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10 Articles in Volume 17, Issue #10
A Guest Editorial on Counterfeit Pain Medication: The Other Epidemic
A Model to Incorporate Functional Medicine into Chronic Pain Care
Chronic Pain and Substance-Related Disorders
Getting at the Root of Opioid-Induced Constipation (OIC) with an Osteopathic Approach
Inside FDA's Guidance on Generic Abuse-Deterrent Opioids
Neural Pathway Pain — A Call for More Accurate Diagnoses
Pain Care in a Natural Disaster
Pharmacological Interventions in Sport-Related Concussion
The Internet of Medical Things
What Type of Withdrawal Symptoms from Tramadol Might a Patient Experience?

Chronic Pain and Substance-Related Disorders

Understanding potential links and mitigation strategies may help physicians when prescribing opioids to patients with substance use disorders.

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

The biggest change in the updated version, DSM-5, is how healthcare providers diagnose the disorder. DSM-5 moved away from a categorical approach (abuse versus dependence) to a dimensional scale, and now uses a criteria count (2 to 11) as an overall severity indicator. The number of criteria met indicates the severity as follows:

Recurrent legal problems with DSM-IV’s criterion for substance abuse led to its removal and a new criterion—craving or a strong desire or urge to use a substance—was added to DSM-5. Early remission from SUD is now defined as at least three but less than 12 months without criteria and sustained remission is defined as at least 12 months without criteria (except craving in both remissions). Additional new DSM-5 specifiers include: “in a controlled environment” and “on maintenance therapy” as the situation warrants.1

Assessing for SUD

There are several elements of a comprehensive patient assessment for SUD. In addition to a physical exam and  a review of co-occurring conditions and mental health disorders (including current mental status), the assessment should include an evaluation of the patient’s substance use history and risk for addiction.


Several factors are involved in a substance use history evaluation:

  • current use of substances (including prescription medications) confirmed by laboratory toxicology testing
  • adverse consequences of usage

  • age at first use
  • treatment history (including support groups)
  • periods of abstinence

  • strength-of-recovery support network

  • family history of SUD
  • history of physical, sexual, or emotional abuse or trauma.18

Current Usage

Some clinicians may question the validity of self-reported drug/alcohol use. One study found that about 9% of patients with chronic pain provided incorrect information about current drug use, mostly regarding illicit drugs (eg, cocaine and cannabis).19 Urinalysis remains the standard means of testing for illicit drug use.

However, the assessment of alcohol use is more complicated and may require the use of a breathalyzer. Other instruments may be more refined: the Alcohol Use Inventory, the Alcohol Dependence Scale, the Michigan Alcoholism Screening Test, the Addiction Severity Index, the Alcohol Use Disorders Identification Test (AUDIT-C), and the CAGE
questionnaire. 2

It is also important to consider that substance use may cause clinically significant distress or impairment in social, occupational, or other important areas of functioning in order for the behavior to be considered disordered.

What SUD Treatment Looks Like

There are several standards available that may be of assistance when considering the treatment of SUD, including the American Psychiatric Association’s Practice Guideline for the Treatment of Patients With Substance Use Disorders,20 the American Society of Addiction Medicine’s Patient Placement Criteria for the Treatment of Substance-Related Disorders,21 the American Psychiatric Association’s Practice Guideline for the Treatment of Patients With Nicotine Dependence,22 and the National Institute on Drug Abuse’s Principles of Drug Addiction Treatment.23

However, according to Division 12 of the APA’s Society of Clinical Psychology, several psychotherapies have been found to have strong research support for treating SUD, including motivational interviewing; motivational enhancement therapy or integrated with cognitive-behavior therapy; contingency management; and seeking safety.24 Each of these is defined further below.

Motivational Interviewing

Motivational interviewing (MI) is a brief person-centered clinical method for strengthening a patient’s motivation for and commitment to change.25 The overall style of MI is collaborative and empathic, and its course normally runs between one and four sessions. MI therapists may use a variety of strategies to evoke and strengthen a patient’s “change talk.”

