How should I approach the management of a patient with opioid dependence who is also experiencing chronic pain?

Management of a patient with opioid dependence who is also experiencing chronic pain requires a careful, integrated approach combining pharmacological and psychosocial treatments tailored to the individual's needs and goals.

Initial assessment should confirm opioid dependence with evidence of regular opioid use and evaluate the nature and impact of the chronic pain, distinguishing between chronic primary and secondary pain where possible.

Pharmacological treatment for opioid dependence typically involves opioid agonist substitution therapy using methadone or buprenorphine, with prescribing decisions made on a case-by-case basis after informed consent. This treatment aims to stabilize opioid use and reduce harm, while also addressing pain management needs ¹.

Chronic pain management should follow NICE guidelines for chronic pain, focusing on multimodal strategies including physical and psychological components, and cautious use of analgesics. Dependence-forming medicines should be reviewed regularly, balancing pain control with risks of dependence and side effects ².

Coordination of care is essential, involving multidisciplinary teams and possibly specialist drug and alcohol services to integrate opioid dependence treatment with pain management. Psychosocial interventions such as motivational interviewing, harm reduction advice, and relapse prevention support both opioid dependence recovery and coping with chronic pain ¹.

Risk reduction measures include immunization against hepatitis A and B, tetanus, and education on safer drug use and overdose prevention, including take-home naloxone ¹.

Regular review of opioid treatment is critical to optimize pain control, minimize side effects, and adjust therapy as needed. Specialist advice should be sought if pain remains inadequately controlled or if complex issues arise ¹,²,³.