Physical pain is a relapse trigger for recovering opioid addicts, especially after they’ve tapered off maintenance medications. While on maintenance medications, most patients can no longer get high from opioids, and so are less likely to take prescribed opioid medication in destructive ways. Once off maintenance medications, patients can again feel euphoria from opioids, even when taking opioid medications as prescribed. This can lead to medication misuse and eventual relapse back into active addiction.
Pain can be acute (think broken bones or a kidney stone), or more chronic and persistent, as in chronic back pain. Acute pain by definition resolves within a short time, and there are ways to reduce the risk of relapse for the relatively short time opioids are necessary. Before a patient on maintenance medications (methadone or Suboxone) even begins a taper, he should have a clear plan for handling an acutely painful event.
Here are some ideas:
- Tell the prescribing physician that you’ve had problems with addiction to opioids in the past. Try to use a non-opioid pain medication if possible
- If you have to take opioids, ask the doctor to prescribe fewer pills at a time, and have more frequent follow up visits, for more accountability
- Have a dependable non-addict hold your pill bottle and dispense to you as prescribed.
- Tell your circle of supporters, whether that’s friends, family, and/or your 12-step group members that you need to take pain pills, and could use extra support and accountability.
- Read the booklet published by Narcotics Anonymous, “In Times of Illness”
- Ask a dependable friend or family member to do daily pill counts for more accountability, if you don’t have someone that can hold your pill bottle
A patient with chronic pain obviously has a more complicated situation. Preferably, the recovering opioid addict can find some way to manage the chronic pain without opioids. If that’s possible, then the patient can slowly bring down their dose of methadone or buprenorphine, knowing that if pain returns, there’s a non-opioid way to managing it.
For a patient who can’t find an adequate non-opioid way to relieve chronic pain, staying on maintenance medications may be the best option. Methadone and buprenorphine (Suboxone) prevent opioid withdrawal symptoms for longer than 24 hours in most patients, which is why we use them to treat addiction. But the anti-pain effect wears off at about six hours after dosing. Therefore, methadone and buprenorphine may not be ideal for pain management, but may be enough to bring the patient’s pain to manageable levels. For this reason, a patient with both pain and addiction may reasonably decide to stay on maintenance medications. If such a patient does taper off maintenance medications, every flare of pain is a potential relapse trigger.
For more on management of pain on maintenance medications like Suboxone and methadone, please see my blog entry of 10/16/11.