The pain is not the part anyone is disputing. Results from the 2019 National Health Interview Survey show that about 20.4 percent of US adults had chronic pain, defined as pain on most days or every day in the past three months [2]. About 7.4 percent had high-impact chronic pain, which limited their life or work activities on most days or every day [2]. This page is for people inside those numbers who have also become dependent on the medication that was supposed to help.
Nothing here suggests stopping a prescription. Opioid withdrawal can occur any time long-term use is stopped or cut back [3], and the decision about a prescription belongs to the prescriber who wrote it. What this page covers is what an honest assessment looks at, what integrated treatment actually does, and why pain care and dependence care have to happen in the same plan rather than in sequence.
Below: why the order of arrival is a distraction, how pain and opioid use tighten around each other, what the assessment separates, what the medications are for, which non-drug approaches have evidence behind them, and what a discharge plan has to carry. Our hub on co-occurring disorders covers the wider category.
Which came first, and why the answer matters less than people think
Here the sequence is usually known, and it still does not settle anything.
Prescription medications such as oxycodone, hydrocodone, morphine, codeine and fentanyl are mainly used for the treatment of pain [1]. So the common story is not a mystery: pain came first, a prescription followed, and the body adapted. Repeated opioid use can lead to dependence, where a person’s body adapts to the presence of the opioid [1]. When the body adapts, it may also respond less and less to the drug, which is tolerance [1].
Knowing that sequence does not tell anyone what to do next, because the pain is still there. Opioid use, even as prescribed by a health care provider or only for a short time, can lead to negative health effects [1]. A plan that treats the dependence and ignores the pain has removed the reason the medication was there.
How pain and substance use reinforce each other
They tighten around each other through sleep, mood and fear.
Pain can affect quality of life and productivity, and it may be accompanied by difficulty in moving around, disturbed sleep, anxiety, depression, and other problems [2]. Every one of those makes pain harder to tolerate, which makes medication feel more necessary.
Then the body’s side of it. Physical dependence means a person needs to take the medicine to prevent withdrawal symptoms, and over time more of the medicine is needed for the same effect [3]. Early withdrawal symptoms include agitation, anxiety, muscle aches, watering eyes, insomnia, a runny nose, sweating and yawning [3]. Muscle aches are on that list, which is the trap in plain sight. TIP 45 states the mechanism directly. Any condition involving pain is likely to worsen during opioid withdrawal, because of a reduced pain threshold and the lack of pain relief afforded by opioid use [6]. It names chronic back pain and dental pain as the common cases.
The third loop is fear, and it is rational. Someone who has lived through both the pain and the withdrawal is not being difficult when they resist a change to the prescription. They are predicting, accurately, that it will hurt. A plan that does not address that is not going to be followed.
If someone is unresponsive, has trouble breathing or may have overdosed, call 911. Use naloxone if it is available [1]. For a mental health crisis, call or text 988.
Assessment for opioid dependence in Georgia
Promises Atlanta, in Dacula, Georgia, publishes medical detox, residential rehab and aftercare planning, and describes itself as a place for people with substance use disorders and co-occurring mental health conditions. Tell admissions about a pain condition and every current prescription on the first call, because both change what is appropriate.
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Promises Atlanta is part of our family of treatment centers. See the Promises Atlanta campus.
Why treating one without the other usually fails
Because each version of half-treatment produces a predictable failure.
Treat the dependence alone and the pain is untreated, which is both cruel and unstable. NIDA’s general position on co-occurring conditions is that it is usually better to treat them at the same time rather than separately [5], and pain is the clearest case of why. Treat the pain alone and nothing about the dependence changes.
Integrated care combines mental health and substance use treatment so patients can receive more convenient, coordinated care in one place [4]. Applied here, that means a pain clinician and an addiction clinician who have read the same notes. It is not a luxury feature. It is the only arrangement in which someone can be honest about both problems in one room.
The stakes are higher in this pairing than in most. The biggest complication of opioid withdrawal is returning to use, and most opioid overdose deaths occur in people who have just detoxed [3]. If someone is unresponsive, has trouble breathing or may have overdosed, call 911 and use naloxone if it is available [1]. For a mental health crisis, call or text 988.
Assessment: separating substance-induced symptoms from an independent disorder
Three questions, and none of them is answered by a drug test.
