Overview
This episode of the Curbsiders Addiction Medicine podcast features Dr. Jesse Merlin discussing best practices for managing chronic pain in patients with opioid use disorder, emphasizing the overlap between the two conditions and practical approaches for clinicians across care settings.
Chronic Pain and Opioid Use Disorder: Definitions and Overlap
- Chronic pain is defined as pain lasting longer than 3 months past normal tissue healing.
- Approximately 20% of the U.S. population experiences chronic pain; 6% have high-impact chronic pain.
- Chronic pain and opioid use disorder frequently co-occur and can exacerbate each other in a reciprocal model.
- Clinicians should recognize patients may experience both conditions simultaneously; each can influence the course and management of the other.
Key Assessment and Stigma Considerations
- Functional assessment (e.g., PEG scale) is critical to understanding pain impact.
- Assess both pain and substance use history carefully; patients may conceal pain due to stigma or "drug-seeking" labels.
- Prior negative healthcare experiences, especially in marginalized populations, can affect patient-clinician trust.
- Validate prior experiences and set expectations for supportive, nonjudgmental care.
Medication Options: Buprenorphine and Methadone
- Buprenorphine is FDA-approved for both opioid use disorder and chronic pain; higher doses and split dosing may help with pain.
- Methadone is similarly effective for pain but is harder to access due to regulatory barriers.
- Evidence for opioid effectiveness in chronic pain is limited; buprenorphine is often preferable due to safety and accessibility.
- Full agonist opioids are generally reserved for specific cases and require careful risk-benefit assessment.
Nonpharmacologic and Behavioral Interventions
- Behavioral therapies (CBT, pain self-management, mindfulness) have strong evidence for chronic pain management.
- Goal setting with patients should focus on achievable, patient-driven functional improvements.
- Utilize local resources, multidisciplinary teams, and reinforce existing patient coping strategies.
Clinical Approaches and Documentation
- Multimodal treatment (behavioral, movement-based, pharmacological) is most effective.
- Gabapentinoids are widely overprescribed with limited evidence; duloxetine and antidepressants may be beneficial.
- Avoid focusing solely on opioids; explore all evidence-based options.
- Accurate, nonjudgmental documentation of behaviors and diagnoses assists future patient care.
Complex Cases and Acute Pain Flares
- Acute pain flares in chronic pain should not generally prompt opioid prescriptions, as this can lead to long-term use.
- Acute pain situations (e.g., trauma, surgery) may warrant short-term opioid use, but many patients with opioid use disorder prefer to avoid opioids altogether.
Take-Home Points
- Chronic pain and opioid use disorder often coexist and interact; clinicians across specialties can effectively treat both.
- Patient-centered, evidence-based, and multimodal approaches optimize management.
- Building trust, validating experiences, and clear documentation are crucial for high-quality care.
Recommendations / Advice
- Employ validated tools for functional and pain assessment (e.g., PEG scale).
- Integrate behavioral and nonpharmacologic interventions early.
- Use buprenorphine as first-line opioid treatment for chronic pain when appropriate.
- Consult local resources and build interdisciplinary networks for comprehensive care.
- Document facts, patterns, and conversations in a clear, unbiased way to support continuity of care.
Resources Mentioned
- opioidalgorithms.org: Practical resources for primary care management.
- “Managing Chronic Pain Before It Manages You” (CBT self-help manual).