It is very common for individuals with opioid use disorder to also experience acute or chronic pain, as this pain may have led to the misuse of prescription opioids in the first place. Research estimates that between 29 percent and 60 percent of people with opioid use disorder report having chronic pain.1
While primary care providers frequently treat patients for pain in their practice, there are special considerations for managing pain in someone taking medications for opioid use disorder. It may not be possible to eliminate the pain, but it can be managed. The goal of this treatment should be to reduce pain, maximize function, and improve quality of life.
Providers use a comprehensive, integrated approach to manage chronic pain for individuals with opioid use disorder. As needed, they incorporate nonpharmacologic and complementary therapies into the treatment plan and address co-occurring mental disorders that may complicate pain management.
How Do You Do It?
Conduct a Thorough Assessment
A comprehensive patient assessment should be conducted to gather information that may help inform clinical decisions and the treatment plan. The patient’s assessment should cover the following areas1:
- Pain and Coping: Identify the origin, type, nature, severity, and location of the patient’s pain. Ask the patient about aggravating and alleviating factors. Understanding the patient’s previous history with treatment for this pain (including methods used and patient response) can also be useful to help make appropriate decisions and to understand the patient’s goals or expectations for pain relief.
- Function: Determine the effect of pain on patients’ daily life, sleep, mood, relationships, and other factors. Ask patients about their goals and expectations for function.
- Co-Occurring Conditions and Disorders: Providers should have already conducted a thorough assessment of the patient’s substance use disorders, mental health conditions, medical conditions, and cognitive impairments. Use the findings of these assessments as well as knowledge of the patient’s history to inform decisions about the treatment or management of pain.
- Physical Status: Perform a physical medical exam to help inform the pain diagnosis and treatment planning. This exam should include the patient’s sensory experiences, relevant musculoskeletal area, and other nonverbal or verbal pain behavior depending on position.
- Mental Status: Assess 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 described in the section on Suicidality.
- Additional Information: Collect any other information that may be relevant to the treatment or management of the patient’s pain. This information may include findings and recommendations from other clinicians, cultural beliefs or concerns, and data from the State’s prescription drug monitoring program. Also, aim to identify potential barriers to the effective management of pain, such as financial or insurance barriers and lack of social supports.
Standardized instruments should be used to screen and assess the patient’s:
- Dimensions of pain (e.g., Brief Pain Inventory, McGill Pain Questionnaire);
- Function (e.g., Katz Index of Independence in Activities of Daily Living, Pain Disability Index [PDF—122 KB]);
- Coping (e.g., Chronic Pain Acceptance Questionnaire [PDF—9.8 KB]); and
- Pain-related fear or anxiety (e.g., Fear-Avoidance Beliefs Questionnaire, Tampa Scale for Kinesiophobia [PDF—119 KB], Pain Catastrophizing Scale [PDF—3.5 MB]).
These instruments have strengths and weaknesses, and a single instrument may not be appropriate for use with all patient populations.1 Historically, providers have also assessed a patient’s pain level using tools such as a numeric rating scale or visual analog scale. However, the utility and validity of these tools has been questioned in relation to chronic pain.
Providers should keep in mind that assessment of pain levels can be complicated. For example, patients may not fully distinguish between pain and suffering, leading them to report higher levels of pain intensity overall.1 Also, providers’ attitudes may inadvertently affect their assessment of a patient’s pain. Clinicians often believe patient’s pain to be lower than what the patient reports and are more likely to underestimate and undertreat pain and disability in women, older adults, minorities, low-income patients, and individuals with substance use disorders.1 For the purposes of this Playbook, we recommend treatment approaches that focus on improving a patient’s pain-related functioning rather than pain level.
Take a Holistic Approach
Providers should aim to take a comprehensive, integrated approach to the complex care and management of pain among individuals with opioid use disorder. They should assemble a multidisciplinary group of providers that can include professionals such as:
- Primary care providers,
- Addiction specialists,
- Pain clinicians,
- Behavioral health professionals, and
- Physical or occupational therapists.1
Ideally, providers are colocated and can take a team-based approach within the same practice, organization, or health system to foster collaboration.1 However, providers in small practices will likely need to seek and coordinate care with external providers in the community.
