Chronic Pain and Opioid Dependency: Breaking the Cycle Safely

It usually starts somewhere legitimate. A back injury that won’t settle. A surgery with a longer recovery than expected. Fibromyalgia, the kind of pain that never shows up on a scan but never fully leaves. A GP writes a prescription, and for a while it does exactly what it’s meant to — makes the pain manageable enough to work, sleep, function. Nobody sets out to develop a dependency. The shift is quiet, a slow recalibration, until the question stops being “does this help my pain” and becomes “can I get through today without it.”

For families watching this happen to someone they love, the signs are confusing because they don’t look like the addiction stories most people expect. It’s a parent or partner who seems less like themselves — more irritable, more withdrawn. It’s noticing more than one doctor, or a month’s prescription gone in three weeks. It’s the low-grade panic when a refill runs even a day late. None of this reflects a failure of character. It reflects a treatment pathway that started with a legitimate medical need and quietly changed shape.

This piece is written for both realities: the person who followed medical advice and ended up dependent on it, and the family member trying to work out whether what they’re seeing is normal pain management or something needing intervention. We’ll cover how legitimate pain treatment tips into dependency, what current UK clinical guidance says about opioids for chronic pain, and what safe, addiction-focused treatment looks like when the underlying pain hasn’t gone away.

How does chronic pain treatment lead to opioid dependency?

Start with a distinction that matters clinically: physical dependence and addiction are related but not identical. Physical dependence means the body has adapted to a drug and produces withdrawal symptoms if it’s stopped or reduced too quickly. Addiction is broader — compulsive use despite harm, often with loss of control over how much or how often it’s used. Chronic pain patients typically enter through the dependence door first, though dependence can progress into addiction over time.

The scale of this in the UK is significant. A 2019 review commissioned by Public Health England (now OHID), “Dependence and withdrawal associated with some prescribed medicines,” found that in 2017/18, roughly one in four adults in England — around 11.5 million people — had been prescribed at least one medicine from five classes carrying dependence or withdrawal risk: opioids, benzodiazepines, z-drugs, gabapentinoids, and antidepressants. Around half had been on a continuous prescription for twelve months or longer.

The mechanism is straightforward pharmacology, not personal failing. Opioids bind to receptors in the brain and nervous system that manage pain signalling. With continued use, the body adapts — neuroadaptation — and those receptors become less responsive, or downregulated. The practical effect is tolerance: the same dose stops being enough, and more is needed for the same relief. This isn’t weak willpower; it’s a predictable biological response to sustained exposure, and it happens to people taking medication exactly as directed.

The stakes of that escalation are not abstract. A widely cited study by Bohnert and colleagues, published in JAMA in 2011 (305(13):1315–1321), examined overdose deaths among US Veterans Health Administration patients and found a dose-dependent relationship between prescribed opioid dose and overdose mortality risk — the higher the dose, the greater the risk. Dependency on a prescribed opioid is not evidence someone did something wrong; it’s a predictable pharmacological outcome of a treatment that, for many patients, quietly outgrows its original purpose.

What are the warning signs of opioid dependency in chronic pain patients?

For families, the signs tend to surface as changes in behaviour around the medication itself: requesting refills earlier than the schedule allows, “doctor shopping” across multiple prescribers, mood tied to dosing (irritability creeping in as a dose wears off), and withdrawal symptoms between scheduled doses — sweating, nausea, restlessness, muscle aches — signalling the medication’s role has shifted from managing pain to managing withdrawal.

On the physical side, the clearest signal is needing progressively higher doses for the same relief. Some patients experience the opposite of what more medication should bring: pain that spreads or intensifies — opioid-induced hyperalgesia, where the drug paradoxically increases pain sensitivity over time — alongside sedation and cognitive fog as doses climb.

Worth naming: “pseudo-addiction,” where genuinely undertreated pain causes a patient’s attempts to get adequate relief to mimic drug-seeking behaviour without reflecting true dependency. Pseudo-addiction typically resolves once pain is properly managed; true dependency does not — which is why family concern needs to lead with curiosity, not accusation.

The relationship between prescription opioids and heroin deserves balanced treatment. Research from the National Institute on Drug Abuse (NIDA) — its “Prescription Opioids DrugFacts” and the report “Prescription Opioid Use Is a Risk Factor for Heroin Use,” found that among people who began misusing opioids in the 2000s, roughly 75% reported a prescription drug as their first opioid. Pooled data from 2002–2012 showed nonmedical use of prescription pain relievers was associated with a roughly 19-fold higher incidence of heroin initiation (0.39% versus 0.02%). For proportion, the same research indicates only around 4–6% of people who misuse prescription opioids go on to use heroin: a real, documented risk factor, not a predetermined outcome.

Why have NHS and NICE guidance moved away from opioids for chronic pain?

