their concerns about their misuse. Most doctors know better than to abruptly stop opioid treatment these days, particularly in patients that have been on therapy for a long time. Don’t let concerns about being “cut off” stop you from being open and honest with your doctor – their goal, and yours, is to control your pain while also keeping you safe. Speak openly and honestly with them so that the two of you together can come up with a treatment plan that works for you.