Today, I review, link to, and excerpt from The Curbsiders’ #487 Chronic Pain & Opioid Use Disorder with Dr. Jessie Merlin.*
*Chan, CA; Merlin J; Roy, PJ; Cohen CA “#487 Chronic Pain & Opioid Use Disorder with Dr. Merlin”. The Curbsiders Addiction Medicine Podcast.https://thecurbsiders.com/addiction June 16th, 2025.
All that follows is from the above resource.
Transcript available via YouTube
Dive into practical, evidence-based approaches to managing pain in patients with opioid use disorder, bust common myths, and explore strategies to support patients. This episode will enhance your skills in providing holistic, patient-centered care. We’re joined by Dr. Jessica Merlin, @JessicaMerlinMD (University of Pittsburgh).
Claim CME for this episode at curbsiders.vcuhealth.org!
By listening to this episode and completing CME, this can be used to count towards the new DEA 8-hr requirement on substance use disorders education.
Episodes | Subscribe | Spotify | iTunes | CurbsidersAddictionMed@gmail.com | CME!
Production Partner: ACAAM
The Curbsiders Addiction Medicine are proud to partner with The American College of Addiction Medicine (ACAAM) to bring you this mini-series. ACAAM is the proud home for academic addiction medicine faculty and trainees and is dedicated to training and supporting the next generation of academic addiction medicine leaders. Learn more about their educational offerings and resources here.
Show Segments
- Intro, disclaimer, guest bio
- Guest one-liner
- Case from Kashlak; Definitions
- Reciprocal Model of Pain and Addiction
- Assessment
- Methadone and Buprenorphine
- Behavioral Interventions
- Goal Setting
- Long-term opioid treatment (LTOT) for chronic pain
- Acute flares of chronic pain
- Diagnosis OUD in a patient on LTOT
- Outro
Chronic Pain & Opioid Use Disorder Pearls
- Opioid use disorder and chronic pain commonly co-occur.
- Reciprocal Model of Pain and Addiction: A model that describes how pain can drive substance use for short-term relief, but over time, substance use can worsen pain, creating a reinforcing cycle.
- Directly ask patients how their addiction and pain intersect to tailor a care plan.
- Recognize that building trust with patients experiencing pain and OUD may take multiple visits. Acknowledge the urgency of pain while managing expectations of needing time to see clinical improvement.
- Utilize the PEG scale (pain intensity, enjoyment of life, general activity) to track pain over time.
- Medications such as buprenorphine and methadone can treat OUD and may help with chronic pain for some patients.
- Cognitive Behavioral Therapy (CBT) and pain self-management programs are often the safest and most effective treatments for chronic pain.
- When setting goals with patients with chronic pain, consider SMART goals – make them specific, measurable, achievable, relevant, and time-bound.
- Be aware that chronic opioid therapy for non-cancer pain has limited evidence of sustained benefit and potential for harm.
- For acute flares of chronic pain, first rule out other medical causes. After appropriate work-up, Dr. Merlin recommends non-opioid management, as flares are often expected in chronic pain.
Chronic Pain & Opioid Use Disorder Notes
Chronic pain is defined as pain lasting more than three months and persisting after normal tissue healing. It affects 20% of the U.S. population, with 6% experiencing high-impact chronic pain (CDC, 2022). Approximately 45% of patients with opioid use disorder (OUD) who are on medication treatment also have co-occurring pain (Delorme, 2023) .
Reciprocal Model of Pain and Addiction
Reciprocal Model of Pain & Addiction (Ditre, 2019): Pain can drive substance use for short-term relief, but worsen over time. Addiction may amplify pain via withdrawal or opioid-induced hyperalgesia, creating a reinforcing cycle. Dr. Merlin emphasizes understanding how these conditions intersect in each individual to help develop a care plan.
Coordinating care remains challenging in a fragmented healthcare system, limiting access to comprehensive treatment tools for patients with both of these co-occurring conditions.
