It is important to remember that patients who misuse substances experience pain just as acutely, and probably more so, than “normal” patients. Their lives are chaotic and difficult and they often suffer from concurrent mental health problems. This in itself increases stress and distress and may make their experience of pain worse. Their coping mechanisms are heavily biased towards use of chemicals to deal with distress and they may not respond easily to non-pharmaceutical measures for pain control. Addiction is a chronically relapsing illness and we should expect our patients to respond accordingly. If a patient who has been stable and productive becomes unstable and chaotic again, this is not an indication of therapeutic failure and a signal to retreat and disengage; it means we have to change our management and try again.

Addiction and chronic pain are rarely curable, just as diabetes is rarely curable. We are tasked with helping these patients to best manage their chronic diseases and we should expect setbacks as much as we enjoy success.

We can use any technique we would use in pain uncomplicated by addiction. Thus we use unconventional analgesics such as tricyclic antidepressants and anticonvulsants for neuropathic pain. Regular paracetamol and short course NSAIDs have the same benefits in musculoskeletal pain. Physical approaches such as physiotherapy, TENS (transcutaneous electrical nerve stimulation) and acupuncture have their place. Behavioural modification with psychology is vital. Opioids do have analgesic effects in opioid misusers, even though popular myths have many patients believing otherwise.