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Chronic Pain and Substance-Related Disorders

Understanding potential links and mitigation strategies may help physicians when prescribing opioids to patients with substance use disorders.
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Chronic, noncancer pain is common among patients being treated for a substance use disorder but studies indicate that such disorders are more than 90% likely to appear before the onset of pain symptoms. It is therefore important for providers to understand the association between chronic pain and substance use disorders. The following article examines assessment and risk for developing a substance use disorder (SUD) in relation to chronic pain and pain management.

Defining Substance Use Disorders

Substance-related disorders encompass 10 separate classes of drugs: alcohol, caffeine, cannabis, hallucinogens (phencyclidine), inhalants, opioids, edatives/hypnotics/anxiolytics, stimulants (amphetamines and cocaine), tobacco, and other (or unknown) substances.1 These disorders are divided into two groups: substance use disorders (SUDs) and substance-induced disorders (ie, intoxication, withdrawal, and other substance/medication-induced mental disorders).

The essential feature of SUD is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems.1 Diagnosis of SUD is typically based on a pathological pattern of behaviors related to use of the substance. To assist with organization, criteria may be considered to fit within four overall groupings:

  • impaired control
  • social impairment
  • risky use
  • pharmacological criteria.


The American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for SUD are nearly identical to the DSM-IV substance abuse and dependence criteria combined into a single disorder (see Table 1 for prevalence rates and diagnoses associated with each class of substance).1,2

View a PDF of Table 1


Unlinking Pain Prevalence and SUD Risk

Patients being treated for a substance use disorder commonly report chronic, noncancer pain,3 and, in turn, a history of SUD occurs frequently among patients who receive treatment for chronic, noncancer pain.4 Between 3% and 48% of patients who suffer from chronic, noncancer pain also have a current substance abuse disorder.5 Lifetime prevalence rates (16% to 74%)5 have been found to be higher than that in the general population (16.7%).6 As noted, 94% of chronic pain patients with lifetime SUDs experience the onset of these disorders before the onset of their chronic pain.7 However, patients with chronic pain are no more likely than any other patient in a primary care setting to have a current SUD, suggesting that chronic pain is not associated with unique risk for substance abuse.8

In a study by Dersh et al,9 the most commonly misused/abused substances in patients presenting with chronic pain were alcohol (current and lifetime) and narcotics (current).The study did not consider marijuana and tobacco use. Another study by Fishbain et al reported current alcohol use among patients with chronic pain to be 4.3% and 7.4% during remission, while current drug dependence (ie, opioids, barbiturates, sedatives, and cannabinoids) was 10.6%, and 0.4% in opioid remission.10

Hoffman et al indicated that 23.4% of chronic pain patients met criteria for active alcohol (9.7%), analgesic (12.6%), or sedative use (7.0%), and an additional 9.4% were in remission11 (see Table 1 for rates of substance abuse associated with chronic pain).10-14

When Excessive Substance Use Leads to Addiction

All classes of substances taken in excess directly activate the brain reward system, which is involved in reinforcing behaviors and producing memories. Illicit substances may produce an intense activation of that system, which then triggers the reward pathways and causes a “high,” leaving normal brain activities neglected.15 Individuals with prior lower levels of self-control may be particularly predisposed to develop SUD, which may reflect impairments of brain inhibitory mechanisms.16 Behavioral effects of SUDs (eg, repeated relapses and intense drug cravings) reflect brain changes that are evident even after detoxification when the individuals are exposed to drug-related stimuli.16

Typically, abused substances act as brain depressants that suppress the production of neurotransmitters. When the patient ceases using the substance of choice, the brain rebounds by producing a surge of adrenaline that may lead to withdrawal symptoms. As a result, the patient may continue to crave the substance and develop an addiction.

Understanding SUD Diagnosis in the DSM-5

After the APA published the DSM-IV in 1994, its approach to substance use disorders has come under scrutiny.17 Strengths were identified, such as the reliability and validity of substance abuse/dependence, but concerns also arose including: whether to retain the division into two main disorders (dependence and abuse), whether SUD criteria should be added or removed, and whether an appropriate SUD severity indicator could be identified.17

Last updated on: December 7, 2017
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