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Chronic Pain Can Disrupt Medication-Assisted Treatment for Opioid Use Disorder

August 12, 2021
Research further links pain severity – even during opioid agonist treatment – to increased opioid cravings, which may lead to illicit opioid use.

Opioid-agonist treatment utilizing methadone or buprenorphine maintenance therapy can be effective in treating opioid use disorder (OUD). However, individuals diagnosed with OUD often experience lapses in medication-assisted treatment (MAT) that can lead to full relapses. One risk factor for lapse is chronic pain experienced during treatment; essentially the individual experiences more pain even while trying to control their pain.

MAT and treatment adherence can be complicated by opioid-induced hyperalgesia, explains Thelma Wright, MD, JD, a pain management specialist and anesthesiologist at the University of Maryland Medical Center. “Patients on high doses of opioids experience more pain just by virtue of the fact that they’re on opioids,” she says.

MAT and treatment adherence can be complicated by opioid-induced hyperalgesia. (Image: iStock)


Opioid Cravings and Chronic Pain: The Link to Illicit Opioid Use

Studies have shown that pain can elevate opioid cravings,1 and some studies have shown that patients with both OUD and chronic pain are more likely to use illicit substances during MAT,2 but the evidence has not been consistent. Other studies have found no association.3,4 With this gap in mind, researchers at Johns Hopkins University School of Medicine and the Intramural Research Program of the National Institute on Drug Abuse (NIDA) designed a study to explore whether opioid craving mediates the association between pain and illicit opioid use during opioid-agonist treatment.

The team performed a secondary analysis of data that had been gathered for a larger project conducted by NIDA’s Intramural Research Program (NIDA IRP). Participants included 56 adults – all of whom were seeking treatment at an office-based outpatient addiction treatment program at the NIDA IRP outpatient treatment research clinic in Baltimore, Maryland, or were already enrolled in treatment elsewhere in the community. All 56 adults qualified for opioid-agonist MAT for OUD.

Patients were excluded from the study if they had a history of diagnosis of psychotic disorder, bipolar disorder, or major depressive disorder, current alcohol use disorder, or sedative-hypnotic use disorder (this exclusion did not apply to the treatment-elsewhere cohort). Conditions that would make it difficult or impossible for patients to self-report (eg, cognitive impairment) or interfere with urine collection for drug monitoring were disqualified as were the use of medications that could complicate medical management (this exclusion did not apply to the treatment elsewhere cohort).

Pain status was assessed using two self-reported criteria:

  • pain other than from opioid withdrawal in the past 3 months
  • pain that is constant or flares up frequently

Of the 56 participants, 20 reported chronic pain. Eighty percent (80%) of the pain group were male; 60% were Caucasian.

Associations among pain, opioid craving, and illicit drug use were examined using ecological momentary assessment (EMA), a data collection method that utilizes repeated sampling of behaviors in real time in the subjects’ natural environments. Participants were given smartphones for providing EMA data. The experimenters programmed the phones to deliver both fixed and random prompts to report drug use, along with a range of correlations. Although the EMA items covered a larger range of data points, this study analyzed only pain, stress, negative mood, opioid craving, and illicit opioid use.

The office-based outpatient treatment cohort underwent twice-weekly urine and breath sampling to verify self-reported substance use during 30 weeks of office-based treatment. The cohort receiving treatment elsewhere in the community and already receiving methadone or buprenorphine treatment were followed for a maximum of 8 weeks. During this time, they visited the NIDA IRP clinic 3 days a week to provide self-reports of substance use along with urine and breath samples.

Pain Severity Associated with Increased Opioid Cravings

The study found that momentary pain severity was significantly associated with greater opioid cravings, and those cravings predicted illicit opioid use in the next moment, suggesting that in addition to stress and negative mood (already established risk factors) pain may be an important risk factor for opioid craving. However, the effect was small, leading the researchers to write, “Whether these moment to moment effects can accumulate over time and pose a clinically meaningful risk for opioid cravings is yet to be determined.”5 While this study did not explore possible mechanisms behind the effect, the researchers did point out that other studies have demonstrated that pain may interfere with “cognitive inhibitory capacity and/or reward processing.”5

These findings may be useful for clinicians seeking to maximize MAT for OUD. “Although [opioid agonist treatment] generally reduces opioid craving,” the study’s authors wrote, “some patients continue to crave. Thus, it is important to provide additional resources for [individuals undergoing MAT] to effectively cope with craving.”5 They suggest mindfulness-based interventions, since such programs have been shown to reduce not only craving, but pain, negative mood, and stress as well.

Improving Medication-Assisted Treatment with Psychological and Behavioral Adjuncts 

Dr. Wright, who was not involved in the study, notes that interventions such as mindfulness training and other psychological modalities can be useful when treating patients with chronic pain, and her clinic does require them as part of treatment. However, in her experience, very few patients willingly avail themselves of such programs. She adds, “More education is needed about the efficacy of a multidisciplinary approach to the treatment of pain.”

Last updated on: August 12, 2021
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