Chronic Pain · Treatment Options · Reviewed by Samuel Caruthers, MD
If you take opioids for chronic pain, you have probably noticed that the conversation around them has changed, and that the change has not always been kind to patients. Prescriptions became harder to fill. Pharmacists asked more questions. Some people found themselves treated as suspects for taking a medication their physician prescribed and they were following exactly as directed.
This article is not another entry in that pile. It is not an argument that opioids are bad, and nothing here suggests you should reduce or stop a medication. That decision belongs to you and your prescribing physician and to nobody else, including a website.
What this article is about is a narrower and more practical question. For certain kinds of chronic pain, opioids tend to work less well than patients and physicians hope, for reasons rooted in how those pain conditions actually operate. Understanding why opens up a conversation about what else might be added.
Opioids do some jobs very well
Let us start where the evidence is strongest. For acute pain, for pain after surgery, for pain from cancer, and in palliative care, opioids are effective and appropriate, and restricting access to them in those settings causes real suffering.
Some patients with long-term non-cancer pain also do well on a stable opioid regimen, function better on it than off it, and have taken it responsibly for years. If that is you, this article is not suggesting your treatment is wrong.
Where they tend to underperform, and why
The difficulty arises in a specific category: chronic pain that is driven largely by changes in the nervous system rather than by ongoing tissue damage. Fibromyalgia, many neuropathic pain conditions, persistent pain after spine surgery, and complex regional pain syndrome all fall broadly into this territory.
Opioids act on opioid receptors, which are effective at dampening pain signals arriving from injured tissue. When the problem is that the nervous system has become amplified, and the signal is being generated or magnified centrally rather than arriving from a damaged structure, that mechanism has less to work with. This is a large part of why patients with these conditions often describe opioids as taking the edge off without ever really touching the problem.
Two further mechanisms complicate long-term use.
Tolerance. Over time the same dose produces less effect, which creates pressure to escalate, which produces more side effects without necessarily producing more relief.
Opioid-induced hyperalgesia. This one is less widely known and worth understanding. In some patients, prolonged opioid exposure appears to increase sensitivity to pain rather than decrease it. The medication intended to reduce pain contributes to an amplified pain state, which can look identical to the original condition getting worse.
A patient whose pain increases on a stable opioid dose is often assumed to be developing tolerance or a worsening disease. Sometimes the medication itself is part of the picture.
Why this is worth raising with your physician
Not as an accusation, and not as a reason to stop anything abruptly, which can be dangerous. But if you have been on opioids for a long time and your pain has gradually crept upward despite a stable dose, it is a reasonable question to ask whether hyperalgesia might be contributing, and whether adding something with a different mechanism would help more than increasing the dose.
What opioid-sparing care actually means
Modern chronic pain management is generally multimodal, meaning several treatments with different mechanisms used together rather than one medication carrying the whole load. The point is not moral. It is arithmetic. Several treatments each contributing partial relief through different pathways often add up to more than one treatment pushed to its limit, and with fewer side effects.
A multimodal plan might include interventional procedures aimed at a specific pain generator, neuropathic pain medications, physical therapy and graded activity, sleep treatment, psychological approaches for the pain-processing side, and, in selected cases, ketamine infusions.
Opioid-sparing does not necessarily mean opioid-free. For many patients it means the opioid stays and stops being the only thing doing the work, which frequently means it does not need to keep climbing.
Where ketamine fits
Ketamine acts at low doses primarily as an NMDA receptor antagonist, a completely different system from the opioid receptors. That difference is the reason it is of interest here rather than as a stronger version of something already being taken.
NMDA receptor activity is closely involved in central sensitization, the amplification process described earlier, and it also has a documented role in the development of opioid tolerance and in opioid-induced hyperalgesia. That gives it two potentially relevant roles: acting on the amplified pain state directly, and acting on the mechanisms that make long-term opioid therapy less effective over time.
In perioperative medicine, low-dose ketamine used alongside opioids has been shown to reduce opioid requirements, which is why it appears in many enhanced recovery protocols. In chronic pain the evidence is considerably thinner. Studies are small, protocols vary, and the duration of benefit reported is inconsistent.
Being straight about the limits
Ketamine is not FDA approved for chronic pain, and its use here is off-label. It is not a replacement for opioid therapy, it is not a detox or withdrawal treatment, and it will not be offered as a way to get someone off medication quickly. Some patients respond well, some partially, and some not at all, and there is no test that predicts which in advance.
What treatment involves
Infusions take place in the office with monitoring throughout, and pain protocols run longer than the brief infusions used for mood conditions. There is a recovery period afterward, and you cannot drive yourself home, so each appointment needs a ride arranged in advance.