Pain Assessment
Pain is often under-recognized in clinical settings, partly because patients may hesitate to report it for fear of being judged or labeled. Creating space to ask about pain—and to understand what matters most to the patient—can be a powerful way to build trust. For some, acknowledging and addressing their pain becomes the starting point for engaging in care for substance use disorders. Dr. Merlin recommends asking patients directly how their addiction and pain intersect with each other.
To track pain over time, the PEG scale (assessing pain intensity, enjoyment of life, and general activity on a 0–10 scale) *offers a simple, validated tool to utilize in primary care (Krebs, 2009). It’s important to remember that both pain and substance use diagnoses carry significant stigma in healthcare, which can lead to frustration, anger, and guardedness in patient interactions. Dr. Merlin encourages clinicians to approach these conversations with empathy, curiosity, and an awareness of how past healthcare experiences may shape the encounter.
*Link to the results of a Google search on the PEG scale
Dr. Merlin recommends that it can take a few visits to build trust, and consider naming the urgency of addressing the pain to the patient, while acknowledging that the driver was not built in a day, and it will take some time for clinical improvement.
Medications for Opioid Use Disorder and Pain
Buprenorphine and methadone are both FDA-approved medications for the treatment of opioid use disorder (OUD). They may also play a role in managing chronic pain, particularly in patients with both OUD and chronic pain.
Certain buprenorphine formulations—such as the buccal film and transdermal patch (typically dosed in micrograms)—are FDA-approved specifically for chronic pain. Other formulations, including sublingual tablets and long-acting injectables (typically at higher doses), are approved for treating OUD.
Patients with co-occurring OUD and chronic pain should receive evidence-based medications for OUD, such as buprenorphine or methadone—collectively referred to as medications for opioid use disorder (MOUD). Dr. Merlin notes that there is limited research on their long-term effectiveness for chronic pain (Lazaridou, 2020), and it’s unknown how best to utilize buprenorphine and methadone for both OUD and chronic pain. In her expert opinion, however, these medications can be valuable tools for patients with both OUD and pain.
One strategy to enhance the analgesic effect of buprenorphine and methadone is split dosing—dividing the total daily dose into three to four doses (e.g., TID or QID). This may improve pain control due to the medications’ pharmacologic properties. However, split-dosing methadone is often not feasible within opioid treatment programs due to regulatory constraints. In contrast, split-dosing buprenorphine every 6–8 hours (Q6–8H) may be more practical and could offer greater pain relief compared to once-daily dosing.
Behavioral Interventions
Behavioral interventions are regarded as effective and the safest intervention to treat chronic pain (Eccleston, 2009). For example, cognitive behavioral therapy protocols exist for chronic pain and are often 12 sessions. In addition, there are manualized versions of CBT called pain self-management programs that focus on reinforcing behaviors such as goal setting, physical activity, sleep, mood, and other strategies (Du, 2017). The 2017 National Pain Strategy recommends self-managed interventions for pain, as they have been demonstrated to be effective (National Pain Strategy). These do not need to be delivered by a clinical psychologist, but can instead be delivered by someone who is trained in a pain self-management model.
Be familiar with your local resources, as there may be someone in the clinic space, such as the social worker, who has experience with CBT that could deliver CBT for chronic pain. Dr. Merlin acknowledges that while interventions such as CBT may be helpful for some, they may not be helpful or accessible for many individuals.
Dr Merlin highlights that few interventions have been designed specifically for OUD and pain. Mindfulness-based interventions may be beneficial for some patients (Cooperman, 2024). Due to the complexity of patients who may have other psychological and social factors at play, it can be difficult to find an off-the-shelf intervention that will be effective for most patients.
In your practice, you can integrate some of these strategies in the way you interact with patients. One way to do this is through goal setting.
