Chronic Pain and Addiction: Navigating Treatment Without Opioids

Introduction

Chronic pain and addiction are among the most challenging co-occurring conditions in medicine. They are deeply intertwined — chronic pain is a major risk factor for opioid use disorder, and addiction significantly worsens pain outcomes. The opioid crisis has brought this relationship into sharp focus, highlighting the need for evidence-based approaches to managing chronic pain in people with addiction. Understanding the pain-addiction relationship and the evidence for non-opioid pain management is essential for anyone working in addiction medicine or recovery.

Key Definitions

Chronic pain: Pain that persists for more than 3 months, beyond the expected period of healing. Affects approximately 50 million adults in the United States.

Opioid-induced hyperalgesia (OIH): A paradoxical increase in pain sensitivity caused by long-term opioid use. A major complication of opioid therapy for chronic pain.

Central sensitization: A state of heightened sensitivity of the central nervous system to pain signals. Associated with chronic pain and worsened by opioid use.

Multimodal pain management: An approach to pain management that uses multiple evidence-based treatments — including medications, physical therapy, psychological therapy, and complementary approaches — rather than relying on a single treatment.

Pain catastrophizing: A pattern of negative cognitive and emotional responses to pain — including rumination, magnification, and helplessness — that significantly worsens pain outcomes.

The Pain-Addiction Cycle

Chronic pain and addiction are locked in a complex cycle:

Pain driving addiction:

• Chronic pain is a major risk factor for opioid use disorder — people prescribed opioids for chronic pain have a 3-19% risk of developing opioid use disorder.
• Pain is a powerful trigger for substance use — people use opioids, alcohol, and other substances to manage pain.
• The psychological distress of chronic pain — depression, anxiety, sleep disturbance — increases addiction vulnerability.

Addiction driving pain:

• Opioid-induced hyperalgesia — a paradoxical increase in pain sensitivity caused by long-term opioid use — worsens pain in people with opioid use disorder.
• Alcohol and other substances can worsen pain through neuroinflammation and central sensitization.
• The lifestyle consequences of addiction — poor sleep, poor nutrition, reduced physical activity — worsen pain.

Non-Opioid Pain Management

Evidence-based non-opioid approaches to chronic pain management:

Physical therapy and exercise: Physical therapy and regular exercise are among the most evidence-based treatments for chronic pain. Exercise reduces pain through multiple mechanisms — including endorphin release, anti-inflammatory effects, and improved physical function. Specific exercise programs (yoga, tai chi, aquatic therapy) have shown efficacy for specific pain conditions.

Cognitive Behavioral Therapy for Pain (CBT-P): CBT adapted for chronic pain addresses the cognitive and behavioral patterns that worsen pain — including pain catastrophizing, avoidance, and activity restriction. Multiple randomized controlled trials have found CBT-P effective for reducing pain intensity, disability, and psychological distress.

Acceptance and Commitment Therapy (ACT): ACT for chronic pain focuses on accepting pain as a part of life and committing to valued activities despite pain. Research has found ACT effective for reducing pain-related disability and improving quality of life.

Mindfulness-Based Stress Reduction (MBSR): MBSR has shown efficacy for chronic pain, reducing pain intensity and improving quality of life through mindfulness-based acceptance and awareness.

Non-opioid medications: Multiple non-opioid medications have evidence for chronic pain, including NSAIDs, acetaminophen, antidepressants (duloxetine, tricyclics), anticonvulsants (gabapentin, pregabalin), and topical agents. These medications carry significantly lower addiction risk than opioids.

Interventional procedures: Nerve blocks, spinal cord stimulation, and other interventional procedures can provide significant pain relief for specific pain conditions without the addiction risk of opioids.

Pain Management in People with Addiction

Managing chronic pain in people with addiction requires special consideration:

Opioids in people with addiction: Opioids are generally contraindicated for people with opioid use disorder, except as MAT (buprenorphine, methadone). For people with other substance use disorders, opioids can be used with careful monitoring, but the risk of developing opioid use disorder is elevated.

MAT and pain: Buprenorphine has analgesic properties and can provide some pain relief in addition to treating opioid use disorder. Methadone also has analgesic properties. People on MAT who have chronic pain may benefit from dose adjustments or supplemental non-opioid pain management.

Multimodal approach: A multimodal approach — combining physical therapy, psychological therapy, non-opioid medications, and complementary approaches — is the most appropriate approach for people with addiction and chronic pain.

Frequently Asked Questions

Can I take opioids for pain if I have a history of addiction?
This is a clinical decision that should be made with a healthcare provider who is knowledgeable about both addiction and pain management. Opioids are generally contraindicated for people with opioid use disorder, except as MAT. For people with other substance use disorders, opioids can be used with careful monitoring and a comprehensive pain management plan. Non-opioid alternatives should be exhausted before considering opioids.

Will my pain get worse if I stop using opioids?
In the short term, stopping opioids can worsen pain due to opioid withdrawal and opioid-induced hyperalgesia. However, in the long term, stopping opioids often improves pain — as opioid-induced hyperalgesia resolves and the brain's natural pain regulation systems recover. This improvement typically takes weeks to months.

Is chronic pain a reason to relapse?
Chronic pain is a significant relapse trigger, and it is important to have a comprehensive pain management plan in place. However, relapse is not inevitable — many people with chronic pain maintain recovery with appropriate pain management and support. Working with a healthcare provider to develop a non-opioid pain management plan is essential.

Key Takeaways

• Chronic pain and addiction are deeply intertwined — pain drives addiction, and addiction worsens pain through opioid-induced hyperalgesia and central sensitization.
• Non-opioid pain management — including physical therapy, CBT-P, ACT, MBSR, and non-opioid medications — is effective and appropriate for people with addiction.
• Opioids are generally contraindicated for people with opioid use disorder, except as MAT.
• A multimodal approach — combining multiple evidence-based treatments — is the most appropriate approach for people with addiction and chronic pain.
• MAT (buprenorphine, methadone) has analgesic properties and can provide some pain relief in addition to treating opioid use disorder.

Additional Resources

Related articles on Sobriety Navigator: Opioid Use Disorder, Medication-Assisted Treatment, Trauma and Brain Changes, Cognitive Behavioral Therapy for Addiction.