Pain Management and Preventing Opioid Addiction

April 7, 2021

For many people, a twisted ankle, stubbed toe, torn rotator cuff, or whiplash injury from a motor vehicle accident can lead to acute pain. While initially uncomfortable, within a few weeks the tissue that was injured recovers and the person moves on with their lives.

For some people, however, the pain continues even after the tissue recovers, and these patients live with chronic pain that will likely always be there and never fully resolve.

How do we manage chronic pain in a safe and effective way? And, is there a role for opioid medications?

Chronic pain is considered a bio-psycho-social condition. This means that pain is not simply from a tissue that is injured. Pain is also generated from our psychologic and social environments. When people are feeling stressed out, this can lead to feelings of anxiety and depression, leading people to avoid activities, creating more stress and more pain. For example, a fight with a significant other, financial struggles, and even feeling lonely and isolated can all worsen the pain.

Hence, effectively managing chronic pain is not just about taking medications and requires a broader approach that also helps people manage their mood and their social situation.

What are the treatment options for chronic pain management?

For chronic pain, the CDC recommends starting with non-medication options.

Non-medication options for chronic pain:

  • Physical therapy
  • Exercise
  • Yoga
  • Acupuncture
  • Aquatherapy
  • Chiropractic care
  • Massage
  • Tens unit/ultrasound
  • Heat/ice
  • Herbal supplements

Additionally, working with a therapist to manage stress, anxiety, and depression can also help to improve pain and quality of life. It is worthwhile for patients to engage in meaningful activities and hobbies even if the pain is still there.

There are three types of therapy that show evidence for improving chronic pain. And, you can work with your therapist using any strategy to set goals to improve your quality of life.

Evidence-based therapies that help with chronic pain:

1- Cognitive Behavioral Therapy (CBT)

Therapists teach patients how they can change their thoughts to change their behaviors. ex: “this pain now is telling me I am overdoing myself. I need to pace myself better so I can stay active and manage my pain.”

2- Biofeedback

Uses electronic sensors connected to specific body areas to teach patients how to recognize physical symptoms of stress and anxiety, like increased heart rate, body temperature and muscle tension, and learn how to respond to reduce these symptoms.

3- Mindfulness 

Teaches patients how to be present “in the moment” and slow down anxious thoughts through techniques such as body scanning, progressive muscle relaxation and meditation. 

Medication options

The CDC recommends non-opioid medications as the preferred treatment for chronic pain.

There are many medications that can be prescribed by your primary care doctor or psychologist that have been shown to improve chronic pain.

These include topical medications, like: lidoderm patches (works to numb the area of pain), diclofenac gel (works as an anti-inflammatory), muscle relaxants, and many patients can receive steroid injections (that also work as an anti-inflammatory). 

These also include medications pills, like SNRIs (venlafaxine and duloxetine), TCAs (amitriptyline and nortriptyline), and anti-epleptic medications (gabapentin and pregabalin), which have been shown to help with both chronic pain AND mood.

Are opioid medications recommended for chronic pain?

Per the CDC guidelines, opioid medications (like oxycodone/Percocet, hydrocodone/Vicodin, Dilaudid, morphine, codeine, fentanyl, methadone) are NOT first-line or routine therapy for chronic pain.

Recent studies have actually shown that anti-inflammatory medications, like ibuprofen, work just as well to manage acute pain flares as do these opioids. (1,2,3)

Another study showed that opioids provided at least 50% pain relief for only 44% of people taking them. This means that some people may get some benefit from opioid medications while a lot of people will not get any benefit from them.

All opioids come with side effects.

Common side effects from opioids include:

  • Erectile dysfunction
  • GI: nausea, constipation
  • Drowsiness
  • Sweating
  • Urinary retention
  • Respiratory suppression
  • Sleep apnea

Additionally, when taken over time, our bodies become “used to” these opioids-- a concept known as tolerance. That means that you will eventually stop feeling pain-relieving benefits and will need higher and higher doses to feel the same relief. 

