Addiction Treatment Options for Opioid Addicted Chronic Pain Patients

What do you do when you’re addicted to opioids, you have/develop a chronic pain condition and you decide you want to get your life back under control with addiction treatment – how can you manage your pain without the use of potent opioid medications?

Though this seems like an impossible situation, with treatment and monitoring you can retake control and still get the opioid analgesia you need.

Three Primary Treatment Options

According to the Canadian Guidelines for the Safe and Effective Use of Opioids for Non Cancer Pain, the three primary treatment options for opioid addicted chronic pain patients are:¹

1. Addiction treatment combined with structured opioid therapy (best for patients who are misusing but not severely dependent).
2. Medication assisted treatment supplemented with short-acting opioids for analgesia as needed.
3. Abstinence-based treatment and non-opioid medications along with non-pharmacological pain treatments.

Read on for a brief explanation of these three primary treatment options.

Structured Opioid Therapy

Opioid abusers can sometimes move back to controlled use by initiating a very structured opioid therapy program.

With this method you get the full benefit of opioids for pain management, and when it works, misuse-controls stop overuse. Examples of patient controls include:

• Patient education.
• Avoiding the riskiest medications (hydromorphone and oxycodone.)
• A written treatment agreement.
• A urine testing program.
• Frequent dosing intervals and regular pill counts – intervals can be as frequent as once daily or twice a week.
• Frequent office visits and other forms of monitoring.
• The involvement of other family members.
• Regular evaluations to ensure that opioids offer significant pain relief (at least a 30% reduction).

Moving to structured opioid therapy is a reasonable first step, especially for not-yet-addicted opioid misusers. If it does not work (you continue to misuse/get addicted) then you have to move on to either medication assisted treatment (MAT) or abstinence-based treatment.

Medication Assisted Treatment

If structured opioid therapy doesn’t work (or if you or your doctor want to take a more aggressive treatment approach) MAT with methadone or buprenorphine can help you gain control of your opioid addiction.

• People on methadone can supplement with short acting opioids for pain relief, and since blockade-level methadone doses eliminate the euphoria from additional opioid use, there is little risk of further abuse.
• People on Suboxone may find that a slightly higher than normal daily dose of Suboxone, split into twice or three times a day dosing, may provide adequate pain relief.

Methadone and Suboxone (buprenorphine) are opioid addiction medications that replace your opioid of abuse. When you take an appropriate daily dose of methadone or Suboxone:

• You feel no withdrawal symptoms.
• You feel no or few drug cravings.
• You are far less able to get high when you use supplementary opioids.

Methadone and buprenorphine are also pain medications. But, though a once daily dose stops withdrawal symptoms and drug cravings for 24 hours, it will only offer a few hours of analgesia (methadone and buprenorphine provide 6 to 8 hours of analgesia.)² To gain sufficient pain relief your doctor might recommend:

• Splitting your daily dose of buprenorphine to expand the analgesic window. In some cases, splitting your daily dose into two or three intervals expands pain relief over the full 24 hours while also providing adequate withdrawal and cravings relief.
• Supplementing your daily dose of methadone or buprenorphine with additional short acting opioids.
  

Note*

Many people in MAT worry that using additional opioids for pain control could rekindle active addiction. However, under-treated pain is a more serious relapse trigger, especially since people on sufficient daily methadone doses won’t feel euphoria from supplementary opioids used to treat legitimate pain.³

Other Issues to Consider

• People on methadone may develop a tolerance to opioid effects and require a higher than normal dosing of short acting opioids for pain relief.
• Although supplementary opioids can be used for buprenorphine patients, because buprenorphine is a partial agonist with a strong affinity for the mu opioid receptor, high doses are typically needed to provide any significant analgesia. For this reason, people on Suboxone who have an ongoing need for supplementary opioid pain management may want to switch from Suboxone to methadone.
• Taking opioids on a fixed schedule, rather than as-needed, takes the decision-making away (do I need this for pain or do I just want to feel good).
  

People on sufficient daily doses of methadone for addiction treatment can take supplementary opioids for pain control without having to worry that these pain-control opioids will cause drug cravings or euphoria.

In an Ideal World

Ideally, you would address your addiction and pain issues at the same time and your ‘pain team’ and ‘addiction team’ would work together. You may find this type of treatment at a multidisciplinary pain clinic or similar.

Abstinence-Based Treatment

Medically assisted detoxification followed by abstinence-based treatment on an inpatient or outpatient basis is an option for people who don’t have easy access to methadone or Suboxone or those who prefer to avoid MAT for personal reasons.

• People in abstinence-based treatment will not use opioids for pain management. Since pain is a major relapse trigger, it’s best to combine intensive addiction treatment with non-opioid and non-pharmacological pain treatments.
  
• Opioid addicted people in abstinence-based treatment – especially people dealing with chronic pain problems – are at elevated risk of relapse. Since even brief periods of opioid abstinence can reset your tolerance to zero, using your 'normal' dose after a week or two of abstinence can lead to fatal overdose.

Addressing Addiction Reduces Overdose Risks

People with chronic pain and addiction are more likely than people with chronic pain alone to overdose. Reasons for this elevated risk of overdose include:

• Increased opioid tolerance from high dose use.
• Increased opioid cravings and binge use.
• Increased use of opioids to self-medicate psychological issues.
• Pain exacerbation from the opioid withdrawal symptoms associated with the ebb and flow blood plasma levels of binging and abuse.⁵
  

Take Home Messages

• If you are abusing your pain medications, you may find that a structured opioid plan allows you to continue using opioids..
• If this does not work, you may want to consider MAT with methadone or Suboxone. These medications will remove drug cravings and withdrawal symptoms and will also provide some degree of analgesia. If more analgesia is needed, you could use supplementary opioids with methadone without experiencing euphoria.
• Abstinence based treatments are an option for people who prefer to avoid MAT. People using abstinence based treatments have to be careful, since relapse is common and even short periods of abstinence can reset tolerance to novice level.
• It’s important to treat chronic pain and addiction at the same time.