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4 Articles in this Series
Injection of Juvederm Treats Neuropathic Pain
Is Smoking Predictive of Medication Abuse?
New Model Predicts Outcomes Before Back Surgery
Urine Drug Testing: What is Optimal Frequency and Duration?

Is Smoking Predictive of Medication Abuse?

A common assumption among pain clinicians is that smoking is a good predictor of medication misuse and abuse. However, a new study calls into question this long-held assumption. According to Ted Jones, PhD, of Pain Consultants of East Tennessee, in Knoxville, most smokers don’t engage in medication-aberrant behavior (MAB).

Dr. Jones came to this conclusion by studying 484 patients who were being evaluated as part of a larger risk-assessment study, in which patients were asked about their smoking status.1 They found a 3-fold higher incidence of MAB among smokers, but, “if you just use smoking as a risk factor all by itself, it doesn’t predict MAB. You can’t just say he’s a smoker, he’s high-risk, because it doesn’t work that way,” Dr. Jones told Practical Pain Management.

Indeed, more than half of current smokers in the study did not engage in MAB during the 6-month follow-up period. Thus, although smoking was found to be statistically associated with MAB, most smokers did not engage in MAB. Therefore, using smoking status as a solitary predictor of MAB “will lead to a large number of false positives,” Dr. Jones said.

In addition, he said that it is difficult to find subsets of smokers who are at high risk for MAB. Noting that although many risk inventory tools are available for use in the pain population, what is surprising, he said, is that of the 6 or 7 risk tools available, only 2 ask about smoking. This may be because the incidence of smoking is so high in the pain population. “We have such a high incidence of smoking at our clinic that everybody would be categorized as medium- or high-risk if smoking status was used as the sole predictor of MAB,” Dr. Jones noted.

As to whether smoking helps or enhances pain, Dr. Jones noted that all of his patients report that smoking seems to help their pain. “The studies will say that smoking is bad, but some of our patients say they took up smoking when they got pain. Or they went back to smoking when they got pain. It’s unclear if it’s due to boredom, or whether there is something in the nicotine that blocks some brain receptors; they get a buzz and they don’t feel the pain. But the patients will routinely say, ‘I smoke more because I have pain.’”

This can put clinicians in an ethical quandary—do you tell them to stop smoking? Not necessarily, Dr. Jones said. “I usually advise my patients to switch to a vapor system. While most of these products are not FDA approved and need more study, conceptually they should be of benefit. This way, they get their nicotine without the harmful carbon monoxide.” According to clinical studies, the carbon monoxide is what damages the lungs and gets into the blood stream. “So I say to my patients: ‘we don’t want to take your nicotine away right now; just go get a vapor.”


  1. Jones T, Moore T. Is smoking really a good predictor of medication aberrant behavior? Presented at: American Academy of Pain Medicine, National Harbor, MD, March 19-22, 2015. Poster 157.


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