Adjust the Treatment Plan
Strategies for pain management in patients receiving medication-assisted treatment (MAT) services should be specified as part of the treatment plan. Providers may want to recommend nonpharmacologic treatments, such as therapeutic exercise, physical therapy, cognitive-behavioral therapy, and complementary and alternative medicine.1
If pharmacologic treatment is clinically indicated, it is best to use Nonopioid Treatments for Chronic Pain (PDF—1.53 MB). For example, the first course of treatment should be nonnarcotic medications such as acetaminophen or nonsteroidal anti-inflammatory drugs.2 Other drugs, such as serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, anticonvulsants, and topical analgesics, may have analgesic properties for certain conditions.1
Additional considerations depend on which medication the patient is taking to treat his or her opioid use disorder. For example, providers may consider adjusting the dose and schedule of buprenorphine in patients with chronic pain.2 The following resources offer guidance and recommendations for providing pain management in individuals with substance use disorders:
- National Practice Guideline Supplement—American Society of Addiction Medicine
- Treatment Improvement Protocol 54: Managing Chronic Pain in Adults with or in Recovery From Substance Use Disorders—Substance Abuse and Mental Health Services Administration
Individuals with chronic pain and opioid use disorders are also more likely to have co-occurring mental health disorders, for which providers should screen. These disorders may further complicate treatment of this patient population. For example, anxiety can contribute to overall suffering and harm a patient’s quality of life. Similarly, depression may interfere with treatment adherence or ongoing management of the patient’s condition.1 If needed, the practice should tailor the treatment team and interventions to address co-occurring mental health conditions.
Anticipate Challenges With Hospitalizations and Other Outpatient Procedures
When patients are hospitalized or undergo procedures in other outpatient settings, it is important for patients and providers to understand the risks and implications of pain management among those taking medications to treat opioid use disorder. For example, patients taking naltrexone should not be prescribed opioids because, as an antagonist, it will block the effects of these drugs. If providers continue to increase the dose of opioids to overcome this blockade, patients may be at risk of respiratory arrest as naltrexone levels decrease over time.1
Patients should always tell their MAT prescriber in advance if they will be having a procedure that may require pain medication.3 Then, members of the care team should engage the patient in a shared decision-making process to discuss pain management options for this procedure.3 The care team should then work to coordinate with the external providers performing the procedure to ensure that the patient’s needs are met and preferences are respected.
MAT prescribers may need to be proactive with the inpatient team around discharge planning for their patient. They should ensure considerations are made around pain management issues with full agonists after discharge or restarting buprenorphine before discharge if needed.
Providers should also prepare patients and their families to explain what medications they are taking and to advocate for their own preferences in emergency situations. Some patients will want to avoid opioid analgesics at all costs, while others may be concerned that undertreated pain may be a trigger for illicit opioid use or prescription opioid misuse.3 In these situations, education and patient engagement in decision making are key.
What Not To Do
- Don’t treat pain as an experience as simple as 0 to 10 on a numeric scale. Conduct a complete assessment to fully understand the patient’s dimensions of pain.
- Don’t forget that pain can be mysterious and scary for patients. Educate them on the biopsychosocial model of pain and reassure them that there is a difference between hurt and harm.
Treatment Improvement Protocol (TIP) 54: Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders
Equips clinicians with practical guidance and tools for treating chronic pain in adults with a history of substance abuse. Discusses chronic pain management, including treatment with opioids, and offers information about substance abuse assessments and referrals.
Reviews various options and tools for managing chronic pain, including identifying appropriate nonopioid medications and nonpharmacologic treatments and facilitating a patient-centered approach.
- Substance Abuse and Mental Health Services Administration. Treatment Improvement Protocol 54: Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. https://store.samhsa.gov/product/TIP-54-Managing-Chronic-Pain-in-Adults-With-or-in-Recovery-From-Substance-Use-Disorders/SMA13-4671. Accessed June 12, 2019.
- American Society of Addiction Medicine (ASAM). National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. Rockville, MD: ASAM; 2015. https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf. Accessed June 12, 2019.
- Substance Abuse and Mental Health Services Administration. Treatment Improvement Protocol 63: Medications for Opioid Use Disorder. Part 4: Partnering Addiction Treatment Counselors With Clients and Healthcare Professionals. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018. Publication No. SMA18-5063PT4. https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP21-02-01-002.pdf