The first is what the pain actually is. Chronic pain is pain that lasts more than several months, variously defined as three to six months, but longer than normal healing [2]. A pain condition with a diagnosis, a scan and a specialist is a different planning problem from pain that has outlived its original cause.
The second is what withdrawal is contributing. Early withdrawal brings muscle aches, agitation and insomnia; later symptoms include abdominal cramping, diarrhea, dilated pupils, goosebumps, nausea and vomiting [3]. Those symptoms are very uncomfortable but are not life threatening [3], and unlike alcohol and sedative withdrawal, uncomplicated opioid withdrawal is not life-threatening [6]. The same TIP 45 paragraph carries the other half. Medical complications associated with opioid withdrawal can develop and should be quickly identified and treated [6]. It names vomiting or diarrhea leading to dehydration or electrolyte imbalance [6]. It names underlying cardiac illness made worse by the autonomic arousal of withdrawal [6]. It names fever that needs its own workup, and panic anxiety growing more intense [6]. MedlinePlus adds breathing stomach contents into the lungs, which it calls aspiration, and which can cause lung infection [3]. And above all the danger sits in what happens afterward.
The third is what else is going on. Anyone going through detox for opiates or opioids should be checked for depression and other mental illnesses, and treating those disorders can reduce the risk for relapse [3]. Accurate diagnosis matters here because symptoms may overlap [4].
If someone is unresponsive, has trouble breathing or may have overdosed, call 911. Use naloxone if it is available [1]. For a mental health crisis, call or text 988.
Our explainers on medical detox and withdrawal symptoms describe what supervision involves.
Integrated dual diagnosis treatment, level by level
The rungs are the same as for any substance. What changes is who else is in the room.
Withdrawal management, where it is indicated, is the shortest and most medical stage. Pain management does not pause during it, and a program that cannot say how it handles pain in that window is telling you something.
Inpatient rehab is where a pain plan that does not depend on escalating opioids gets built, if it is going to be built at all. That work is slow, and it is worth asking a program how much of it happens before discharge.
Step-down and outpatient care is where it is tested against a real body doing real work. Most people need long-term treatment after detox, which can include self-help groups, outpatient counseling, intensive outpatient treatment and inpatient treatment [3]. Our guide to levels of care explains how the rungs fit together.
Medication considerations when both are present
Medication is the standard of care for the dependence, and it is not the same conversation as pain relief.
Medications are the standard of care for opioid use disorder, and the ones approved by the US Food and Drug Administration are methadone, buprenorphine and naltrexone [1]. Research has shown these medications can reduce the risk of return to drug use and of overdose death [1]. People who go through withdrawal over and over should be treated with long-term methadone or buprenorphine maintenance [3].
This page gives no doses, no schedules and no instructions for changing a prescription. Those are decisions for a prescriber who has examined the person, and contacting your provider is the right step if you are using or withdrawing from opioids [3]. Our page on medication assisted treatment explains how these medications work alongside therapy.
One practical note for the pain side. Bring the full prescription list, the prescriber’s details and any imaging or specialist letters to the assessment. A pain history reconstructed from memory at intake is how a plan ends up ignoring the thing it most needs to account for.
Therapies with evidence for co-occurring presentations
Two evidence bases have to be used at once, and neither is a substitute for the other.
On the substance use side, cognitive behavioral therapy, contingency management, and motivational interviewing can help individuals build coping skills [4]. Treatment may include medications, psychosocial interventions, or a combination, depending on the needs of the individual and the substance or substances involved [5].
On the pain side, a growing body of evidence suggests that some complementary approaches, such as acupuncture, hypnosis, massage, mindfulness meditation, music-based interventions, spinal manipulation, tai chi, qigong, and yoga, may help to manage some painful conditions [2]. Keep the hedge that NCCIH uses. These are described as approaches that may help manage some conditions, not as replacements for medical care, and what suits one pain condition may do nothing for another.
Our overviews of substance abuse counseling techniques and dialectical behavior therapy describe what the behavioral sessions involve.
Relapse risk and what aftercare needs to cover
This is the section that matters most, because the risk is not evenly spread over time.
Withdrawal reduces the person’s tolerance to the medicine, so those who have just gone through withdrawal can overdose on a much smaller dose than they used to take [3]. That single sentence is the reason aftercare for opioids is not optional and the reason a planned step-down beats an abrupt finish. If someone is unresponsive, has trouble breathing or may have overdosed, call 911 and use naloxone if it is available [1]. For a mental health crisis, call or text 988.