Treatment usually begins with a series rather than a single infusion, with maintenance at longer intervals if the series helps. Your existing medications are reviewed carefully beforehand, since some combinations require adjustment, and any change is coordinated with the physician who prescribes them.
| Approach | Mechanism | Where it fits |
|---|---|---|
| Opioids | Opioid receptors | Strong for acute, post-surgical, and cancer pain; less reliable in centralized pain |
| Neuropathic agents | Nerve signaling and descending inhibition | First line in nerve-related pain, limited by side effects for some |
| Interventional procedures | Specific anatomical pain generators | Effective when a structure can be identified as the source |
| Ketamine infusion | NMDA receptors, central amplification | Considered in centralized or neuropathic pain, off-label and self-pay |
What multimodal care looks like in practice
The word gets used loosely, so here is a concrete version. A patient with persistent nerve-related pain in a leg might be on a neuropathic agent, doing a structured physical therapy programme, receiving a targeted injection to a specific joint or nerve, working on sleep, and taking a modest opioid dose that has stayed stable for years.
No single element there is carrying the whole load. Each contributes some relief through a different pathway, and the combined effect is usually better tolerated than the equivalent relief from one medication pushed high enough to produce it alone.
The reason this matters for a conversation about ketamine is that adding it, when appropriate, follows the same logic. It is not a replacement for the rest of the plan. It is another mechanism in a stack.
Questions worth bringing to your prescribing physician
If this article has raised something you want to discuss, these are more productive than asking whether you should come off your medication.
- Has my dose increased over time without a matching improvement in function, and what does that suggest?
- Is my pain the kind that responds well to opioids, or is it more centralized or nerve-related?
- Are there treatments with a different mechanism that could be added to what I am already taking?
- If we added something else, is there a realistic prospect of my current dose becoming unnecessary to increase further?
- Is opioid-induced hyperalgesia worth considering in my case?
Framed that way, the conversation is about improving a plan rather than defending a prescription, which tends to go better for everyone involved.
A word about how you may have been treated
Many patients on long-term opioid therapy have had experiences that were, frankly, degrading. Being counted at the pharmacy counter. Being asked the same questions in a tone that implied the answers were already disbelieved. Having a physician retire or leave a practice and discovering that nobody else will continue the prescription, through no fault of your own.
Those experiences change how people approach a new pain practice. Patients arrive braced, expecting to justify themselves, sometimes downplaying how much pain they are in because they have learned that reporting it accurately invites suspicion.
We would rather you did not do that here, because underreporting makes it harder to help you. The purpose of asking about your medication history is to understand what has and has not worked, not to audit you.
What we will not do
We will not tell you to come off your medication, we will not treat you as a problem to be managed rather than a patient to be helped, and we will not promise that any treatment here will let you stop something you currently rely on.
What we will do is look at your whole picture and give you a straight assessment of whether adding a different mechanism is likely to help, including saying so if we do not think it will.
Our Parsippany office serves patients across Morris County, including Denville and Mountain Lakes, with additional locations in Clifton, Hackettstown, and Hamburg.
Frequently asked questions
Are you going to try to take me off my pain medication?
No. Changes to a prescribed opioid regimen are made by the physician who prescribes it, with your agreement, and never abruptly. Our interest is in whether something with a different mechanism could be added usefully.
Can I have ketamine infusions while taking opioids?
Often yes. Your full medication list is reviewed first, because some combinations need adjustment, but taking opioids does not automatically rule out treatment.
Is ketamine an opioid?
No. Ketamine acts primarily on NMDA receptors, a different system entirely. That is precisely why it is of interest in patients for whom opioid-based approaches have plateaued.
Does ketamine treat opioid withdrawal or addiction?
That is not what we offer. This is a chronic pain practice. If addiction treatment is what you need, that is a different kind of care and we would help you find it rather than pretend otherwise.
What is opioid-induced hyperalgesia?
It is a state in which prolonged opioid exposure appears to increase pain sensitivity rather than reduce it. It can resemble worsening disease or simple tolerance, and it is worth considering when pain climbs steadily despite a stable dose.
Do you take insurance?
This is an out-of-network practice and we do not participate with Medicare or Medicaid. Ketamine infusion for chronic pain is generally not covered, and you will get clear costs before any treatment.
Wondering whether anything else can be added to what you are already doing?
A consultation looks at your full regimen and gives you an honest read on whether a different mechanism would help. No judgment, and no pressure to change anything.
Medical disclaimer. This article is for general educational purposes and is not medical advice, nor does it create a physician-patient relationship. Nothing here is a recommendation to start, stop, reduce, or change any medication, including opioids. Stopping or reducing opioid medication without medical supervision can be dangerous. Ketamine infusion therapy for chronic pain is an off-label use and is not FDA approved for this indication, and it is not a treatment for opioid withdrawal or substance use disorder. Individual results vary and no outcome is guaranteed. Discuss your circumstances with a qualified physician who has reviewed your full history. If you are experiencing a medical emergency, call 911.