Opioid Use Disorder in a Patient With Chronic Pain
A 45-year-old construction worker with chronic low back pain after a fall is referred for 'medication nonadherence.' He has been on oxycodone 10 mg every 6 hours for 2 years. He admits to using extra pills, obtaining two early refills from an emergency department, and occasionally snorting crushed tablets. He denies heroin use. He has a history of alcohol use disorder in remission for 5 years. He is tearful and says, 'I need the pills to work; without them I can't support my family.' His pain is 8/10 despite oxycodone. Urine drug screen is positive for opioids and negative for others; PDMP shows three prescribers and two pharmacies. He has no current suicidal ideation. He asks to be switched to 'something stronger.'
1. How do you formulate his diagnosis and risk, and what would you do in the first visit?
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His behavior is not simply 'nonadherence'; it meets criteria for opioid use disorder: using more than prescribed, obtaining from multiple prescribers, snorting, and continued use despite functional consequences. I would assess severity, overdose risk (dose, snorting, alcohol remission, sleep apnea), mental health, and pain. I would not abruptly stop opioids, because withdrawal and untreated OUD increase overdose risk. In the first visit I would take a nonjudgmental history, check PDMP, urine drug screen, hepatitis and HIV status, and offer naloxone. I would explain that buprenorphine or methadone is first-line and can treat both OUD and pain. I would coordinate with his pain physician and set clear boundaries: one prescriber, one pharmacy, random checks, and no early refills. I would also screen for depression and suicide.
2. How do you initiate medication for opioid use disorder while addressing his chronic pain?
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Buprenorphine is a good option because it treats OUD and pain. He would need to be in mild-to-moderate withdrawal before induction to avoid precipitated withdrawal; I would use a home or office induction protocol with clear instructions. Starting dose is typically 2–4 mg, titrated to 8–16 mg/day, with pain dosing sometimes split. Methadone is an alternative but requires daily clinic visits, which may conflict with work. I would not simply escalate oxycodone. I would coordinate with physical therapy and nonopioid adjuvants, and monitor urine, PDMP, and function. I would explain that buprenorphine has a ceiling effect on respiratory depression, which lowers overdose risk. Follow-up within a week and naloxone are essential.
3. How do you manage his request for 'something stronger' and the ethical/legal issues?
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I would validate his suffering but be clear that 'stronger' full agonists are not the standard of care for OUD and would increase risk. I would explain that the problem is not insufficient strength but loss of control and safety. I would offer buprenorphine or methadone, not punitive discharge. Ethically, I must avoid abandonment and provide evidence-based care; legally, I must follow prescribing rules, PDMP checks, and documentation. I would not accuse him of drug-seeking in a stigmatizing way; I would name the diagnosis and offer treatment. If he refuses medication for OUD, I would still offer harm reduction, naloxone, and close follow-up. I would document the shared decision and boundaries.