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10 Articles in Volume 7, Issue #7
Burning Mouth Syndrome
Chronic Pain Program in a Primary Care Setting
Chronic Persistent Pain Can Kill
Education and Exercise Program for Chronic Pain Patients
Managing Pain in Intensive Care Units
Oxycodone to Oxymorphone Metabolism
Patulous Eustachian Tube: Part 1
Rational, Emotive, Ethical Approaches to Bio-psychosocial Pain Care
Smoking and Aberrant Behavior in Chronic Pain Patients
Structuring Opioid Therapy

Smoking and Aberrant Behavior in Chronic Pain Patients

A narrative review of smoking and aberrant drug-taking behavior in chronic pain patients together with emerging clinical implications.

Smoking rates in the United States among adults with persistent pain are high (30% to 64%) compared to the general population (21%). Furthermore, current evidence demonstrates that pain patients who smoke are at higher risk for aberrant drug-taking behavior (ADTB) on opioid therapy compared to non-smokers. Aberrant drug-taking behaviors involve a spectrum of nonadherent behaviors with opioid therapy that range from “rare, highly aberrant” to “common, not aberrant” related to addiction-related outcomes. The goal of this narrative review was to qualitatively examine studies on smoking and ADTB in patients with persistent pain and discuss emerging clinical implications.

Understanding the role of specific risk factors that predict aberrant drug-taking behaviors with opioid therapy is critical to improving pain management outcomes. Several studies suggest a relationship between cigarette smoking and aberrant drug-taking behaviors. This narrative review evaluates the evidence for a connection between smoking and aberrant drug-taking behavior with opioid therapy for persistent pain. Further, we propose a theoretical framework for understanding empirical linkages between smoking and aberrant drug-taking behaviors and critically evaluate the clinical significance of smoking when treating patients with persistent pain.


A literature search was conducted using PubMed, PsychInfo, and Medline with the four concepts: smoking, pain, aberrant behaviors, and opioids. A search for each concept was conducted separately and then combined.


Six studies showed that current smoking is associated with higher levels of analgesic use (Antonov et al., 1996;1 Antonov et al.,2 1998; Corrigall et al., 1992;3 Friedman et al., 2003;4 Jamison et al., 19915) and more ADTB than nonsmoking (Michna et al., 20046). Smokers with more severe nicotine dependency are more likely to misuse opioid medication than smokers with lower nicotine dependency.6 Michna and colleagues (2004)6 showed that current smoking and an index of tobacco dependence (e.g., smoking within 1 hour of waking) were among the most useful predictors of problems with opioid use among persistent pain patients. In this study, 61% of patients at low-risk for aberrant drug behaviors and 82% of patients at high-risk were current smokers.

Additional evidence for the smoking and ADTB connection is demonstrated by the development of two screening instruments that assess a patient’s risk for nonadherence with opioid use. These instruments assess current smoking status in the determination of risk potential for opioid misuse and include the Screening Instrument for Substance Abuse (SISAP)7 and the Screener and Opioid Assessment for Patients in Pain (SOAP).8 When developing the SISAP, Coambs and colleague7 retrospectively analyzed a large epidemiologic dataset and showed that current smoking and previous smoking status were significant risk factors for substance abuse. Specifically, the item, “Have you ever smoked cigarettes?” accurately identified 76% of patients who had substance abuse problems.7 While this important study established a fundamental link between smoking and risk of ADTB, the study aims and design do not allow for elaboration on the potential mechanisms of the association or a clinical explanation. Table 1 highlights selected study findings from the review results.

Table 1: Summary of Selected Studies on the Relationship between Smoking and Specific Analgesic Use Behaviors
Study Study Design Sample Outcome
Michna et al., 20046 Cross-sectional interview-based survey 145 chronic low back pain patients 82.2% of patients at high risk for ADTB and 61.0% of patients at low-risk for ADTB were current smokers.
Friedman et al., 20034 Cross-sectional survey 48 chronic pain patients on opioid therapy Current smoking status differentiated pain patients who had substance abuse disorders from patients without a substance abuse history.
Coambs et al., 19967 Retrospective population-based survey 9,915 adults I Canada Current and former smoking status were strong predictors of substance abuse.
Antonov et al., 19961 Population-based survey 13,295 adults in Sweden Current smoking status (26.0%) was positively associated with current analgesic use in women, but not men.
Antonov et al., 19982 Population-based survey 11,996 adults in Sweden Current smoking status was significantly associated with prescription analgesic use in men and with nonprescription analgesic use in women.

Theoretical Framework for Smoking-ADTB and Potential Clinical Implications

Much research identifying the association between smoking and the risk for ADTB during opioid therapy has been preliminary in nature. We propose three different explanations or profiles for understanding linkages between smoking and ADTB. As described in the section below, these profiles or “groups” involve the hypothesized roles of pseudoaddiction; substance abuse disorders, and chemical coping/negative affect reduction.

