The opioid crisis continues to impact communities across the United States. In 2022, the nation mourned over 100,000 opioid-related deaths, marking the highest annual figure as 1999. While recent data indicates a significant decrease in these rates,opioid use disorder (OUD) remains a critical public health concern,affecting countless individuals and placing immense strain on healthcare systems nationwide.

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Understanding Opioid Use Disorder

OUD is characterized by a problematic pattern of opioid use leading to significant impairment or distress. This often manifests as compulsive behaviors, intense cravings, and a rapid escalation in opioid consumption, severely impacting an individual’s health and overall well-being. compounding the issue,chronic pain is prevalent in 45% to 64% of patients with OUD,making effective pain management a particularly complex challenge.

According to Isabelle Zerfas, PharmD, pain management clinical pharmacy specialist at the University of Michigan Health, this certainly has been an exciting year, as opioid-related deaths have decreased by 24%.This is the first year of decline in opioid-related deaths as 2018 and has been attributed to widespread distribution of naloxone, which is now available over the counter, changes in drug supply, and resumption of prevention and response programs following the COVID-19 pandemic.

Federal initiatives, such as the elimination of the X-waiver (removing restrictions on buprenorphine prescriptions) and the Mental Health Parity and Addiction Equity act (ensuring equitable insurance coverage for mental health and substance use disorder treatments), have considerably improved access to OUD treatment. Telehealth prescribing has further expanded access, particularly for those in remote areas or with transportation challenges.

Challenges in Chronic Pain Management for Patients with OUD

Despite progress, effective chronic pain management for patients with OUD remains a significant hurdle. Persistent social stigma, regulatory complexities, and the limited integration of addiction care into mainstream medical settings continue to impede treatment efforts. Disparities in access to care, particularly for racial and ethnic minorities, rural populations, and individuals with low socioeconomic status, further exacerbate the problem.

Abbey Galligan, PharmD, BCPS, clinical pharmacy specialist in pain management at the University of Michigan Health, notes, Despite the success amid the opioid epidemic, there remains room for improvement in management of opioid use disorder. Such as, we know 35% of treatment facilities do not offer MOUD, [and] overdose is a leading cause of death for Americans aged 18 to 44. there are also large racial, ethnic and geographical disparities for MOUD.

Another challenge lies in the misdiagnosis of patients with complex persistent opioid dependence (C-POD), a nuanced clinical phenomenon distinct from OUD. Patients with C-POD frequently enough do not exhibit compulsive behaviors and gradually develop poor pain control. C-POD is associated with neurobiological features such as opioid-induced hyperalgesia, persistent dysphoria, and neurological changes in pain and emotional regulation systems.

These neurobiological changes result in heightened pain sensitivity, reduced tolerance for discomfort, and emotional instability, complicating clinical assessments and treatment planning. Consequently, patients with C-POD may be misclassified as having OUD or undertreated for their pain, leading to inadequate care and worsening outcomes.

Recognizing these neurobiologic changes as a outcome of long-term opioid use helps us shift from accusation and blame to understanding and appropriate treatment planning.
Isabelle Zerfas, PharmD

Management Strategies for OUD and C-POD

Medication-assisted treatment (MAT), combining pharmacologic therapy with psychosocial support, is the cornerstone of OUD treatment. Buprenorphine is often preferred, particularly in the context of widespread fentanyl use, with effective dosing typically ranging between 24 and 32 mg per day.

Galligan explains,Twenty-four to 32 milligrams per day predicts the best treatment outcomes compared to lower doses. That’s especially true now in the era of fentanyl, as every patient now that we see here, primarily with OUD, is using fentanyl and not heroin.

Methadone, another effective option, is often administered at doses around 120 mg per day or higher, although its use is more tightly regulated. Naltrexone is generally less preferred due to challenges with initiation and patient adherence but may be suitable for certain individuals.

A comprehensive treatment approach should also include tapering patients off opioids when clinically appropriate, optimizing non-opioid analgesics for pain management, integrating non-pharmacologic interventions (e.g., cognitive behavioral therapy, physical therapy), and addressing co-occurring psychiatric conditions.

Managing C-POD requires a more nuanced approach. Abrupt opioid tapering can lead to significant functional decline. Clinicians should consider maintaining a patient’s current opioid regimen if tapering results in worsened pain or diminished quality of life. Buprenorphine remains a key pharmacologic tool, but dosing must be individualized and may exceed typical doses used for chronic pain management. Methadone can also be considered, though access is often limited.

According to Galligan, For patients with C-POD and chronic pain, we typically follow methadone dosing for pain, which is lower doses 2 to 3 times per day.This is because analgesic benefits last 8 to 12 hours.

Non-pharmacologic strategies are central to C-POD management and should be maximized. These include physical therapies, behavioral interventions, and referrals to psychiatric or psychological care when appropriate. Identifying and addressing underlying pain drivers, such as undiagnosed mood disorders, trauma, or central sensitization, is also essential.

Both OUD and C-POD share several foundational management strategies. Non-opioid analgesics (e.g.,NSAIDs,acetaminophen) and complementary therapies (e.g., massage, aromatherapy, specialized pain psychology) can provide meaningful relief and support patients’ physical and emotional well-being.

The Critical Role of Pharmacists

Pharmacists are uniquely positioned to screen for potential opioid misuse, counsel patients on appropriate use of MOUD, and help reduce stigma through patient-centered interaction. In both community and clinical settings, pharmacists can monitor adherence, detect early signs of relapse or treatment complications, and collaborate with prescribers to adjust therapy as needed.

Pharmacists play a really critically important role in medication management in this area,and also patient advocacy…making sure that if you see something, say something to your provider team.
Isabelle Zerfas, PharmD

In cases of C-POD, pharmacists can provide valuable insights into complex medication regimens, help identify opioid-induced adverse effects (e.g., hyperalgesia, tolerance), and recommend appropriate non-opioid alternatives or adjunctive therapies. They also play a vital role in educating patients about the rationale behind individualized treatment strategies and support gradual opioid tapering when appropriate.

Effectively addressing OUD and C-POD requires a comprehensive, individualized approach that incorporates both pharmacologic and non-pharmacologic strategies. Pharmacists, through their accessibility and clinical expertise, are key partners for supporting safe medication use, optimizing pain management, and advocating for equitable, stigma-free care.