Tips on Goal Setting in Chronic Pain
- Ask patients how they spend their days
- Learn what people wish they could do, but can’t, despite chronic pain
- Make goals manageable
- Try setting a SMART goal (specific, measurable, achievable, relevant, time-bound)
Treatment Plan
Providing patients with both pharmacologic and non-pharmacologic interventions to treat their chronic pain is key, as no one intervention has a very large effect size. Multidisciplinary pain clinics can often provide different treatment strategies so people can combine the effect sizes to improve an individual’s chronic pain.
Medications
For managing pain, consider medications like SNRIs such as duloxetine*, in addition to acetaminophen and NSAIDs. It’s also important to treat any co-morbid depression that may be present.
*Link is to the results of a Google search “duloxetine for chronic pain.”
Chronic Opioids in Chronic Pain
When treating chronic pain, clinicians must weigh the potential benefits and harms of all available therapies, always considering the individual needs of the patient. It’s essential to take into consideration that there can be harms as well with tapering opioids (Lagisetty, 2023). Long-term use of full opioid agonists is generally considered less appropriate due to their risk profile and limited evidence of sustained benefit. Dr. Merlin reminds us that as clinicians, we can set boundaries, just as patients can set boundaries (e.g., patients can say no to therapies we suggest that are not a good fit for them, and clinicians can say no to therapies that are not appropriate for a patient’s care)
Dr. Merlin emphasizes that opioids lack strong supporting evidence for effectiveness in managing chronic non-cancer pain. One pivotal study – the SPACE trial – compared opioids to nonsteroidal anti-inflammatory drugs (NSAIDs) for chronic back pain, OA of the hip and knee (Krebs, 2018). The trial found that opioids did not outperform NSAIDs in improving function and, in some circumstances, were associated with worse outcomes (Krebs, 2018).
Dr. Merlin notes that this does not mean opioids are never effective—some patients may experience meaningful relief. However, we currently lack precision tools to predict which individuals will benefit most from opioid therapy without experiencing significant harms. Until such personalized medicine approaches are available, broad use of opioids for chronic pain remains a judgment call.
In one complex case, such as patients with advanced cancer, co-occurring opioid use disorder (OUD), and chronic pain, expert consensus has provided some guidance. A panel concluded that for patients with a life expectancy of less than one year, the use of opioids for chronic pain may be appropriate. However, if the prognosis exceeds one year, the risk-benefit calculus shifts, and more caution is warranted (Merlin, 2021)
In the recent VA guidelines for the use of opioids in the management of chronic pain (VA DOD Opioids for Chronic Pain, 2022), it recommends that if the patient is receiving daily opioids for chronic pain, buprenorphine is the preferred opioid instead of a full agonist opioid due to a lower risk of side effects (strength of recommendation – weak)
Acute Flares of Chronic Pain
Chronic pain fluctuates; there can be better and worse days. Ask a patient if what they are experiencing is within the range of their typical worst week, or if it is outside of that (e.g., worst pain I’ve ever felt). Always be sure to rule out acute medical processes that could be contributing if the pain is outside of the realm of their normal chronic pain. If, after careful history and assessment, it is deemed to be an acute flare of chronic pain, rather than acute pain from an active medical process, Dr. Merlin avoids using opioids for management of acute flares of chronic pain, as this is an anticipated aspect of chronic pain.
Diagnosis of OUD in patients prescribed opioids
Approximately 8-12% of individuals who are on long-term opioids develop opioid use disorder (Vowles, 2015). For patients who are prescribed opioids, it takes careful history to determine if an individual has developed opioid use disorder. It may look different than individuals who are taking non-prescribed opioids. One example is stress in relationships that can occur if a family member has to dispense medications to the patient. Dr. Merlin encourages people to document behaviors in a non-judgmental way, with non-stigmatizing language to communicate with other individuals. Clinicians may consider using this resource to support navigating various scenarios of opioid misuse: Consensus-Based Opioid Misuse Algorithms.
Links
