Chronic pain and opioid use disorder together

A man in his fifties has been taking oxycodone for eight years for low back pain after two spine surgeries. The dose went up gradually. In recent months, he asked for early refills twice, and the pharmacy warned that he also receives prescriptions from another doctor. At the visit, he says the pain is worse than ever and that without the medication he cannot get out of bed. The scene is fictional and was written for teaching. This text uses that encounter as a setting for clinical reasoning: how to assess when chronic pain and opioid use disorder coexist, without falling into "all or nothing", how to think about acute pain in someone on agonist treatment, and how to reduce a long-standing dose safely.

NEXO is a daily medical diagnosis game: one clinical case a day, up to six progressive clues, and ICD-10 proximity feedback across five levels.

The text avoids being a prescribing protocol. Doses, conversions and tapering schedules follow the guidelines and protocols of each service, under supervision. The choice between buprenorphine and methadone and the initiation of buprenorphine have already been discussed in other posts in the series, and here the focus is on how to think about the meeting of pain and the disorder. If you play the case of the day on NEXO, you will recognize the move: each new clue changes the weight of the hypotheses, and no single clue closes the case.

Key points

• Chronic pain and opioid use disorder can coexist, and recognizing one of them opens space to treat both.
• Physical dependence and tolerance are expected with prolonged use and are different from opioid use disorder.
• The 2022 CDC guideline recommends individualized decisions, avoids abrupt discontinuation and advises offering treatment for the disorder when it is present.
• Observational studies link dose reduction and opioid discontinuation to a higher risk of overdose and mental health crisis, which reinforces the importance of pace and follow-up.
• Acute pain in someone on agonist treatment is often undertreated; buprenorphine is generally maintained in the perioperative period.

Why "all or nothing" fails in this encounter

Faced with a person who has chronic pain and signs of problematic opioid use, two extreme responses often appear. The first is to keep everything as it is, for fear of withdrawal, conflict or worsening the pain. The second is to stop at once, for fear of causing harm or of being complicit. Both leave the person without treatment for at least one of the problems.

The 2022 CDC guideline for prescribing opioids for pain recognizes this dilemma. It recommends that decisions be individualized, that benefits and risks be reassessed with the person, that abrupt discontinuation be avoided in those using higher doses for a prolonged time, and that treatment for opioid use disorder be offered or arranged when it is present (Dowell et al., 2022). The post on harm reduction beyond all or nothing develops this logic for other scenarios.

What the evidence says about long-term opioids

A systematic review by Chou et al. for the National Institutes of Health found insufficient evidence on the benefit of long-term opioids in chronic pain and evidence of dose-dependent harms, such as overdose, fractures and myocardial infarction (Chou et al., 2015). The SPACE randomized trial compared opioids with non-opioid analgesics in people with chronic low back pain or hip or knee osteoarthritis pain and showed that opioids were inferior to non-opioids in function over twelve months, with no advantage in pain-related function (Krebs et al., 2018).

These data help explain why a long-standing high dose deserves reassessment. They also remind us that reassessing is different from withdrawing: the person who has used an opioid for years has an adapted physiology, and the change must respect that.

Physical dependence, tolerance and use disorder

The distinction between physical dependence and opioid use disorder is central to the reasoning. Anyone who uses an opioid every day for months will develop tolerance and will have withdrawal if they stop abruptly. This is an expected physiological response, not a diagnosis. Opioid use disorder involves loss of control, use despite harm, impairment in important roles and intense craving, in addition to tolerance and withdrawal.

Manhapra and colleagues described a gray zone between these two poles, which they called complex persistent opioid dependence: people on prolonged use who develop symptoms that are hard to separate between pain, withdrawal between doses and worsening mood, without clearly meeting the criteria for the disorder, and who may worsen with either maintenance or reduction (Manhapra and colleagues, 2020).

Finding	Physical dependence	Gray zone	Opioid use disorder
Tolerance and withdrawal	Present, expected	Present, with withdrawal between doses	Present, but insufficient for the diagnosis
Control over use	Use as agreed	Requests for an increase, difficulty with the regimen	Loss of control, use beyond what was prescribed
Function	Maintained or better with treatment	Gradual worsening of pain and mood	Impairment at work, in the family and in health
Other sources of opioid	Absent	Sometimes	Common, but not required
Most helpful clue	Stability over time	Worsening despite a dose increase	Use despite clear harm

The table is a support for reasoning, not a diagnostic instrument. The formal criteria follow the manual adopted by the service, and the assessment needs time and a relationship of trust.

