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Chronic Pain Opioid Guidelines for People with Active Addiction, People in Recovery and People on MAT

Pain management for people with substance use disorders or addiction histories is tricky business.

  1. People with substance use disorders or addiction histories often experience chronic pain (for example, up to 60% of people with opioid addictions report chronic pain.)1
  2. Though opioid drugs provide strong analgesia, people with active addiction or addictive histories are at higher risk of drug-misuse and addiction. For this reason, many people in recovery feel reluctant to use opioids for pain management and many doctors feel reluctant to prescribe opioids to people with addiction or addiction history issues.
  3. However, uncontrolled pain is a significant risk factor for relapse or worsened substance use.

So if you’ve got pain and addiction/addiction history, you may feel like you’re between a rock and a hard place - what should you do?

Well, to help you with this, read over the opioid use guidelines from SAMHSA for people with active addiction, people in recovery and people on methadone or Suboxone.  These guidelines take you step-by-step from low-risk pain management strategies all the way to opioid use (if needed). By following these guidelines and by observing safe opioid use practices, you can reduce your risk of opioid misuse and addiction while still keeping all pain-management strategies on the table.

Opioids Guidelines for Active Addiction/Recovery

Here are the chronic pain treatment progression guidelines (from SAMHSA) for people:2

  1. With active substance use disorders.
  2. In recovery.
  3. In recovery using methadone or Suboxone.

Opioid Progression Guidelines – People In Recovery

  1. Try opioid alternatives first and proceed to opioids only if the benefits clearly outweigh the risks.
  2. Start with non-opioid analgesic medications, such as NSAIDs and others. Combine medications with non-pharmacological treatments (massage, heat and cold therapy, TENS and others), physical and occupational therapies for functional restoration and mental health treatments to reduce aggravating issues, such as poor sleep, uncontrolled stress, untreated mental illness and others.
  3. If this combination of non-opioids and non-pharmacological treatment results in sufficient pain relief, stop here and do not continue on to opioid use. If analgesia isn’t sufficient, consider whether the benefits of opioid use outweigh the risks, and they do, start an opioid trial.
  4. If opioids don’t cause a substantial improvement in pain, quality of life or functioning, then wean off and continue with other therapies. If opioids result in significant improvements, continue with them while monitoring to make certain that positive results continue (pain relief may diminish over time) and while monitoring for adverse effects, like addiction.
  5. Should addiction relapse occur, initiate substance abuse treatment and begin the pain management guidelines for people in active addiction (see below)

Opioid Guidelines for Methadone and Suboxone Users

  1. Consider increasing the methadone or Suboxone dose for improved pain-relief. At the same time, begin non-pharmacological pain treatments, physical and occupational therapy and mental health and wellness treatments.
  2. If pain relief remains inadequate and if the benefits of opioids outweigh the risks, begin an opioid trial (opioids in conjunction with methadone therapy).
  3. If opioids don’t provide significant pain relief, quality of life or functional improvements, discontinue by weaning off.
  4. If opioids provide significant benefits, continue with the therapy while monitoring for misuse and any reductions in benefits.
  5. Should opioid addiction relapse occur (uncontrolled use) intensify substance abuse treatment and begin the pain management guidelines for people in active addiction (see below).

Because at sufficient doses, methadone blocks the euphoria of supplementary opioids, a person can use opioids for pain while on methadone without getting high and without losing control over their use.

Opioid Guidelines – People with Active Addiction

Opioids are rarely an appropriate chronic pain treatment for people with an active drug or alcohol use disorder.  If someone with active addiction requires chronic pain treatment, the steps are:

  1. Start addiction treatment. Do not use opioids yet. If you are abusing opioids, either start tapering off or continue to use under the close direction of an addiction professional while receiving addiction treatment.
  2. Try non-opioid analgesics and non-pharmacological pain treatments, such as physical therapy, CBT and complementary therapies.
  3. Once stabilized and in recovery, continue with the pain management steps outlined above, within the ‘in recovery’ guidelines.

Reducing Opioid Risks

If you and your doctor feel opioids are necessary despite an elevated risk for addiction, you can safeguard against problems by taking precautionary measures to reduce your risks. Examples of precautionary measures include:

  • Agreeing to a program of urine testing (which checks for drug misuse)
  • Agreeing to frequent visit intervals and small prescriptions.
  • Agreeing to have family members or others from your support network involved – these people can be entrusted with keeping the supply and handing medications on schedule and monitoring for signs of abuse.
  • Using opioids with less rewarding properties (such as codeine or tramadol) rather than more potent opioids like oxycodone.
  • Using slow release opioids when possible – possibly transdermal patches. 

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