Pain and opioid use disorder (OUD) are tightly intertwined and highly comorbid. OUD arises in some patients who receive opioids as treatment for acute or chronic pain. Opioid misuse can provide potent analgesia, and opioid withdrawal can exacerbate pain. Treating chronic pain in patients with OUD is a challenge, but keeping the following principles in mind can be helpful.

As treatment options for patients with opioid use disorder (OUD) expand, it’s important to have a handy overview available to guide your conversations with patients. In this fact sheet, we cover the most evidence-based treatments and provide guidance for how to choose among them.

Research shows that effective opioid use disorder (OUD) treatment must include a medication such as buprenorphine, methadone, or injectable naltrexone as its main component (Amato L et al, Cochrane Database Syst Rev 2011;(10):CD004147). Nonetheless, psychosocial approaches can be valuable adjuncts to medications for many patients. In this fact sheet, we provide an overview of psychosocial options to consider when working with patients with OUD. Some of these treatments can be delivered by psychiatrists, while others may require referral to specialized providers. Having this information on hand is especially useful when a patient is not responding to standard treatments alone.

The purpose of this fact sheet is not to provide details on pharmacology or the use of these medications, but rather to help you decide which might be best for a given patient. For more detailed information on each agent, see the appropriate medication fact sheet.

Naltrexone is used in the treatment of alcohol and opioid use disorder.

Lofexidine is an alpha-2 agonist (similar to clonidine and guanfacine) that is used to reduce the intensity of opioid withdrawal symptoms. It effectively blunts some of the most distressing symptoms such as anxiety and tachycardia. It is generally not effective for pain symptoms such as generalized achiness and headache, so it should be used with an analgesic like ibuprofen or acetaminophen. Data indicate that lofexidine is similarly effective to clonidine for management of opioid withdrawal but with a marginally better side effect profile (Kuszmaul AK et al, J Am Pharm Assoc 2020;60(1):145–152). However, given its much higher price tag, we recommend you stick to clonidine.

Nalmefene is an opioid antagonist that has high affinity for opioid receptors and is more potent and longer acting than naloxone. Whether we need this or the newer nasal spray version remains up for debate. Nalmefene is likely not required for most patients; stick with naloxone (now available over the counter) for opioid overdose.

Buprenorphine (Subutex, available now only as generic) is the active ingredient in Suboxone (buprenorphine/ naloxone) and is responsible for the effectiveness of the combination medication in opioid use disorder (OUD). In the past, buprenorphine alone was preferred for the initial (induction) phase of treatment, while Suboxone was preferred for maintenance treatment (unsupervised administration). Currently, the combination is favored for both induction and maintenance as it, at least theoretically, decreases misuse and diversion.

After you have initiated buprenorphine, see patients weekly at first to make sure the dose is right. Increase the dose if they are experiencing cravings—the maximum dose is typically 24 mg daily. Doses can be split if patients are having withdrawal symptoms between doses. Multiple doses per day can be helpful for patients with chronic pain. For most patients, the optimal dose will be 16–24 mg daily. Eventually you can see patients monthly.

Nalmefene is used to reverse opioid overdose in emergency situations.