And, when taken for more than a few weeks, your body will become dependent on them. That means if you miss a dose, you will start to feel awful withdrawal side effects, like agitation/anxiety, nausea/vomiting/diarrhea, and sweating.

There is also the risk of addiction. In fact, 10% of patients who are prescribed opioids for chronic pain go on to develop an addiction, in which they lose control of the medication, it consumes their life and causes many negative consequences personally and professionally (losing trust of loved ones, losing a job, unable to take care of kids or fulfill daily adult responsibilities).

If your doctor decides to prescribe opioids for chronic pain, this decision will usually be made after careful consideration of the benefits vs harms (also with an understanding that medications are only one small part of treating chronic pain). If you are prescribed opioids for chronic pain, you might have to come off other medications that interact with opioids and put you at risk for overdose and death. 

You will also be monitored frequently to ensure you are taking opioids safely and not developing an addiction. This often includes: signing a pain contract, frequent clinical visits, urine toxicology testing, pill counts, and your doctor will check the state’s prescription monitoring program to ensure you are taking your medications appropriately. Your doctor might also prescribe you the life-saving medication naloxone, in case you were to overdose.

Can buprenorphine/naloxone (Suboxone) be used to treat chronic pain?

Buprenorphine (a partial opioid) and found in the medication Suboxone does have pain-relieving properties. However, this is not what it is meant to be used for. When patients develop an addiction to opioids, buprenorphine/naloxone (Suboxone) can help patients by preventing cravings and withdrawals and overdose. Buprenorphine has other functions as well; it can also serve as a mild mood booster.

So, while it is used as a form of medications for addiction treatment (MAT) to treat addiction, it can also provide some pain relief and improved mood.

Other formulations of buprenorphine (a patch and an under-the-tongue formulation) are prescribed specifically for pain and NOT for addiction.

Putting it all together

Many patients suffer on a daily basis from chronic pain. While a patient’s pain will never likely be “cured” and they will always live with some pain, that does NOT mean they must continue to suffer.

One question to ask yourself is “What would my life be like if my pain were not there?” In thinking about this question, you can generate goals for yourself that may help you be happier even if you continue to live with pain.

There are a LOT of pain management strategies that exist. Many of these do NOT involve medications, and it will be important for you to find the best strategies that help you achieve your goals.

Opioid medications have a lot of side effects, can be unsafe, and can lead to addiction, overdose, and death. For these reasons, they are not considered the first-line treatment for chronic pain.

If you are started on opioids for chronic pain and you are worried that you are developing an addiction, talk to your doctor about getting addiction treatment.

Bicycle Health’s Online Suboxone Treatment

Bicycle Health is a telehealth company that helps patients dependent on opioids by providing evidence-based treatment--Buprenorphine/naloxone (Suboxone).

To learn more about the success rates and safety of Bicycle Health’s telemedicine addiction treatment in comparison to other common treatment options, call us at (844) 943-2514 or schedule an appointment here.

Photo Courtesy of Adrian "Rosco" Stef on Unsplash.

About the Author

Randi Sokol, MD, MPH, MMedEd

Randi Sokol, MD, MPH, MMedEd, is an Assistant Professor at the Tufts Family Medicine Residency Program and Instructor at Harvard Medical School. She is Board Certified in both Family Medicine and Addiction Medicine. She earned her B.A. at the University of Pennsylvania, her Medical Degree and Masters in Public Health from Tulane University, completed Family Medicine Residency at UC-Davis, and earned a Masters in Medical Education through the University of Dundee.

Citations

(1) Chang AK, et al.Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency DepartmentA Randomized Clinical TrialJAMA. 2017

(2) Mazer-Amirshahi M, Dewey K, Mullins PM, et al.: Trends in opioid analgesic use for headaches in U.S. emergency departments. Am J Emerg Med. 2014; 32: 1068-1073.

(3) Barnett ML, et al. The treatment of actue pain in the emergency department: A White paper postiion statement prepred for the American Academy of Emergency Medicine.

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