People with Opioid Use Disorder may change their behavior. Possible signs can include:

• Spending time alone (avoiding family / friends)
• Losing interest in activities enjoyed previously
• Decline of personal hygiene
• Depression
• Change in appetite (eating less / more)
• Overly energetic (talking fast /being incoherent)
• Acting nervous or cranky
• Rapid mood changes
• Changes in sleeping patterns
• Missing appointments
• Criminal behaviour
• Ignoring responsibilities (work / school / family)

Reference link: VIEW

Most people who take opioids as prescribed do not develop an opioid use disorder. When taken not as directed by a healthcare provider, opioids are risky. This can include taking opioids by crushing a pill, snorting or injecting.

“This life-threatening practice is more dangerous if the pill is a long- or extended-acting one. A rapid delivery of the drug into your body can cause an overdose.” It is also risky to take more than the prescribed dose of opioids or taking opioids more often than prescribed.  “Risk increases with the length of time taking opioids. The risk of misusing opioids a year after starting a short course increases after only five days on opioids.”

Additional factors (e.g. genetic, psychological, and environmental) can also play a role.

Reference link: VIEW

"Known risk factors of opioid misuse include:

• Unemployment
• Family history of substance use
• Personal history of substance use
• Young age
• History of criminal activity or legal problems
• Regular contact with high-risk people or high-risk environments
• Heavy tobacco use
• History of severe depression or anxiety
• Stressful circumstances”

Reference link: VIEW

Pain is more than a physical sensation. It has biological, psychological, and emotional factors.

Chronic pain can cause anger, hopelessness, sadness, and anxiety.

Non-pharmacological methods of managing pain should be considered first in chronic non-cancer pain, then non-opioid medications.

Effective medical, surgical, rehabilitative, and physiotherapeutic treatment may be helpful. AFMC UGME module “Core Concept in the Management of Pain”

Psychological treatments can be an important part of pain management.

Understanding and managing thoughts, emotions and behaviours that accompany pain can improve coping skills and reduce the intensity of pain.

In collaboration with a healthcare provider, choose treatments that feel comfortable. Initiate, adapt, and evaluate a treatment plan as you implement it.

A 30% reduction in pain or improved function is significant. Even a smaller improvement may be meaningful in day-to-day life. ( AFMC UGME module “Core Concept in the Management of Pain” )

Non-pharmacological methods of managing chronic pain can include:

Sleep Hygiene 

Sleep, or lack thereof, is a challenge for many Chronic Pain patients. For more information about improving sleep, please see:

• https://painhealth.csse.uwa.edu.au/pain-module/sleep-and-pain/
• American Academy of Sleep Medicine. Healthy Sleep Habits. 2021. https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/
• Sleepwell | It's no dream. Sleep well without sleeping pills. (mysleepwell.ca)

Physical Activity

• Physical activity is recommended for chronic pain conditions such as low back pain, fibromyalgia, and osteoarthritis.
• Group activities can increase engagement, commitment and decrease feelings of isolation.
• Home based physical therapy can also be explored as an option.
• After a good work-out, exercise can hurt, but it does not mean that it is dangerous. Most physical activity is safe and recommended as part of chronic pain management. Work with your healthcare provider to develop the most appropriate exercise program. Reference link: VIEW
  • Be patient:
    • A minimum of 30 minutes, five days per week is recommended, but people with pain may find this goal overwhelming.
    • As little as 15 minutes per day has major benefits (If that's too much, start with 5 minutes of gentle movement. Every little bit helps.)
• A little more intense activity than normal, repeated daily, can reap benefits.  The goal is to retrain your nervous system to understand that movement is safe. As a result, you will gradually increase your activity and build strength.
• Track your progress to evaluate the effects of physical activity on pain and function.
• For more information, please see: https://painhealth.csse.uwa.edu.au/pain- module/movement-with-pain/

Physiotherapy

• Passive and active physiotherapies are recommended for low back pain, neck pain, and neuropathic pain.
• Passive therapies do not require active involvement. It is useful in short-term. Examples include massage therapy, TENS and laser therapy.
• Active therapies require “homework”, usually stretching or strengthening work in between treatments.

Self-Management Programs

• Self-management is on managing oneself and taking responsibility for one’s own behaviour and well-being.
• Self-management plays a key role in chronic pain management
• Self-management programs are primarily educational, using interactive and collaborative methods facilitated by trained peers or healthcare providers. Topics include goal-setting, self-monitoring, and psychological and exercise therapies.
• Programs can be provided individually or in groups, in person or virtually. Whatever the mode, take an active part in managing your pain!

