Chronic Pain

A thorough assessment helps guide effective pain management and treatment decisions. Whenever possible, use structured approaches and standardized tools to evaluate not just pain intensity but also its impact on daily life and overall functioning. Key areas to assess are as follows:¹⁹⁰

• Pain and Coping: Identify the origin, severity, and characteristics of pain. Ask about aggravating/alleviating factors and previous treatment experiences. Aim to understand the patient's goals for pain relief.
• Function: Determine the effect of pain on patient's daily life, sleep, mood, relationships, and other factors. Ask patients about their goals and expectations for function.
• Co-occurring Conditions and Disorders: Consider the patient's substance use, mental health, medical conditions, and cognitive function when determining treatment options.
• Physical Status: Conduct a physical exam to assess the patient's sensory experiences, relevant musculoskeletal areas, and observable pain-related behaviors.
• Mental Status: Evaluate the patient's mood and cognitive capacity (e.g., attention or memory). If there are signs or symptoms of suicidal ideation or behaviors, take appropriate actions as outlined in the Suicidality section.
• Additional Information: Collect and review any other information that may help you treat or manage your patient's pain, including other clinicians recommendations, the patient's cultural beliefs, and any barriers to care (e.g., financial constraints, insurance coverage) that your patient may be facing. Collect any other information that may be relevant to the treatment or management of the patient's pain.

Assessing patient pain levels can be complicated. Patients may conflate pain with suffering, leading to inflated pain reports.⁴ Clinicians, in turn, often underestimate pain—particularly in women, older adults, minorities, low-income patients, and individuals with SUDs—resulting in undertreatment.¹⁹⁰ Given these challenges, the Playbook emphasizes treatment approaches that prioritize improving pain-related function over pain intensity alone.

While numeric rating scales and visual analog scales are often used to assess pain, their validity in chronic pain assessment is questionable.⁵ When appropriate, use validated, standardized instruments such as the ones listed in the Resources section.

Managing pain in individuals with OUD requires a comprehensive, integrated approach. Whenever possible, assemble a multidisciplinary team that may include:

• Patients;
• Primary care providers;
• Addiction specialists;
• Pain clinicians;
• Nurses;
• Pharmacists;
• Behavioral health professionals; and
• Physical or occupational therapists.¹⁹⁰

Note the prominent position of the patient as a member of the team (see the Develop a Shared Care Plan section). Including clinic leadership along with financial leadership, as part of the team can be helpful. Treatment of OUD is not always well compensated, and few primary care practices operate with high margins, so devising strategies to make MOUD financially sustainable can be challenging. More information on billing and reimbursement can be found under the Financial Sustainability section.

In practices that provide a more comprehensive array of services for people with OUD, providers are often co-located, facilitating a team-based approach within the same practice.¹⁹⁰ If you work in a smaller practice, you may need to coordinate with external providers in the community to ensure comprehensive care.

Individuals with chronic non-cancer pain treated with opioids are at higher risk of developing OUD. Often, the narrative focuses more on their pain and may minimize or cover up the development of an OUD. Acknowledge their pain and their addiction and reassure them that you will address both.

Three situations in which a patient with OUD may be treated for pain are:

• Pain in patients with an untreated OUD;
• Pain in patients engaged in OUD treatment with a partial or full opioid agonist (i.e., buprenorphine or methadone); or
• Pain in patients engaged in OUD treatment with opioid antagonists (i.e., naltrexone).

In all three situations, first determine the cause of the pain and identify an appropriate treatment approach.

Nonpharmacological treatments may be effective at reducing pain or the perception of pain such as:

• Therapeutic exercise;
• Physical therapy;
• Cognitive-behavioral therapy (CBT); and
• Complementary and alternative medicine.^190,195

If pharmacologic treatment is indicated, start with non-opioid medications first, such as the following:

• Acetaminophen; Nonsteroidal anti-inflammatory drugs (NSAIDs);⁷
• Serotonin-norepinephrine reuptake inhibitors (SNRIs);
• Tricyclic antidepressants;
• Anticonvulsants; and
• Topical analgesics.¹⁹⁰

Of note, buprenorphine is a common treatment for chronic pain.⁸

Patients with chronic pain and OUD often have co-occurring mental health conditions that can complicate treatment. Anxiety, depression, and PTSD can amplify pain perception, interfere with treatment adherence, and reduce quality of life.¹⁹⁰ For guidance on mental health screening and treatment approaches, see the Counseling and Other Psychosocial Supports section.

Patients receiving medications for OUD face unique challenges when hospitalized or undergoing outpatient procedures. Ensure your patients understand how their medications impact pain management and communicate with their care teams in advance.

• Do not stop buprenorphine: Increasing buprenorphine or using traditional opioids on top of buprenorphine can work for acute pain.⁹
• Patients cannot receive opioids if they are taking naltrexone: As an opioid antagonist, naltrexone blocks the effects of opioids. Attempting to override this blockade with escalating doses can lead to respiratory arrest as naltrexone levels decrease over time.¹⁹⁰
• Encourage early communication: Patients should inform you, as the prescriber of their medication for OUD, before any procedure requiring pain management.
• Coordinate with external providers: Engage in shared decision-making with the patient and collaborate with specialists to ensure the pain management approach aligns with their needs and preferences.
• Plan for discharge: Work with inpatient teams to address post-discharge pain management, considering the patient's medication for OUD. Possibly restart or adjust buprenorphine dose before discharge.
• Prepare patients for emergencies: Educate patients on their medications and equip them to advocate for their pain management preferences and needs in urgent care settings. Some patients will want to avoid opioids entirely, while others may fear undertreated pain may be a trigger for return to use. Providing education and engaging your patient in decision-making can help them navigate these situations confidently.