Pain Management for People with
Serious Illness

in the Context of the Opioid Use Disorder Epidemic


The United States continues to face an opioid use disorder (OUD) epidemic, with opioid overdoses killing more than 130 people per day.1 In response to the epidemic, policy and regulatory changes have been put in place to significantly decrease the national opioid prescribing rate over recent years.2 While such changes aim to stem the OUD epidemic, they also can have a significant impact on clinicians’ approaches to treating pain in patients living with serious illness. Clinicians, patients, and families may be caught between the OUD epidemic—and the responses to that epidemic—and the need to manage the pain of serious illness.

The National Academies of Sciences, Engineering, and Medicine hosted a workshop to explore the intersection of the OUD epidemic and serious illness care. Here’s what some of the participants said.


  • Potential ways to address the pain management needs of people with serious illness in the context of widespread opioid use disorder

  • How limitations on opioid prescribing affect people with serious illness and clinicians’ abilities to care for these patients

  • How clinicians manage the care of those with co-occurring serious illness and substance use disorder
“We have individuals with chronic pain and serious illness that need to have individualized care and value-based care, and we have individuals who are struggling with a substance use disorder that need the same things. And I think there are ways that we can collaborate better to make sure that we raise the level of patient outcomes for everyone involved."

—Jessica Nickel, Addiction Policy Forum

Patient Stories

Watch the video: Rosanne Leipzig and Ora Chaikin

Watch the video: Cardinale Smith

“There are millions of Americans who are living with serious illness, who are living with pain, who truly do benefit from the analgesic effects of opioids. And the lack of access and the lack of ability to obtain these medications can have real consequences.”

—R. Sean Morrison, Icahn School of Medicine at Mount Sinai

Workshop participants presented the following approaches:


  • Training clinicians to be competent in assessing and managing pain, prescribing opioids safely, and assessing and managing opioid use disorder. (Daniel Alford, Patrice Harris)
  • Providing clinicians with support, mentoring, and training in appropriate opioid prescribing. (Stefan Kertesz)
  • Educating clinicians to secure and ensure continued access to opioid medications for their seriously ill patients and limit the number of short-term prescriptions they are writing. (Heather Wargo)
  • Training physicians in managing pain with modalities other than opioids. (Daniel Alford)

Pediatric Care Opportunities

  • Expanding access to interdisciplinary pediatric outpatient pain clinics, inpatient services, mental health services, and drug treatment programs covered by health insurance. (Stefan Friedrichsdorf)
  • Separating the pediatric agenda to address the need to prescribe opioids for children with serious illness from the adult agenda. (David Steinhorn)
  • Training pediatricians and primary care physicians to teach adolescent patients and their parents about protecting themselves from substance use disorder. (Jessica Nickel)
“Pain [in children] is common. It is underrecognized, and it is undertreated."
—Stefan Friedrichsdorf, Children’s Hospital, Minneapolis, MN


  • Assessing the capacity of states to deal with the opioid epidemic and identifying evidence-based and promising practices they can deploy and evaluate not just in terms of reducing the number of prescriptions filled or overdose deaths, but also in terms of patient outcomes. (Hemi Tewarson)
  • Allowing substance use disorder treatments—particularly methadone maintenance therapy—to be incorporated into routine medical care and the health care system. (Keith Humphreys, Jessica Merlin)
  • Eliminating barriers and expanding access to medications to treat opioid use disorder, including providing more resources to community health centers across the nation to help increase access in rural areas. (Michael Botticelli, Patrice Harris)
  • Reimbursing substance use disorder treatments at the same level as health conditions like cancer and heart disease. (Keith Humphreys)
  • Ensuring physicians are using their state’s prescription drug monitoring program as a data tool. (Patrice Harris)

Opportunities in Care for Substance Use Disorder

  • Acknowledging that pain and substance use disorder may occur together—and treating both. (Jessica Merlin)
  • Increasing access to palliative care and pain specialists who are trained to screen for opioid use disorder and to treat opioid use disorder in the palliative care setting. (Cardinale Smith)
  • Increasing communication between clinicians in the chronic pain and serious illness world and clinicians in the substance use disorders field. (James Tulsky)
  • Reducing societal stigma facing pain patients and those with substance use disorders by promoting the message that chronic pain and substance use disorder are both health conditions. (Jessica Nickel)
“There are a lot of different ways that chronic pain, serious illness, and addiction can come to intersect in a given patient. Chronic pain and addiction are both common. People can come into their serious illness already having one or the other or both."
—Jessica Merlin, University of Pittsburgh


  • Conducting research on the intersections among serious illness, pain management, and substance use disorders. (Jessica Merlin)
  • Studying the effects of mandated policies and collecting data on adverse events, particularly suicidality. (Stefan Kertesz)
  • Accelerating the collection, analysis, and dissemination of data to help policy makers. (Michael Botticelli)
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Want to learn more?

Read the full Proceedings of a Workshop at

SOURCE: NASEM. 2018. Pain Management for People with Serious Illness in the Context of the Opioid Use Disorder Epidemic: Proceedings of a Workshop.

Statements, recommendations, and opinions expressed are those of the individual participants. They are not necessarily endorsed by the National Academies of Sciences, Engineering, and Medicine and should not be construed as reflecting any group consensus.

To learn more about the Roundtable on Quality Care for People with Serious Illness, please visit