The honest answer is that clinical guidance has genuinely changed. In April 2021, the National Institute for Health and Care Excellence published guideline NG193, “Chronic pain (primary and secondary) in over 16s.” Its findings were unambiguous: NICE found no evidence for opioid effectiveness in chronic primary pain and explicitly recommends against opioids, NSAIDs, benzodiazepines, and antiepileptics for it — recommending instead supervised exercise, psychological therapies such as CBT or ACT, time-limited acupuncture, and, for some patients, select antidepressants including amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine, or sertraline.

This isn’t isolated. The Cochrane Library’s 2023 update, “High-dose opioids for chronic non-cancer pain: an overview of Cochrane Reviews” (Els et al.), found a critical lack of high-quality evidence for long-term opioid effectiveness — modest short-term benefit over placebo, inconclusive long-term improvement, and persistent serious adverse events. NICE and Cochrane describe the same gap from two angles: the evidence for long-term opioid use in chronic pain was never as strong as decades of prescribing assumed.

The real-world impact is measurable. NHS England released figures in March 2023 showing opioid prescriptions had been cut by almost half a million — an 8% fall — over the preceding four years, estimated to have saved nearly 350 lives and prevented more than 2,100 incidents of patient harm — a national policy correction, not a fringe clinical opinion.

What this leaves behind is a genuine gap for patients started on long-term opioids years ago, under prescribing norms once considered standard, now dependent on a class of medication their own national guidelines no longer support. That’s not a contradiction they created — it’s medicine evolving faster than any individual treatment plan, and it’s exactly the group that needs a pathway addressing both the dependency and the pain condition that started it.

What happens in the brain and body during long-term opioid use?

Beyond dependency itself, long-term opioid use carries a less-discussed physiological risk: respiratory depression. Opioids suppress the brainstem’s drive to breathe, and at higher doses this can reduce oxygen reaching the brain. Even short of overdose, repeated low-grade hypoxic episodes can contribute to cumulative brain changes over months or years.

This is an area where hyperbaric oxygen therapy (HBOT) has documented, if narrow, relevance. A published case report, available via PMC/NCBI, describes a patient treated with HBOT for delayed post-hypoxic leukoencephalopathy (DPHL) — a delayed-onset brain injury that can follow opioid overdose — using an acute session at 2.8 ATA followed by 62 further sessions at 2.0 ATA over 140 days, with documented resolution of neurological symptoms. This is a single case report, not a controlled trial: evidence HBOT can play a meaningful role in recovery from opioid-related hypoxic brain injury in some cases, not a guaranteed outcome for any individual.

Broader hyperbaric research into hypoxic-ischemic brain injury has examined mechanisms by which HBOT may support recovery, including increased cerebral oxygen metabolism and reduced neuronal cell death in injury models — mechanism evidence about hypoxic brain injury broadly, not opioid-specific proof. This is why an effective approach to opioid dependency arising from chronic pain addresses the physiological injury alongside the behavioural dependency — the framework Holina brings to this population.

How Holina Rehab Treats Chronic Pain and Opioid Dependency

Holina is not a pain clinic. What we treat is the dependency — the physiological and behavioural relationship someone has developed with opioids — not the underlying pain condition, which needs its own ongoing medical management. Most clients arrive having done everything right by conventional standards and became dependent anyway. Treatment starts from that reality, not from blame, and rebuilds using an addiction-focused clinical framework.

Medically supervised withdrawal is the starting point for nearly every client, because coming off long-term opioids without clinical oversight carries real risk. Where medication-assisted treatment is appropriate, Holina’s clinical team works from an individualised comparison of Suboxone vs Naltrexone vs Methadone — each with different mechanisms and suitability depending on history and severity of dependency, with no default; the choice is made with the client.

For clients with a history of opioid overdose or documented hypoxic episodes, hyperbaric oxygen therapy is positioned as part of a broader recovery plan supporting recovery from opioid-related brain injury — grounded in the case-level evidence above, alongside rather than instead of the rest of a client’s clinical programme.

Underneath much of this population, there is often unresolved trauma feeding how the nervous system processes pain. Holina addresses this through NARM (the NeuroAffective Relational Model) and somatic therapy, both working with nervous-system dysregulation rather than purely cognitive patterns. Where a client also has a diagnosed behavioural health condition alongside their substance dependency — anxiety, depression, or complex trauma responses being common here — Holina treats both concurrently as part of its Dual Treatment programme, run in parallel, because treating one in isolation rarely holds.

Family therapy addresses the “unwitting enabler” dynamic common in prescription-origin dependency — a partner or parent who spent months or years managing refills or covering for missed obligations, because it didn’t look like the addiction they expected.

