Managing Chronic Pain During the Opioid Overuse Epidemic

A high level of comorbidity exists between substance use disorders and chronic pain.

LAS VEGAS—The dramatic increase in opioid overuse and abuse in the United States (US) over the past few years has led the Centers for Disease Control and Prevention (CDC) to declare an “opioid overuse epidemic.”1

Since 1999, the number of opioid prescriptions has increased almost 4-fold, but without any decrease in the amount of pain reported by Americans.2 In addition, the number of opioid overdose-related deaths has nearly quadrupled since 1999 and more than half of those deaths have been attributed to prescription opioids.2,3

Today, chronic pain specialists face the dilemma of how to treat a patient’s pain appropriately without feeding the opioid overuse epidemic.

Many clinicians find chronic pain challenging to treat since substance abuse disorders often co-occur with chronic, noncancer pain.4 In addition, patient expectations and pressure on providers to promote patient satisfaction make it difficult for providers to explore nonopioid options for pain control.5

David Cosio, PhD, a psychologist with the Pain Clinic at the Jesse Brown VA Medical Center in Chicago, addressed the issues surrounding chronic pain management in the midst of the opioid epidemic in “Falling Down the Rabbit Hole: A Primer for Chronic Pain Management and Comorbid Substance Use Disorders,” presented at PAINWeek 2016.”6

The main objective of the presentation was to equip clinicians to treat patients with chronic pain effectively while minimizing the risk of opioid overuse and abuse. Dr Cosio discussed the circumstances that led to the opioid epidemic, the link between chronic pain and substance use disorders, new CDC guidelines on how to manage chronic pain, and strategies to appropriately select patients for opioid treatment.

“The field of pain management has undergone a circuitous journey,” Dr Cosio told Clinical Pain Advisor. “US attitudes about opioid therapy have shifted repeatedly, and abuse and addiction to opioids continue to challenge the clinical community.”

One of the main takeaway messages from Dr Cosio’s presentation is that there is a high level of comorbidity between substance use disorders and chronic pain. In a 2008 study, that results from which were published in 2011, and that included more than 5800 patients receiving opioids for chronic pain, 20% carried a diagnosis of substance use disorder.7

“Patients with substance use disorders have been found to be at greater risk for aberrant medication-related behaviors, increased risk for prescription opioid misuse and abuse, and are potentially more difficult to treat and are at higher risk for comorbidities such as depression, anxiety, and sleep disturbances,” he said.

Dr Cosio also discussed the CDC guidelines on managing chronic pain that were published in March 2016, as well as strategies for exploring nonopioid and nonpharmacological treatment options prior to considering opioid therapy.

According to Dr Cosio, clinicians should not consider opioid treatment for patients with chronic pain until all other options for pain control are exhausted. He thus designed a “decision tree” to help guide healthcare practitioners in this regard.8

He outlined a plan to help clinicians use opioids to treat pain while minimizing the potential for abuse. “Providers may benefit from using opioid agreements, random urine toxicology screens, state prescription drug monitoring databases, opioid risk tools, and the ability to schedule frequent follow-up appointments when selecting candidates for an opioid trial,” he said.

Dr Cosio also emphasized the importance of the relationship between healthcare provider and patient as being the “number 1 predictor for getting better.”


  1. Centers for Disease Control and Prevention. Injury prevention & control: opioid overdose.  Available at: Updated 2016. Accessed September 1, 2016.
  2. Centers for Disease Control and Prevention. Injury prevention & control: opioid overdose. Understanding the epidemic. Available at: Updated 2016. Accessed September 1, 2016.
  3. Centers for Disease Control and Prevention. Injury prevention & control: opioid overdose. Opioid data analysis. Available at: Updated 2016. Accessed September 1, 2016.
  4. Morasco BJ, Gritzner S, Lewis L, Oldham R, Turk DC, Dobscha SK. Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. Pain. 2011;152(3):488-497.
  5. Zgierska A, Miller M, Rabago D. Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA. 2012;307(13):1377-1378.
  6. Cosio D. Falling down the rabbit hole: a primer for chronic pain management and substance abuse disorders. Presented at: Pain Week 2016. Las Vegas, NV; September 6-10, 2016.
  7. Morasco BJ, Duckart JP, Dobscha SK. Adherence to clinical guidelines for opioid therapy for chronic pain in patients with substance use disorder. J Gen Intern Med. 2011;26(9):965-971.
  8. Cosio D. How to set boundaries with chronic pain patients. J Fam Pract. 2014;63(3 Suppl):S3-S8.

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