Medication Management for Chronic Pain

Key facts

Non-opioid-first: what that means in practice

For chronic pain that is not from cancer, the medications with the best balance of benefit and safety are not opioids. The 2022 CDC Clinical Practice Guideline states that non-opioid therapies are preferred for subacute and chronic pain, and that opioids should be considered only when the expected benefit for pain and function outweighs the risks. That is the practice's starting point. It does not mean medication is unimportant; it means the right medication is chosen for the kind of pain you have:

• Joint and inflammatory pain: NSAIDs such as naproxen, meloxicam or celecoxib, at the lowest effective dose and with attention to stomach, kidney and heart risk; topical diclofenac gel for hands and knees; acetaminophen up to 3,000 mg a day for people who cannot take NSAIDs.
• Nerve pain (sciatica, neuropathy, postherpetic neuralgia, CRPS): gabapentin or pregabalin, titrated over weeks to a working dose; duloxetine or venlafaxine; low-dose tricyclics (amitriptyline, nortriptyline) at bedtime; lidocaine patches and capsaicin on the painful skin.
• Widespread or sensitized pain (fibromyalgia, long-standing back pain): duloxetine, milnacipran, pregabalin, low-dose tricyclics, together with exercise and sleep treatment.
• Muscle spasm: cyclobenzaprine or tizanidine for short courses, usually at night; not intended for long-term daily use.
• Sleep: treated directly, because poor sleep lowers pain thresholds; sedating pain medications at bedtime, sleep hygiene, and sleep apnea evaluation when indicated.

Each medication is started one at a time, with a target dose and a date to judge it, usually 4 to 8 weeks. Medications that are not helping are stopped rather than accumulated. Gulf Coast Pain & Spine provides medication management at its Houston, Webster and Pearland (opening November 2026) offices.

Controlled substances: how decisions are made

Opioids, benzodiazepines, carisoprodol and some other pain-related medications are controlled substances regulated by the DEA, the Texas Medical Board (Title 22, Texas Administrative Code, Chapter 170) and Texas prescription law. Decisions about controlled substances are made by the physician after evaluation and records review. No controlled substance is prescribed at a first visit on the strength of a request, and none is prescribed through the patient portal or by phone. Before any decision, the physician reviews:

• Your complete records, including prior prescribers' notes and the reason any previous prescription was started or stopped
• The Texas Prescription Monitoring Program (PMP) record, which Texas law requires a prescriber to check before prescribing opioids, benzodiazepines, barbiturates or carisoprodol
• Your diagnosis, what non-opioid treatments have been tried, and what a controlled medication is expected to achieve for your function
• Risk factors: personal or family history of substance use disorder, untreated mental health conditions, sleep apnea, other sedating medications, prior overdose
• Whether the pain has a treatable source that a procedure would address more safely

Texas also requires electronic prescribing of controlled substances and limits opioids for acute pain to a 10-day supply with no refill (chronic pain, cancer pain and hospice care are exempt).

If a controlled substance is part of your plan, the goal is defined in terms of function (walking, working, sleeping) as well as pain, at the lowest effective dose, with a set date to review whether it is still earning its place. Opioids and benzodiazepines are not prescribed together except in rare, documented circumstances, because the combination sharply raises the risk of fatal overdose.

The controlled-substance agreement and monitoring

Any patient receiving a controlled substance from the practice signs a controlled-substance agreement, which is a standard safety document in Texas pain practices and which we review with you. Its terms:

• One prescriber, one pharmacy. Controlled medications come only from this practice and are filled only at the pharmacy you designate. If another doctor (a dentist, a surgeon, an emergency room) prescribes a controlled medication, you tell us within one business day.
• Texas PMP checks before every controlled prescription and at intervals during care.
• Urine drug testing at the start of treatment and at random intervals afterward, typically at least once or twice a year and more often when indicated. The test confirms the prescribed medication is present and that non-prescribed substances are not. Results are discussed with you.
• Pill counts may be requested; you bring your medication to the visit.
• No early refills, no phone or portal refills, and no refills without a visit. Prescriptions are written for a defined period and renewed only at a scheduled appointment. Lost, stolen or damaged prescriptions are not replaced.
• Safe storage. Controlled medications are kept locked and away from children, teenagers and visitors, and unused medication is returned to a take-back site.
• No driving or operating machinery when a new dose is started or increased, and no alcohol with opioids or benzodiazepines.
• Participation in the rest of the plan: physical therapy, procedures, psychology referrals and other treatments are not optional extras alongside a prescription.

A breach of the agreement is discussed with you and documented. Depending on the breach, the physician may adjust monitoring, taper the medication, or end controlled-substance prescribing while continuing other care.

Naloxone and overdose safety

Naloxone reverses an opioid overdose and is available over the counter and by prescription. Following the CDC guideline and Texas Medical Board guidance, we co-prescribe naloxone and teach household members how to use it when risk factors are present: an opioid dose of 50 morphine milligram equivalents a day or more, any use of a benzodiazepine or other sedative alongside an opioid, a history of overdose or substance use disorder, sleep apnea or lung disease, or kidney or liver disease. Having naloxone in the house is a safety measure, not a judgment.

Tapering support

Many patients arrive on a long-standing opioid or benzodiazepine dose and want to reduce it, or find it is no longer helping. Reducing a dose that has been taken for months or years should be gradual and supported; abrupt stopping causes withdrawal, uncontrolled pain, and, with benzodiazepines, can be dangerous. The CDC and HHS recommend tapers of about 10 percent per month or slower for long-term users, with pauses when needed, and faster tapers only when safety requires them. A taper plan at the practice includes a written schedule, non-opioid medications and procedures to cover the pain during the taper, treatment of sleep and mood, regular check-ins, and naloxone. Patients with opioid use disorder are referred to addiction medicine for buprenorphine or other treatment, which the practice supports and coordinates.

What to bring to a medication visit

• Every medication bottle, including over-the-counter drugs and supplements, or a current list with doses
• Records from previous prescribers, including the reason any medication was started or stopped
• Pharmacy name and phone number
• A two-week log of pain, sleep and activity

Related pages: chronic pain, patient policies, insurance, new patients.

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