Chronic Pain and Opioid Use Disorder: Treating Both at the Same Time

Very few people arrive at residential treatment saying “I have an opioid use disorder.” Far more often, the sentence starts somewhere else: a back injury in 2019, a shoulder surgery, an autoimmune condition, a car accident that never fully resolved. The prescription was legitimate. The pain was real. And somewhere in the years that followed, the line between treating pain and needing the medication stopped being visible from the inside.

This is one of the harder presentations in addiction medicine, because the two problems argue with each other. Treat the pain aggressively and you may feed the use disorder. Remove the opioids and you may leave someone in genuine physical distress with no plan. People in this situation are often bounced between a pain clinic that will not manage addiction and a program that will not manage pain. Both problems are treatable, at the same time, by the same team.

Why Pain and Opioid Use Disorder Get Tangled Together

Two things happen over months and years of opioid therapy that make this predictable rather than unusual. The first is tolerance: the same dose does less, so the dose climbs, and the climb feels medically justified because the pain is genuinely still there. The second is that opioid withdrawal itself hurts. Muscles ache, joints throb, the nervous system turns up its sensitivity. So a person tapering down does not experience “less medication” — they experience their original pain plus withdrawal pain, arriving together, and reasonably conclude the medication was the only thing working.

There is also a phenomenon clinicians watch for called opioid-induced hyperalgesia, in which long-term opioid exposure appears to increase sensitivity to pain rather than reduce it. How often it occurs, and how much it contributes in any individual case, is still being studied. But it is one reason some people report that their pain is more manageable several months after coming off high-dose opioids than it was while on them — a result that surprises almost everyone who experiences it. The National Institute on Drug Abuse maintains accessible overviews of how opioid tolerance and dependence develop, and it is worth reading before assuming the problem is a character issue rather than a physiological one.

What the First Week Actually Feels Like

Honesty is more useful here than reassurance. In a medically managed detox, the first three to five days off short-acting opioids are physically miserable for most people: sweating and chills alternating, restless legs, a gut that will not settle, and almost no real sleep. When chronic pain is in the picture, add the specific complaint people voice most on day two, which is that their original pain site is now screaming. A person with lumbar disc disease will say their back has never been this bad. It is not imagined and it is not permanent.

What changes the week is what the medical team does with it. Comfort medications for nausea, cramping, and autonomic symptoms. Non-opioid analgesia where it is appropriate. Position changes, heat, gentle movement rather than bed rest, and a nursing staff that treats a 3 a.m. pain report as clinical information instead of drug-seeking. By roughly day five to seven, most people describe the withdrawal layer peeling off and the underlying pain becoming a defined thing again — still there, but no longer amplified by a nervous system in crisis. That distinction, felt rather than explained, is often the first moment a person believes treatment might work.

The Fear That Keeps People Out of Treatment

The most common reason people with chronic pain delay care is not denial. It is a specific and rational fear: that a treatment program will take away the only thing that lets them function and hand them a worksheet in return. Some have already had that experience somewhere else.

A program should be able to answer that fear directly at the assessment call, before admission. What is your approach to pain? Will there be a physician involved in pain management, not just addiction treatment? What happens if my pain is worse in week two? Who coordinates with my orthopedist or rheumatologist while I am here? Anyone can ask these questions of our admissions team at (877) 328-1968. A program that cannot give concrete answers is probably not the right setting for this presentation.

Medications That Can Address Both Problems

Medication decisions belong to a prescriber who has examined the person, so what follows is orientation, not a recommendation. Buprenorphine is often central to this conversation because it treats opioid use disorder and has analgesic properties of its own, which means for some people it addresses both targets with one medication. Dosing for pain can differ from dosing for use disorder alone, and the transition has to be timed carefully against the last opioid dose.

Naltrexone is a different tool entirely — it blocks opioid effects and offers no analgesia, so pain has to be covered by other means before it makes sense. Beyond opioid-specific medications, prescribers frequently build a non-opioid regimen from options used in chronic pain care generally, including certain antidepressants and anticonvulsants that act on nerve pain, topical agents, and scheduled non-opioid analgesics. The American Society of Addiction Medicine publishes clinical practice guidance on opioid use disorder treatment that informs how programs structure these decisions.

Non-Medication Pain Care That Earns Its Place

Some of what gets offered as holistic pain management is filler; the test is whether it changes what a person can actually do. Graded movement and physical therapy address the deconditioning that years of pain-driven inactivity produce, and deconditioning is itself a pain generator. Sleep restoration matters enormously, because pain tolerance drops sharply after poor sleep and poor sleep is nearly universal in early recovery. Cognitive behavioral approaches adapted for chronic pain target the catastrophizing loop — the jump from “this hurts” to “this will never improve and my life is over” — which measurably affects how disabling pain feels.

Trauma treatment belongs on this list too. A significant share of people with long-standing pain also carry post-traumatic stress, and the two amplify each other through a shared nervous system. Programs that integrate mental health treatment with addiction care are addressing both rather than sequencing them years apart.

When Other Substances Are Also in the Picture

Chronic pain rarely travels alone. Alcohol is a very common addition, used for sleep or for the hours when the prescription has worn off, and benzodiazepines are frequently co-prescribed for muscle spasm or anxiety. This changes the medical picture in a way that cannot be improvised at home. Withdrawal from alcohol and from benzodiazepines carries a risk of seizures, and in severe cases can be life-threatening — unlike opioid withdrawal, which is agonizing but not usually dangerous on its own. Anyone drinking heavily every day, or taking a benzodiazepine regularly, needs medically supervised withdrawal with a physician-directed taper. Stopping abruptly, or tapering without supervision, is the scenario that puts people in an emergency room. SAMHSA operates a free, confidential national helpline that can direct anyone to medically supervised options in their area, and the CDC publishes public guidance on opioid prescribing and overdose prevention.

One more safety point that applies to everyone in this group: tolerance falls fast after a period without opioids, so a return to a previously normal dose carries serious overdose risk. Naloxone should be in the house, and the people around the person should know where it is and how to use it.

What Families Notice

Families here often describe years of not knowing what they were looking at. The person was in pain, so the sleeping, the irritability, and the careful attention to refill dates all had an explanation. What families report noticing in hindsight is narrowing — fewer activities, fewer people, more of the day organized around medication timing — and a defensiveness that appeared only around that one subject.

The instinct to police the pill bottle is understandable and almost never productive. What helps more is being clear about what you have observed without diagnosing it, staying connected, and being informed enough about residential treatment to answer questions when the person is finally ready to ask them.

Building a Plan That Holds After Discharge

Residential treatment stabilizes this presentation; it does not finish it. A discharge plan for someone with chronic pain has to name specifics: who prescribes going forward, what the pain regimen is and who adjusts it, what the plan is for a flare, which specialists are involved and whether they are communicating with each other, and what happens if surgery becomes necessary later. Leaving without those answers means solving a medical problem alone under pressure, which is the circumstance that started this.

If you are weighing residential care for yourself or someone in your family, our team can talk through the clinical picture, coverage, and whether this level of care fits — call (877) 328-1968 or check your benefits through our insurance verification page.

This article is for educational purposes only and is not medical advice, a diagnosis, or a treatment recommendation. Decisions about opioid medications, tapering, and pain management should be made with a qualified clinician who knows your history. If you are experiencing a medical emergency, or you suspect an overdose, call 911.