Psychological Treatment and Counselling

• Cognitive behavioural therapy (CBT) is a well-recognized psychological treatment for chronic pain. The basic principle of CBT is that feelings, thoughts, and behaviours influence each other. The sensation of pain cannot be targeted directly but thoughts and behaviours can be modified, which will then affect the feeling.
• Changing beliefs (thoughts) about the perceived danger represented by pain changes the pain experience (feeling) thus, increasing confidence to exercise (behaviour) and improves the sensation of pain.
• Other types of psychological treatment include mindfulness-based interventions, acceptance, commitment therapy, and respondent behavioural therapies.
• Working with a psychologist/counsellor, involves discussions about physical and emotional health. The psychologist/counsellor may ask about the pain experienced, where and when it occurs, and what contributing factors may affect it. (In addition, they will likely ask about any worries or stressors, including those related to pain. You also may be asked to complete a questionnaire that explores thoughts and feelings about pain.)
• Understanding your concerns will help the psychologist develop a treatment plan.
• The plan often involves teaching relaxation techniques, changing old beliefs about pain, building new coping skills and addressing any anxiety or depression that may accompany your pain.
• A psychologist can help develop new ways to think about problems and support in finding solutions.
• Studies have found that psychotherapy can be as effective as surgery for relieving chronic pain. Psychological treatments for pain can alter how the brain processes pain sensations.
• A psychologist/counsellor can also help with lifestyle changes to permit continued participation in work and recreational activities. Pain often contributes to insomnia, a psychologist/counsellor may suggest sleeping methods that could improve overall sleep quality. AFMC UGME module “Core Concept in the Management of Pain”

Medications that can help with chronic pain

• Five classes of non-opioid medications can be used to manage non-cancer chronic pain: non- opioid analgesics (e.g. Acetaminophens, NSAIDs, Antidepressants, Anticonvulsants, Cannabinoids, and Transdermal compounds.)

Non-opioid analgesics

Acetaminophen

• Acetaminophen is a pain medication that you take by mouth. It is also used to prevent or reduce fever. In combination to NSAIDs, it is useful in pain caused by arthritis. The recommended dose of acetaminophen is 1000-4000 mg/day. The maximum dose (4000 mg per day) is for short term treatment (5 days or less). Many medications (such as over-the- counter cough, cold, and pain medications) contain acetaminophen. Take care to avoid accidentally ingesting over the maximum dose. At too high a dose, acetaminophen can be toxic to the liver. People with liver disease or who chronically use alcohol could experience liver toxicity with lower doses. AFMC UGME module “Core Concept in the Management of Pain”

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs):

• NSAIDs, or non- steroidal anti- inflammatory drugs decrease inflammation, fever, and pain. They are indicated for chronic, nonspecific low back pain. AFMC UGME module “Core Concept in the Management of Pain”

Some examples include:

• Ibuprofen: 200 mg every 4-6 hours, maximum 1200 mg/day
• Naproxen: 220 mg 1-2 pills every 6-8 hours, maximum 660 mg/day
• Ketorolac: 10 mg every 6-8 hours, maximum 40 mg/day
• Celecoxib: 100-200 mg twice a day, maximum 400 mg/day

Some side effects include:

• "Non-aspirin NSAIDs can increase the chance of heart attack or stroke.” People who have heart disease, smoke, have high blood pressure, high cholesterol, diabetes or related risk factors, are at greater risk. “This risk can occur early in treatment and may increase with longer use".

"Other side effects can include:

• Heart failure
• Bleeding in the intestines or stomach
• Feeling bloated
• Heartburn
• Stomach pain
• Nausea, vomiting
• Diarrhea
• Constipation"

Reference link: AFMC UGME module “Core Concept in the Management of Pain”

Antidepressants

• While antidepressants are normally used to treat depression, some can also be used in the management of neuropathic pain.

Some examples of Antidepressants include:

• Tricyclic Antidepressants (TCAs):
  • Amitriptyline can be used in neuropathic pain.
  • Side effects include constipation, weight gain, and dry mouth and eyes. It can be sedating so should be used with caution in the frail and elderly.
  • Desipramine and Nortriptyline can be considered if amitriptyline is not effective. They are less sedating. Reference link: AFMC UGME module “Core Concept in the Management of Pain”

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs):

• • Venlafaxine can be used in Neuropathic pain.
  • Duloxetine has been approved for painful diabetic neuropathy, Fibromyalgia, and low back pain, as well as Major Depressive Disorder and Anxiety.
    • All SNRIs have similar side effects, including
      • Heart palpitations
      • High blood pressure or low blood pressure with position change
      • Nausea or upset stomach
      • Weight gain
      • Fatigue
      • Liver toxicity
      • Sexual dysfunction

Reference link: AFMC UGME module “Core Concept in the Management of Pain”