Finding Freedom, Mind and Body: Pain Management During Addiction Treatment

The first avenue often explored for those suffering from opioid addiction and chronic pain involves non-opioid medications, which can offer safe, effective pain relief without risk of addiction. While some of these medications are simply non-opioid pain relievers such as NSAIDs, they may also include off-label use of antidepressants and anticonvulsants. According to the Mayo Clinic, “Some of the more effective and commonly used medications for chronic pain are drugs that were developed to treat other conditions.” Antidepressants in particular are considered a “mainstay in the treatment of many chronic conditions, even when depression isn’t recognized as a factor.” Although the exact pain-relieving mechanism of antidepressants isn’t fully understood, experts believe that they may alter neurotransmitter activity to reduce pain signals.

Although many people experience significant pain relief through the use of antidepressants, the effects are not instant. Unlike opioids or NSAIDs, it can take several weeks to see the full effects of these medications.

Methadone and buprenorphine can be used with great success as relapse prevention medications,and are an integral part of treatment for many struggling with opioid addiction regardless of genesis. However, these medications can also provide pain relief benefits without the risks attendant to prescription opioid painkillers, and buprenorphine in particular is currently in use for chronic pain management even in non-addicted patients. As Dr. Lucinda Grande, a family physician who specializes in chronic pain and addiction medicine, writes,

Buprenorphine is often, in my experience, like a magical key that frees people from their seemingly inescapable dungeon. It is an opioid pain medication with a unique profile that fits the lock precisely. It blocks withdrawal symptoms and craving. There is no drug ‘high.’ Patients trade sluggishness for a fresh energy. Best of all, the hovering risk of overdose death vanishes.

While these medications can provide great relief for many, you must be continuously monitored for the duration of your treatment, making them impractical for some.

As the dangers of mass opioid prescription have become undeniable, there has been a surge of interest in non-medication based chronic pain intervention. From individual psychotherapy to yoga, acupuncture to mindful meditation, a range of psychotherapeutic and holistic practices have shown various degrees of promise in the treatment of chronic pain for both addicted and not addicted patients. A study published last year in Addiction found that pairing behavioral and social support through group meetings significantly helped opioid-addicted veterans suffering from chronic pain by applying “techniques that help patients adapt to pain, distract from pain, and conceive techniques to function concurrently with pain.” Although the group met only for a total of 10 weeks, the effects lasted significantly longer—approximately one year.

While it is not known exactly why most of these approaches work, Dr. Sean Mackey, Chief of the Pain Management Division at Stanford University, believes that a large part of it is in the emotional and behavioral changes promoted by these therapies. “Many treatments we use in substance abuse overlap with chronic pain treatment—the psychological and behavioral skills are the same,” he explains. By developing meaningful coping skills, you can potentially learn to manage your pain both practically and emotionally, diminishing its damaging impact on your life and your need for other types of treatment.

Ideally, you would be able to walk away from the substance of addiction and never turn back. However, with some types of addictions abstinence-based recovery is simply not possible—food addiction, sex addiction, and, yes, sometimes opioid addiction. There are some forms of pain that do not respond fully to non-opioid treatments or even to methadone and buprenorphine, making an abstinence-based approach both inhumane and dangerous, as your pain may spur you toward illicit drug use in an attempt to find relief. In these cases, your overall quality of life, drug-use history, and stage of recovery and must be carefully considered to determine if you are a candidate for structured opioid therapy.

Structured opioid therapy is “the use of opioids (other than methadone or burprenorphine) to treat chronic non-cancer pain, including patient education, a written treatment agreement, agreed-on dispensing intervals, and frequent monitoring.” In these cases, patients who are not currently using other drugs may be prescribed opioid painkillers—preferably one that is different from the drug of addiction—under strict supervision and in tightly controlled dosages. This form of treatment is generally considered a last resort for those recovering from opioid addiction, as it carries a significant relapse risk and may require extensive oversight in the form of regular urine drug screening, pill and patch counts, and ongoing effectiveness evaluations. However, when used in concert with a variety of other supports, structured opioid therapy can be a promising option. Says Dr. Mackey,

While even the most careful clinical pain management cannot eliminate risk of opioid misuse in patients with a history of addiction, good communication, knowledge of non-opioid treatment alternatives and appropriate monitoring and care in structuring opioid management can reduce risk significantly.