CHRONIC PAIN & ADDICTION

Where Chronic Pain and Addiction Meet

My background is in pain medicine. I came to addiction medicine through it, after recognizing — over years of practice — that a significant number of chronic pain patients were also struggling with addiction, mental illness, or both, and that the standard clinical response to this was to discharge them. That approach never made sense to me. A cardiologist doesn't discharge a patient for also having diabetes.

Chronic pain and addiction are frequently intertwined, and understanding the relationship between them is essential to treating either one effectively. Pain drives substance use; substance use complicates pain; withdrawal amplifies pain; and the emotional weight of living with chronic pain — the anxiety, the depression, the disruption to identity and function — often underlies both.

The Neuroscience of Chronic Pain

Chronic pain is not simply a persistent version of acute pain. The transition from acute to chronic involves fundamental changes in how the nervous system processes nociceptive signals — changes that are increasingly well characterized and that explain why chronic pain is so resistant to purely biomedical interventions.

Central sensitization is among the most important of these processes. With persistent nociceptive input, the neurons of the dorsal horn of the spinal cord undergo changes that dramatically amplify pain signaling: increased receptor expression, reduced inhibitory interneuron activity, and a lowering of the threshold for neuronal firing such that stimuli that would normally produce no pain become painful, and stimuli that produce mild pain become severe. The brain itself undergoes structural and functional reorganization — alterations in the prefrontal cortex, anterior cingulate, and insula that affect both the sensory and affective dimensions of pain.

Pain perception is also profoundly shaped by psychological and emotional state. The descending modulatory system, which runs from the periaqueductal gray and rostral ventromedial medulla down to the spinal cord, regulates the gain on incoming pain signals — and it is powerfully influenced by anxiety, depression, fear, and prior experience. Stress activates this system in ways that amplify pain. This is not a psychological explanation for physical pain; it is the neuroscience of how pain actually works. Treating chronic pain as a purely mechanical problem, addressable with the right medication or procedure, misses most of what is happening.

How I Approach It

I treat chronic pain as a co-occurring condition alongside addiction — not as two separate problems requiring separate specialists. This means addressing the medical management of pain, the dependence on any pain medications, and the psychological and emotional factors that are sustaining both. Many people with chronic pain have a history of trauma, loss, or difficult early experiences; the pain has often become entangled with those experiences in ways that neither the patient nor their previous physicians have fully understood.

This kind of integrated treatment is rare. Most addiction specialists decline to engage with chronic pain, and most pain physicians don't engage seriously with psychological dimensions. My background makes it possible to hold both.

For patients who have developed dependence on opioids or other pain medications, the approach to tapering is gradual and medically supervised, paced around the individual's clinical stability. The goal is not simply to remove medication but to arrive at a state where pain is managed more effectively, and with less collateral cost, than before.

Getting in Touch

The first conversation is free and completely confidential. There is no obligation of any kind.

Call directly: (646) 418-7077