Clues that call for a deeper conversation

• Frequent requests for renewal before the due date or repeated reports of lost prescriptions.
• Prescriptions from more than one prescriber or from several pharmacies.
• Use of an opioid to relieve anxiety, insomnia or sadness, not only pain.
• Worsening pain despite a progressive dose increase.
• Use of other substances, especially alcohol and benzodiazepines.
• Concern from family members about the use or about episodes of excessive sedation.

Each clue on its own has several possible explanations. Early renewal may indicate poorly controlled pain, withdrawal between doses or use outside what was agreed. The reasoning calls for curiosity, not accusation.

The bias of distrusting pain

When a person has an opioid use disorder, or even when there is suspicion, their pain starts to be read with distrust. Every complaint becomes a possible search for the drug. This bias has consequences: Alford and colleagues described how acute pain in people on methadone or buprenorphine treatment is often undertreated and pointed out four common misconceptions among professionals: that the maintenance agonist already treats the pain, that additional opioids cause relapse, that the combination causes respiratory depression and that the pain complaint is merely a search for the drug (Alford and colleagues, 2006).

The label weighs on the decision. Kelly and Westerhoff showed that the way a person who uses a substance is named changes professionals' judgment of blame and punishment (Kelly and Westerhoff, 2010). The post about stigma and language shows how to replace labels with person-centered descriptions.

How the bias shows up in the chart

Anchoring on the label. The word "dependent" on the first line makes any complaint a suspicion.

Attributing everything to the disorder. A new pain, somewhere else, is read as a search for the drug, and the physical exam stays superficial.

Affective bias. Irritation with frequent requests reduces the patience to listen and examine.

The post about affective bias explains how the professional's emotions change the reasoning, and the theme appears often in consultations about opioids.

Opening the conversation and assessing without a label

The way you open the conversation changes the answer. "You are addicted" shuts down the dialogue. "I noticed some signs that the medicine may be causing more problems than it helps with, and I wanted to understand how it is going for you" opens space. Motivational interviewing helps when there is ambivalence: the person fears the pain without the medicine and, at the same time, notices that life has shrunk. The post on motivational interviewing for students and residents explains how to explore both sides without pressuring.

The assessment includes pain, function, mood, sleep, use of other substances and the person's goals. Measuring only pain intensity tends to push the decision toward increasing the dose. Asking what the person wants to get back to doing, such as walking to the bakery or sleeping through the night, gives a functional goal that serves as a yardstick for any change.

Phrases that often help

• "What does the pain stop you from doing today that you would like to get back to doing?"
• "How has the medicine been working over the last few months, for the pain and for the rest of life?"
• "Sometimes, over time, the medicine stops helping as much and starts causing other problems; does that make sense to you?"
• "If we change something, I want to do it together with you and at your pace."

The fictional example, again

Back to the man from the opening: the early renewals, the prescriptions from another doctor and the pain that worsens despite the growing dose are clues that call for conversation, not a conclusion. One possible reading is opioid use disorder. Another is poorly controlled pain with withdrawal between doses. A third is the gray zone described by Manhapra and colleagues. The next appointment can explore what happens in the hours before the next dose, whether he uses the medicine to sleep or to relieve distress, whether he has already tried to reduce and what happened, and what he would like to recover in his routine. The answers change the weight of each hypothesis and, with that, the course of action.

Recording the open hypotheses, and not a closed label, protects the next appointment. Whoever sees the patient next finds the reasoning, the clues still missing and what was agreed, and avoids starting over from distrust.

Approaches beyond the opioid

The SPACE trial reminds us that non-opioid analgesics can offer comparable or better function in some chronic pains (Krebs and colleagues, 2018). The CDC guideline also recommends considering non-pharmacological therapies and non-opioid analgesics as a central part of chronic pain care (Dowell and colleagues, 2022). For the person living with pain and use disorder, this means building a care network: guided physical activity, physical therapy, addressing sleep, attention to mood and psychological support, according to what is available at the service.

This network has an extra role in dose reduction. When the person has other ways of dealing with pain and distress, the reduction stops looking like the removal of the only available tool. Combining these approaches before touching the dose usually makes the conversation easier.

