SUD 101: Opioids for Pain: Understanding and Mitigating Risks-Course Content

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Video Summary

Roger Chow presents an overview on “Opioids for Pain: Understanding and Mitigating Risks” for the SAMHSA-funded PCSS-MOUD program. He reviews the high prevalence of chronic pain (often defined as >3 months) and historically high U.S. opioid prescribing, which rose sharply alongside opioid sales, overdose deaths, and treatment admissions. Although prescription opioid overdose deaths have declined since about 2010–2017, deaths from synthetic opioids (especially fentanyl) have surged since ~2013, following earlier “waves” of prescription opioids and heroin. He notes many people who use heroin now report starting with prescription opioids, linking prescribing to illicit opioid harms.<br /><br />Chow explains key opioid pharmacology: mu-receptor effects, development of tolerance and physical dependence (distinct from addiction), and the absence of a true dose ceiling—yet observational data show overdose risk rises with higher morphine milligram equivalents (MME). Methadone is highlighted as particularly risky due to variable, long half-life and QTc prolongation/torsades risk.<br /><br />Because clinicians cannot reliably predict who will develop misuse/OUD, he recommends “universal precautions”: comprehensive assessment, time-limited opioid trials, regular reassessment, and consistent monitoring. Risk mitigation includes screening for substance use and mental health comorbidities, treatment agreements, PDMP review, periodic urine drug testing, avoiding benzodiazepines/other depressants, cautious dosing, naloxone co-prescribing, and consultation/referral when needed. Aberrant behaviors should be evaluated in context; serious or repeated behaviors, lack of benefit, or intolerable harms warrant tapering (avoid abrupt discontinuation) and assessment/treatment of OUD (methadone, buprenorphine, naltrexone).<br /><br />He emphasizes that non-opioid and nonpharmacologic therapies are preferred for acute and chronic pain, focusing on function. Evidence such as the SPACE trial shows opioids were not superior to non-opioids at 12 months for back pain/osteoarthritis. Active approaches (CBT, exercise, mind-body therapies, interdisciplinary rehab) and selected medications (NSAIDs, SNRIs, gabapentinoids for neuropathic pain, topical agents) should be prioritized.

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Keywords

motivational interviewing

addiction psychiatry

substance use disorders

opioid use disorder

change talk

sustain talk

OARS skills

reflective listening

DARN-CATS framework

SMART goals

MI spirit (partnership acceptance compassion autonomy)

opioids for chronic pain

opioid prescribing trends

opioid overdose epidemic

synthetic opioids fentanyl surge

heroin initiation from prescription opioids

mu opioid receptor pharmacology

tolerance and physical dependence vs addiction

morphine milligram equivalents MME risk

methadone half-life QTc prolongation torsades

universal precautions opioid therapy

risk mitigation PDMP urine drug testing naloxone

non-opioid pain management SPACE trial CBT exercise