Holina’s Thailand setting is a genuine clinical asset, not a backdrop. Mindfulness and Buddhist-influenced practice are built into the programme as pain-coping alternatives — meditation and somatic grounding that give clients tools to manage pain sensation without medication, aligned with NICE’s own push toward non-pharmacological chronic pain management.

Finally, Thrucare — Holina’s two-year aftercare model — matters more for this population than almost any other. Chronic pain dependency carries an especially high relapse-into-prescribing risk, because the original pain condition doesn’t disappear when treatment ends. Thrucare manages that long tail, rather than treating recovery as something that concludes at discharge.

What families can do now

How you open the conversation matters as much as what you say. Lead with concern about function and quality of life, rather than confronting the substance itself first — an accusation about pills tends to trigger defensiveness and shuts the conversation down before it starts.

Do not encourage an abrupt stop to a long-term opioid prescription. Withdrawal from sustained opioid use can be medically dangerous and needs clinical supervision, with a proper taper — never suddenly, and never without a doctor involved. In the meantime, document patterns you’re observing — refill timing, mood changes tied to dosing, evidence of multiple prescribers — information genuinely useful in a clinical intake conversation, not a case built against someone. Holina also offers support for families navigating this alongside their loved one.

Get one factual anchor for yourself before the harder conversation. A callback from Holina’s team costs nothing, and it exists to de-escalate the “am I overreacting” spiral families can sit in for months. You can speak with our admissions team to talk it through before you speak with your loved one — and avoid ultimatums framed around willpower. What you’re looking at is physiological dependency, not a discipline problem; treating it as a character issue deepens shame rather than opening a path forward.

Frequently asked questions

Is it possible to become dependent on opioids even when taking them exactly as prescribed?

Yes. Dependency can develop through neuroadaptation regardless of whether medication is taken exactly as directed — a biological response to sustained exposure, not a result of misuse. The 2019 OHID review found roughly 11.5 million adults in England were prescribed a dependence-forming medicine in 2017/18, with around half on continuous prescriptions for 12 months or more.

What’s the difference between physical dependence and addiction?

Physical dependence means the body has adapted to a drug and produces withdrawal symptoms when it’s stopped or reduced. Addiction involves compulsive use despite harm and loss of control over consumption. Someone can be physically dependent without being addicted, though the two often co-occur, particularly with long-term opioid use.

Do NICE guidelines say I should stop my opioid pain medication immediately?

No. NICE guideline NG193 informs prescribing decisions for new and ongoing chronic pain treatment, not unsupervised self-withdrawal. If you’re on a long-term opioid prescription, any reduction should happen through a supervised taper with your doctor — never abruptly, never alone.

Why did my GP prescribe opioids for years if NICE now advises against it for chronic pain?

Clinical guidance has genuinely evolved. NG193 was published in April 2021, and many patients on long-term opioid treatment were started years earlier under prescribing norms once considered standard. This is a shift in the evidence base, not a reflection of anything done wrong.

Can chronic pain be managed without opioids at all?

NICE’s guidance for chronic primary pain recommends supervised exercise, psychological therapies like CBT and ACT, time-limited acupuncture, and select antidepressants such as amitriptyline or duloxetine — all instead of opioids. Holina’s programme adds somatic therapy and mindfulness-based practice as further non-pharmacological tools.

Will treating the addiction make my pain worse?

Not typically, and it may improve. Long-term opioid use can cause opioid-induced hyperalgesia, where the drug itself increases pain sensitivity over time. Many clients find pain sensitisation eases once the cycle of use and withdrawal is broken, under proper medical support, though this varies by individual.

What is Thrucare and why does aftercare matter for pain-related dependency specifically?

Thrucare is Holina’s two-year aftercare model. It matters especially here because relapse risk is tied to the original pain condition recurring, not just to cravings — the pain itself doesn’t go away once treatment ends. Thrucare manages that ongoing risk over the long term, rather than treating recovery as complete at discharge.

Is medication-assisted treatment (Suboxone, Naltrexone, Methadone) available at Holina?

Yes. Holina’s clinical team works from an individualised comparison of Suboxone, Naltrexone, and Methadone, choosing an approach based on each client’s history, dependency severity, and goals, under medical supervision throughout.

How does HBOT fit into treatment — is it a pain treatment or an addiction treatment?

Neither, exactly. At Holina, HBOT is positioned toward supporting recovery from opioid-related hypoxic brain injury, based on documented case-report evidence, and offered as one part of a broader treatment plan — not a standalone pain therapy or guaranteed outcome.

How do I start the conversation with a family member who doesn’t think they have a problem?

Lead with concern about function and quality of life rather than confronting the medication directly, avoid ultimatums about willpower, and get a factual anchor for yourself first — a free callback with Holina’s team can help before you speak with your loved one. See “What families can do now” above for the full approach.

Clinically reviewed by Dr. Natalie Lindemann — Clinical Director, Holina Global · Last reviewed 18 August 2026.