When there is a disorder: treat the pain and the use

When the diagnosis of opioid use disorder becomes clear, agonist treatment becomes part of pain care, and not an alternative to it. The CDC guideline advises offering or arranging medication treatment for the disorder (Dowell and colleagues, 2022). The choice between buprenorphine and methadone depends on the context, the person's preference and access, and the post on buprenorphine or methadone discusses how to make this choice with the person.

Switching from a long-standing opioid to buprenorphine has particularities, such as the risk of precipitated withdrawal. The post on precipitated withdrawal at the start of buprenorphine explains the reasoning behind induction, and this text avoids repeating the receptor pharmacology.

Who takes care of what

When chronic pain and use disorder coexist, the person often moves between several services: primary care, pain clinic, disorder treatment service and emergency department. Each one sees a part of the picture. Agreeing on who prescribes the agonist, who follows the pain and how information circulates avoids overlapping prescriptions, contradictory messages and gaps at the weekend. This agreement also reduces the chance of the person being treated as a suspect at every new visit, because the record shows that there is organized care and a reference professional.

Splitting the dose across the day

In people who use buprenorphine and also have chronic pain, dividing the usual daily dose into doses every 6 to 8 hours is an option described in clinical guidance, for better pain coverage (VA, 2022). The decision follows the service's protocol and the individual assessment.

Acute pain in someone on agonist treatment

A person on methadone or buprenorphine treatment can break a leg, have appendicitis or need surgery. At these times, the maintenance dose treats withdrawal, but it rarely suffices for acute pain. The review by Alford and colleagues recommends keeping the maintenance dose, treating acute pain with multimodal analgesia and, when necessary, additional opioids in doses adjusted to tolerance (Alford and colleagues, 2006).

In the perioperative period, the practice of stopping buprenorphine before surgery was common for a long time. A panel from several anesthesia and pain societies recommended that buprenorphine generally be maintained in the perioperative period, without routine interruption, and that it can even be started in this period in selected people (Kohan and colleagues, 2021). The final decision is made with the anesthesia team and the service, considering the size of the surgery and the dose in use.

What usually goes into the reasoning

1. Confirm the maintenance dose with the service that follows the person.
2. Keep the agonist and agree on what to do if the person has to fast.
3. Use multimodal analgesia, with non-opioid analgesics and regional techniques when possible.
4. Adjust additional opioids to tolerance, with monitoring.
5. Agree on the transition back to the usual regimen at discharge, with communication to the service of origin.

Reducing a long-standing opioid dose

When a person has used an opioid for years and shared decision-making points to reducing it, the pace of the reduction is a safety question. A cohort study with data from United States insurers showed that dose reduction in people who had used stable doses for a long time was associated with a higher rate of overdose and mental health crisis in the following months (Agnoli and colleagues, 2021). A later analysis by the same group found this association up to two years after the start of the reduction (Fenton and colleagues, 2022). In United States veterans, stopping opioids was associated with a higher risk of death from overdose or suicide, and the risk was higher in those who had used opioids for longer (Oliva and colleagues, 2020).

These studies are observational and have limitations: people whose dose is reduced may differ from those who keep it. Even so, they changed the way reduction is thought about. The 2022 CDC guideline recommends that reduction be gradual, individualized and closely followed, with attention to mood, suicide risk and the emergence of substance use disorder (Dowell and colleagues, 2022).

Before reducing: what to check

Before starting the reduction, it is worth checking a few points with the person. What functional goal do they want to reach? Is there depression, anxiety or suicidal ideation that needs treatment before or alongside? Is there use of other substances, such as alcohol and benzodiazepines, that increases the risk of overdose? Does the person have naloxone at home and know how to use it? Who is the reference professional if withdrawal or pain become difficult? These answers help agree on a realistic pace and a path for rapid return. The post on opioid overdose and the naloxone decision discusses when naloxone enters the reasoning.

Signs that call for a pause or a change of strategy

• Major worsening of mood or suicidal ideation.
• Intense withdrawal that compromises function.
• Seeking opioids from other sources or use of illicit substances.
• Worsening pain that leads to loss of function.

Faced with these signs, the response can be to slow down, pause or reassess the diagnosis. When a substance use disorder that was previously hidden appears, switching to agonist treatment may be safer than insisting on the reduction.