Motivational Enhancement Therapy

Motivational enhancement therapy (MET) combines the clinical style of MI with individual assessment feedback that may be particularly helpful for less-ready patients, where the initial task is to develop ambivalence about change.26 MI and MET may be combined with other approaches, such as cognitive behavior theory (CBT).27-28

Contingency Management

Contingency management (CM) is a structured behavioral therapy that involves frequently monitoring the behavior targeted for change, and reinforcing the behavior each time it occurs using tangible and escalating reinforcers. CM usually lasts 8 to 24 weeks and is typically provided as an adjunct to another treatment (standard group treatment, 12-step therapy, CBT, MET, etc.). It has been shown to have modest research support for the treatment of cocaine use disorder.24

Seeking Safety

Seeking safety (SS) is a present-focused counseling model that aims to help patients attain safety from trauma and/or substance abuse. Considered extremely safe, the model directly addresses both trauma and addiction without requiring patients to delve into the trauma narrative. It can be conducted over any number of sessions, although the more sessions the better.29  

Other Interventions

When in reference to alcohol use disorder specifically, there is strong research support for behavioral couples therapy (BCT).30 When delivering BCT to a married or cohabiting alcoholic patient, a therapist may treat the substance-abusing patient with his/her intimate partner and work to build support from within the dyadic system for abstinence. When in reference to tobacco use disorder, smoking cessation with weight gain prevention programs have modest research support. These programs are based in CBT, and address smoking cessation first, followed by weight control.24 It may also be more effective to combine counseling with medication than either component alone.31 A previous article provides a more in-depth look at the treatment of comorbid substance use disorders and chronic pain.32

Managing Addiction Risk in Patients Treated with Opioids

Many frontline practitioners may be reluctant to prescribe an opioid for chronic pain management among patients with a diagnosed SUD for fear of addiction, misuse, or diversion. As noted, opioid abuse (9%) and illicit drug use (16%) have been found to occur in patients with chronic pain.33 Thus, many providers may choose to implement different mitigation strategies in an attempt to reduce these occurrences.

Prescribers may begin treatment by working their way up the World Health Organization’s dated pain analgesic ladder before prescribing opioids.34 Others may attempt to identify red flags (eg, doctor shopping, borrowing or stealing opioids, selling their prescriptions, prescription forgery, reporting lost/stolen medications, disproportionate pain, and/or negative interactions with other pain providers) to predict such occurrences.35

A common concern expressed by providers is how to distinguish a patient who is misusing opioids from a patient who is potentially addicted. The author’s recommendation to providers is to ask open-ended questions and to spend more time listening to patients in order to learn and understand usage, as well as potentially related histories. (See Table 2 on previous page regarding clinical features used to identify opioid misuse and addiction.)36

The CDC guidelines for the initiation, selection, and assessment of opioid therapy risk recommend that clinicians incorporate risk mitigation strategy plans, including an assessment and history of a patient’s SUD.24 One study demonstrated that questions regarding family substance abuse history, past problems with drugs/alcohol abuse, and/or legal problems may be useful in predicting aberrant drug-
related behavior.37

Another recent study indicated the importance of considering current
opioid prescriptions and sleep patterns along with a substance use history in universal screening of patients with chronic, noncancer pain for opioid misuse.38

There are several other mitigating strategies practitioners may use against opioid diversion and misuse.39 Numerous screening tools are available to help identify at-risk patients, including the Opioid Risk Tool, the Screener and Opioid Assessment for Patients with Pain (SOAPP), and the Brief Risk Interview.

The CDC has also recommended that prescribers use data from the prescription drug monitoring program, urine drug screening, opioid pain agreements, and that they utilize universal precautions.24 Presently, a combination of these strategies is recommended to stratify risk, identify and understand aberrant drug-related behaviors, and tailor treatments accordingly.40 Unfortunately, only limited data are available regarding the efficacy of any of these strategies.41

It’s  best to conceptualize addiction as a chronic illness that waxes and wanes, and recognize that substance abuse, much like diabetes, heart disease, and chronic pain, may be largely influenced by a patient’s behavior. These practices may assist in assessment and treatment planning so that providers can master strategies for effective, brief interventions that have shown to reduce substance misuse.42

The views expressed in this article are those of the author and do not necessarily represent the views of the Department of Veterans Affairs or any other governmental agency.

Last updated on: December 7, 2017
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