Addiction and Chronic Pain: When the Treatment Becomes the Problem

How pain and addiction become entangled

The relationship between chronic pain and addiction is bidirectional and complex. For a significant proportion of people in treatment for substance use disorders, the original use of the substance was not recreational. It was therapeutic - an attempt to manage pain that conventional medicine had failed to adequately address, or pain for which opioids had been legitimately prescribed.

In the United States, the opioid epidemic is largely a story of prescribed pain management that became dependency. In Australia, the UK, and elsewhere, similar patterns emerge at smaller scale. But opioids are not the only substance implicated. Benzodiazepines, prescribed for the anxiety and sleep disruption that frequently accompany chronic pain, create their own dependence. Alcohol - available without prescription, immediately effective at numbing both physical and psychological pain - is perhaps the most common self-medication for chronic pain globally.

Understanding this pathway matters for treatment, because addressing addiction without addressing the underlying pain is likely to fail, just as addressing pain with the same substances that created the dependence in the first place perpetuates the cycle.

The neurological overlap between pain and addiction

Chronic pain and addiction share neurological substrate in ways that are not coincidental. Both conditions involve dysregulation of the same neurological systems - particularly the dopamine reward pathway and the opioid system. Chronic pain alters brain structure and function in ways that increase vulnerability to addiction. And addiction, in turn, alters pain perception - typically increasing sensitivity to pain (a phenomenon called hyperalgesia) in ways that make the underlying pain worse.

Opioid-induced hyperalgesia is particularly important to understand. Long-term opioid use paradoxically increases pain sensitivity, so that over time the person requires increasing doses to achieve the same pain control, while simultaneously experiencing more pain from the drug-induced sensitisation. This is one reason why chronic high-dose opioid treatment for non-cancer pain frequently fails - not because the person is not in genuine pain, but because the opioids themselves are making the pain worse.

The emotional dimensions of pain - how pain is experienced, how threatening it feels, how much it dominates attention - are mediated by the same circuits that process stress, fear, and emotional salience. Both chronic pain and addiction can create what neurologists describe as a threat hypervigilance state, in which the nervous system is chronically primed for threat in ways that amplify suffering and narrow behavioural options.

What effective treatment looks like for co-occurring pain and addiction

The clinical consensus has shifted substantially over the past twenty years away from opioid-centred pain management and toward multimodal approaches that address the neurological, psychological, and physical dimensions of chronic pain without relying on substances that create dependency. This is sometimes called the biopsychosocial model of pain management, and its evidence base is substantially stronger than continued opioid prescribing for most forms of chronic non-cancer pain.

Pain rehabilitation rather than pain management

Traditional pain management focuses on reducing the pain signal - typically through medication, injection, or surgery. Pain rehabilitation takes a different approach: it focuses on improving function and quality of life despite the presence of pain, rather than eliminating pain as a precondition for living. This distinction is not semantic. Many people with chronic pain will not achieve complete pain relief through any means. The goal becomes living well with manageable, if not absent, pain.

Pain rehabilitation programmes use a combination of graded physical exercise (which has direct analgesic effects through endogenous opioid release and central sensitisation reversal), psychological therapies including CBT and Acceptance and Commitment Therapy (ACT), physiotherapy, and sometimes occupational therapy. They are typically delivered in multidisciplinary settings.

Addressing the addiction component

For people who have developed dependence on opioids, benzo or alcohol in the context of chronic pain, addiction treatment must proceed in parallel with pain rehabilitation rather than sequentially. Expecting someone to address addiction first and then their pain, or vice versa, is clinically unrealistic. The two conditions reinforce each other and must be treated together as dual diagnosis.

This means that residential programmes treating this population need both clinical competency in addiction and genuine capability in chronic pain management - including pain psychology, physical rehabilitation, and informed prescribing that can safely manage withdrawal from pain medications while supporting pain relief through non-addictive means.

The role of non-opioid pain treatments

Several medication classes are effective for chronic pain without the addiction liability of opioids: anticonvulsants such as gabapentin (though this class has its own dependence risks at high doses), tricyclic antidepressants, SNRIs, and topical agents. Interventional procedures - nerve blocks, spinal cord stimulation - may be appropriate for specific pain conditions. Mindfulness-based stress reduction (MBSR) has a substantial evidence base for chronic pain and operates through neurological mechanisms quite distinct from medication.

Withdrawal from long-term opioids in people with chronic pain

Opioid withdrawal is profoundly unpleasant even in people who do not have chronic pain. In people whose baseline is already characterised by significant physical pain, opioid withdrawal can be experienced as unbearable - not only because of the withdrawal syndrome itself but because the withdrawal period unmasks the underlying pain in its full intensity, often amplified by opioid-induced hyperalgesia. This is one of the primary reasons people with chronic pain and opioid dependence relapse rapidly after stopping without structured support.

Medically supervised opioid tapering - reducing the dose slowly over a period of weeks to months, rather than stopping abruptly - is significantly more tolerable and more likely to succeed than rapid detoxification. The taper rate should be individualised based on the duration of opioid use, the dose, and the person's clinical state. Adjunctive medications can manage some of the withdrawal symptoms. Pain management strategies should be optimised as the opioid dose reduces.

The psychological dimension of pain and addiction

For many people with chronic pain and addiction, the substance use serves a psychological function that extends beyond pain relief: it manages the despair, isolation, and loss of identity that chronic pain creates. Living with unremitting pain is profoundly demoralising. It disrupts work, relationships, physical capacity, and self-concept. Substances - at least initially - restore some of what pain has taken away.

Therapy that addresses only the addiction without attending to the psychological impact of chronic pain is unlikely to succeed. Approaches like Acceptance and Commitment Therapy (ACT), which works directly on the relationship between pain, suffering, avoidance, and values-based action, are particularly well-suited to this population. The goal is not to convince the person that their pain is not real or not severe. It is to help them build a life that is workable despite the pain - which requires accepting its presence rather than organising life around its elimination. Integrating trauma-informed approaches is also valuable, as many people with chronic pain have experienced medical trauma or adverse events that compound the psychological burden.

About the author

Christopher Murray

Dip.C.Hyp · HPD · NLP · MNCH

Christopher Murray is a cognitive hypnotherapist, NLP practitioner, and author of The Confidence Reset. Co-founder of the Sansun Group, he works with high-functioning individuals internationally and advises families and clients navigating addiction treatment and rehabilitation across Asia.

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