How NEXO helps train this reasoning

In NEXO, the case of the day is fictional, with a real clinical presentation and up to six progressive clues. You propose a diagnosis by looking for the ICD-10 code and receive feedback on proximity in five levels, which shows whether the guess landed on the exact code, the same category, the same group, the same chapter or a different chapter. This format connects with the theme of this text: separating physical dependence, poorly controlled pain and opioid use disorder requires reading overlapping clues, and the feedback shows how close the guess came.

To use the case of the day as training, try three habits. Before each guess, ask whether the most salient label is covering another explanation. When a complaint looks like "drug seeking", write down the most likely clinical alternative. After the result, note which clue you read with too much or too little suspicion.

Three exercises with cases

Separate the three pictures. For a fictional case of prolonged use, write what favors physical dependence, the gray zone and opioid use disorder.

Plan for acute pain. For a fictional person on buprenorphine treatment who is going to have surgery, write the steps you would discuss with the team.

Rewrite the opening. Take an accusatory sentence from a consultation and rewrite it with person-centered language and a focus on function.

The post on learning based on clinical cases shows why training with cases helps lock in this type of decision.

The limits on using the game are described on the NEXO Economy page. If you research the teaching of clinical reasoning, the page for Researchers explains how to get in touch. Professionals who write or review cases find information on Curator and on Creators, and institutions can learn about the proposal on the partnerships page.

Frequently asked questions

Does physical dependence mean opioid use disorder?

Physical dependence is an expected adaptation to daily, prolonged use and appears in anyone in that situation. Opioid use disorder involves loss of control, use despite harm and impairment in life, and the diagnosis calls for a broader assessment.

Should everyone on a high dose for a long time reduce it?

The CDC guideline recommends reassessing benefits and risks with the person and deciding on an individual basis. Reduction is one of the options, alongside maintenance with follow-up and switching to agonist treatment when there is a disorder.

What is a safe pace of reduction?

The pace is individual and follows the service's protocol. In general, gradual reductions, with pauses when needed and monitoring of mood and function, are preferred to rapid reductions.

Can people on buprenorphine receive analgesia in the emergency department?

They can and should. The maintenance dose is usually kept, and acute pain is treated with multimodal analgesia and, when necessary, additional opioids adjusted to tolerance, with monitoring.

Should buprenorphine be stopped before surgery?

A panel from several societies recommended keeping buprenorphine in the perioperative period, in general, and deciding together with the anesthesia team. The dose and the size of the surgery are part of the conversation.

How should frequent requests for refills be approached?

With curiosity. An early refill can indicate poorly controlled pain, withdrawal between doses, use outside the agreed plan or other sources of opioid. Asking how the medication has been used helps choose the next step.

Final checklist

• I assessed pain, function, mood, sleep and use of other substances, in addition to pain intensity.
• I separated physical dependence, the gray zone and opioid use disorder before deciding.
• I opened the conversation without a label and with a focus on functional goals.
• I offered agonist treatment when the disorder became clear.
• For acute pain, I kept the agonist and agreed on multimodal analgesia with the team.
• I planned any reduction gradually, with monitoring of mood and overdose risk.

Want to practice reasoning with progressive clues? Play the case of the day.

References

1. Agnoli A, Xing G, Tancredi DJ, et al. Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids. JAMA. 2021. PMID 34342618.
2. Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006. PMID 16418412.
3. Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015. PMID 25581257.
4. Dowell D, Ragan KR, Jones CM, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain, United States, 2022. MMWR Recomm Rep. 2022. PMID 36327391.
5. Fenton JJ, Magnan E, Tseregounis IE, et al. Long-term Risk of Overdose or Mental Health Crisis After Opioid Dose Tapering. JAMA Netw Open. 2022. PMID 35696163.
6. Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy. 2010. PMID 20005692.
7. Kohan L, Potru S, Barreveld AM, et al. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Reg Anesth Pain Med. 2021. PMID 34385292.
8. Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018. PMID 29509867.
9. Manhapra A, Sullivan MD, Ballantyne JC, et al. Complex Persistent Opioid Dependence with Long-term Opioids: a Gray Area That Needs Definition, Better Understanding, Treatment Guidance, and Policy Changes. J Gen Intern Med. 2020. PMID 33159241.
10. Oliva EM, Bowe T, Manhapra A, et al. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ. 2020. PMID 32131996.
11. U.S. Department of Veterans Affairs, Pharmacy Benefits Management Services. Perioperative Pain Management Guidance for Patients on Chronic Buprenorphine Therapy Undergoing Elective or Emergent Procedures. 2022. va.gov.