Group 1: Pseudo-addicted Group

While nicotine is clearly analgesic in studies of acute pain (often in opioid naïve subjects, e.g., Flood & Daniel, 2004;9 Jamner et al., 1998;10 Perkins et al., 199411), it is unclear whether smoking produces analgesic effects in patients with persistent pain. In fact, behaviors displayed by smokers that are perceived as aberrant may be motivated by the undertreatment of pain or inadequate analgesia. Weissman & Haddox (1989)12 proposed the iatrogenic phenomenon of pseudo-addiction wherein patients who have inadequate pain relief can be confused for addicts in their desperate attempts to seek relief. While Jamison et al. (1991)5 reported that many patients smoke to relieve severe pain intensity, other studies showed that nicotine-opioid interactions may lead to diminished pain relief (Zevin & Benowitz, 1999).13 These findings include, but are not limited to, the decreased efficacy of propoxyphene in smokers compared to non-smokers (Anon, 1973);14 the increased metabolic clearance of pentazocine in smokers (Vaughan et al., 1976);15 the need for higher doses of pentazocine in smokers compared to non-smokers (Keeri-Szanto & Pomeroy, 1971),16 and evidence for smoking inducing the metabolism of codeine (Yue et al., 1994).17 Thus, the smoking–ADTB connection could be the result of smokers receiving less analgesia from “routine” doses of opioids than do non-smokers, and subsequent pseudo-addictive behaviors that are in pursuit of enhanced pain control.

Group 2: “Substance Abuse Disorders Group”

It is not surprising that many patients who smoke also have comorbid substance abuse disorders. Indeed, 34% of individuals with alcohol disorders and 52% with substance abuse disorders meet full criteria for DSM-IV nicotine dependence (Grant et al., 2004;18 Romberger & Grant, 200419). Thus, smoking may be a proxy for current substance abuse disorders in smokers with persistent pain. Additional research is needed to evaluate the relationship between smoking and ADTB while controlling for the potential confounding effects of comorbid substance abuse. Smoking is likely to be a more socially acceptable form of substance use to report to a pain clinician than is alcohol or illicit drug abuse. Thus, smokers, especially heavy smokers, should be screened for the presence of other comorbid substance use disorders.

Group 3: Smoking and Chemical Coping/Negative Affect Group

While smokers with comorbid substance use disorders are likely to require referral to an addictions medicine specialist, there is a large middle ground of persistent pain patients who have problems adhering to the rules of opioid therapy, are very-drug-focused, and who fail to make progress towards psychosocial goals in pain management. Although many of these patients display ADTB, they are unlikely to meet criteria for opioid addiction in that their behavior is not as compulsive, as “out of control,” or as obviously, and acutely, harmful as in substance use disorders. These smokers may self-medicate or engage in “pill-popping,” particularly when experiencing heightened psychological distress and negative affect, including depression, anxiety and anger (“Chemical Coping/ Negative Affect Group”). Bruera and colleagues (Strasser et al., 200520) have used the term “chemical coping” to describe the tendency to rely on psychoactive substances as a means of coping with psychosocial distress. Smoking is widely used as a mood regulation strategy to decrease negative affect (e.g., depression, anxiety, and anger) and increase positive affect in smokers. Negative affect and mood disorders are common among smokers and those with persistent pain. Thus, the routine practice of screening for the presence of depression and anxiety as part of a comprehensive pain assessment and the availability of psychological interventions for these conditions are critical to improving pain outcomes, and may be most relevant for smokers with pain.

To date, no known study has prospectively identified covariates of the smoking-ADTB relationship or meaningful patient subgroups due to different study focus or limitations with design. Thus, evaluating the mechanisms that drive the smoking–ADTB relationship may inform the development of tailored interventions that address different risk profiles for opioid abuse. Understanding profiles of the smoking-ADTB relationship would help clinicians tailor therapy by being prepared for the need to overcome inadequate analgesia due to nicotine-opioid interactions in some patients; obtaining addiction medicine consultation for patients with co-morbid substance use disorders; and applying psychotherapeutic interventions for chemical coping and depression in others. Clinical pain management of complex patients would be aided by an evidence-based, theory driven approach that guides the clinical decision to utilize and combine specific interventions.


This narrative review showed that pain patients who smoke are at higher risk for ADTB on opioid therapy compared to non-smokers. Current smoking is associated with higher levels of analgesic use and more ADTB than nonsmoking. Further, smokers with more severe nicotine dependency are more likely to misuse opioid medication than smokers with lower nicotine dependency. Despite these linkages, smoking is a poorly understood risk factor for ADTB in pain patients receiving opioid therapy. No known studies have suggested guidelines for opioid therapy among pain patients who continue to smoke. Although smoking-related items have appeared on screening instruments aimed at assessing a patient’s risk potential for opioid misuse, the clinical implications of the smoking-ADTB association require clarification.

While pain clinicians interested in tailoring opioid therapy and risk factor assessment are being pointed in the direction of smoking, no study has aided clinicians by providing a deeper understanding of the smoking-ADTB association so that specific interventions might be employed. Clearly, the relationship between smoking and aberrant behaviors is complex given that not all smokers are prone to opioid misuse. In this review, we proposed three potential explanations for the linkage between smoking and ADTB, including pseudoaddiction; substance abuse disorders, and chemical coping/ negative affect reduction. Evaluating these potential covariates and moderators of ADTB would identify subgroups of patients at risk for aberrant behavior and help clinicians tailor therapy by:

  • being prepared for the need to overcome inadequate analgesia due to nicotine-opioid interactions in some patients;
  • obtaining addiction medicine consultation for patients with comorbid substance use disorders, and/or
  • using psychotherapeutic interventions for chemical coping and depression in others.

Hence, by assessing the characteristics of smoking behavior and specific psychosocial risk factors for ADTB, pain clinicians may be able to develop effective treatment strategies that address relevant comorbidities in vulnerable subgroups of patients and increase their chance of achieving successful pain management outcomes.

Last updated on: May 25, 2017
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