So the discharge plan has to name several things in writing. Who is managing the pain, with a date. Whether medication for opioid use disorder is continuing, and who prescribes it. Whether naloxone is in the house, and whether the people around the person know where it is. NIDA says naloxone and nalmefene are available as nasal sprays and can be carried and administered by anyone, and that naloxone is sold over the counter without a prescription [1]. A named human to call on a bad night. And a plan for the specific situations that used to end in taking more.
Depression and other mental illnesses belong on that list too, because treating them reduces the risk of relapse [3]. Our page on how to get into rehab covers what the first call involves.
Frequently Asked Questions
Will my pain medication be stopped if I go to treatment? Not as a default, and not by anyone who has not examined you. What happens to a prescription is decided by prescribers with your records in front of them, and the right first step is to contact your provider if you are using or withdrawing from opioids. Bring the full medication list and any specialist letters to the assessment, so the pain condition is part of the plan from the start rather than a complication discovered later.
Is opioid withdrawal dangerous? The symptoms are very uncomfortable but are not life threatening, and unlike alcohol and sedative withdrawal, uncomplicated opioid withdrawal is not life-threatening. The same TIP 45 paragraph adds that medical complications associated with opioid withdrawal can develop and should be quickly identified and treated. The danger sits around it. Breathing stomach contents into the lungs, which MedlinePlus calls aspiration. Dehydration from vomiting and diarrhea. Underlying cardiac illness made worse by the autonomic arousal of withdrawal. And above all the drop in tolerance afterward: most opioid overdose deaths occur in people who have just detoxed. If someone is unresponsive, has trouble breathing or may have overdosed, call 911 and use naloxone if it is available. For a mental health crisis, call or text 988.
What is the difference between dependence and addiction? Dependence means the body has adapted, so the medicine is needed to prevent withdrawal symptoms, and over time more is needed for the same effect. That can happen to someone taking a prescription exactly as written. Addiction is a different thing: opioids promote brain activity that can lead to changes in mood and thinking, and opioid use disorder has its own diagnosis and its own treatment. The two overlap often, which is why an assessment rather than a self-diagnosis is the useful next step.
Can chronic pain be managed without relying on opioids? For some conditions there is evidence for non-drug approaches. NCCIH reports that a growing body of evidence suggests some complementary approaches, including acupuncture, hypnosis, massage, mindfulness meditation, spinal manipulation, tai chi and yoga, may help to manage some painful conditions. Keep the hedge in that sentence. What works for one pain condition may do nothing for another, and none of it is a decision to make without the clinician treating the pain.
Does insurance cover treatment when chronic pain is part of the picture? Usually in some form, though the specifics decide everything. Marketplace plans must include mental health and substance use services among the essential health benefits, and they cannot apply yearly or lifetime dollar limits to that care. Ask whether pain treatment and addiction treatment are billed separately before admission. We claim no network status with any carrier, so verify benefits against your own member ID.
Sources
- National Institute on Drug Abuse. Opioids. National Institutes of Health. https://nida.nih.gov/research-topics/opioids
- National Center for Complementary and Integrative Health. Chronic Pain and Complementary Health Approaches: Usefulness and Safety. National Institutes of Health. https://www.nccih.nih.gov/health/chronic-pain-what-you-need-to-know
- MedlinePlus. Opiate and opioid withdrawal. National Library of Medicine, National Institutes of Health. https://medlineplus.gov/ency/article/000949.htm
- National Institute of Mental Health. Finding Help for Co-Occurring Substance Use and Mental Disorders. National Institutes of Health. https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health
- National Institute on Drug Abuse. Co-Occurring Disorders and Health Conditions. National Institutes of Health. https://nida.nih.gov/research-topics/co-occurring-disorders-health-conditions
- Center for Substance Abuse Treatment (2006). Detoxification and Substance Abuse Treatment, TIP 45, Chapter 4: Physical Detoxification Services for Withdrawal From Specific Substances. SAMHSA, NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK64116/
- HealthCare.gov. Mental health and substance abuse health coverage options. US Centers for Medicare and Medicaid Services. https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/
This page is for general information and is not medical advice. Only a licensed clinician who knows your history can tell you what is right for you. If you or someone you know is in immediate danger, call 911. For free, confidential support 24/7, call or text 988.
Author
Chief Medical Officer,
The Recovery Village
