Managing Chronic Pain in Patients With Opioid Dependence

Abstract

Chronic pain may last for months to years, and is often heightened by co-morbid opioid dependence; setting realistic expectations for both patient and physician is therefore a key step in formulating treatment plans. Chronic pain is influenced by psychological, social and environmental factors in addition to somatic pathology, thus treatment needs to encompass more than just analgesia. The specific treatments should address contributors to and sequelae of chronic pain and addiction (e.g., social isolation, physical disability, depression, anxiety, obesity, financial stress, housing instability) and include multimodal interventions: psychosocial engagement, physical mobility and conditioning, weight loss, substance use treatment, and medications. Psychosocial treatments include evidence-based cognitive behavioral therapies, substance abuse treatment groups, 12-step programs and other social activities. Physical mobility and conditioning can be accomplished with physical therapy, yoga, or other exercise programs, and are essential to avoid loss of function and a negative functional spiral. In the setting of obesity, diet in combination with exercise can decrease pain and improve function. Substance abuse treatment is essential for patients with comorbid pain and opioid dependence. Opioid replacement therapies may have some added analgesic benefit. Medication can help decrease the pain level and alleviate some of the complicating conditions but is unlikely to be effective when used in isolation. Opioid analgesics are generally not recommended in cases of patients with opioid dependence because of mixed evidence for efficacy and high risk.