Current Psychiatry Reports

, Volume 14, Issue 5, pp 462–468

Management of Pain With Comorbid Substance Abuse

  • Daniel Krashin
  • Natalia Murinova
  • Jane Ballantyne
Substance Use and Related Disorders (JR McKay, Section Editor)


Substance use disorders are a large public health problem in the United States. Over the past decade, there has been a trend of increased prescription drug misuse, morbidity, and mortality related to prescription opioids. For providers who treat pain, this has led to clinical dilemmas as the newly appreciated risks must be balanced with the benefits of treatment, particularly in patients with known substance use disorders. Acute, chronic, and palliative each present distinct issues in pain treatment. A best practices model of pain treatment, including risk stratification and integrative treatment, may provide the best prospect for safe and effective treatment.


Addiction Substance abuse Acute pain Chronic pain Palliative care Cancer pain Aberrant behavior Opioid abuse Opioid addiction Opioid dependence Drug diversion Opioid tolerance Risk management Risk stratification Screening Pain management Urine drug screening Psychological testing Substance abuse treatment 


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Ballantyne JC, LaForge KS. Opioid dependence and addiction during opioid treatment of chronic pain. Pain. 2007;129:235–55.PubMedCrossRefGoogle Scholar
  2. 2.
    Administration SAMHS. Results from the 2010 National Survey on drug use and health: summary of national findings. MD: Rockville; 2011.Google Scholar
  3. 3.
    Morasco BJ, Gritzner S, Lewis L, et al. Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. Pain. 2011;152:488–97.PubMedCrossRefGoogle Scholar
  4. 4.
    Catalano RF, White HR, Fleming CB, Haggerty KP. Is nonmedical prescription opiate use a unique form of illicit drug use? Addict Behav. 2011;36:79–86.PubMedCrossRefGoogle Scholar
  5. 5.
    Cicero TJ, Surratt HL, Kurtz S, et al. Patterns of prescription opioid abuse and comorbidity in an aging treatment population. J Subst Abus Treat. 2012;42:87–94.CrossRefGoogle Scholar
  6. 6.
    Ahlbeck K. Opioids. A two-faced Janus. Curr Med Res Opin. 2011;27:439–48.PubMedCrossRefGoogle Scholar
  7. 7.
    Paulozzi LJ, Kilbourne EM, Shah NG, et al. A history of being prescribed controlled substances and risk of drug overdose death. Pain Med. 2012;13:87–95.PubMedCrossRefGoogle Scholar
  8. 8.
    • Maxwell JC. The prescription drug epidemic in the United States: a perfect storm. Drug Alcohol Rev. 2011;30:264–70. An excellent overview of the analgesic misuse problem in the USA. PubMedCrossRefGoogle Scholar
  9. 9.
    Boudreau D, Von Korff M, Rutter CM, et al. Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf. 2009;18:1166–75.PubMedCrossRefGoogle Scholar
  10. 10.
    Okie S. A flood of opioids, a rising tide of deaths. N Engl J Med. 2010;363:1981–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Von Korff M, Kolodny A, Deyo RA, Chou R. Long-term opioid therapy reconsidered. Ann Intern Med. 2011;155:325–8.Google Scholar
  12. 12.
    Green TC, Black R, Grimes Serrano JM, et al. Typologies of prescription opioid use in a large sample of adults assessed for substance abuse treatment. PLoS One. 2011;6:e27244.PubMedCrossRefGoogle Scholar
  13. 13.
    Kalant H. What neurobiology cannot tell us about addiction. Addiction. 2010;105:780–9.PubMedCrossRefGoogle Scholar
  14. 14.
    O'Brien C. Addiction and dependence in DSM-V. Addiction. 2011;106:866–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Heit HA. Addiction, physical dependence, and tolerance: precise definitions to help clinicians evaluate and treat chronic pain patients. J Pain Palliat Care Pharmacother. 2003;17:15–29.PubMedGoogle Scholar
  16. 16.
    Jamison RN, Ross EL, Michna E, et al. Substance misuse treatment for high-risk chronic pain patients on opioid therapy: a randomized trial. Pain. 2010;150:390–400.PubMedCrossRefGoogle Scholar
  17. 17.
    •• Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. Off J Am Pain Soc: J Pain. 2009;10:113–30. These guidelines contain a wealth of specific advice for managing common dilemmas in pain treatment. Google Scholar
  18. 18.
    Younger JW, Chu LF, D'Arcy NT, et al. Prescription opioid analgesics rapidly change the human brain. Pain. 2011;152:1803–10.PubMedCrossRefGoogle Scholar
  19. 19.
    • Skurtveit S, Furu K, Borchgrevink P, et al. To what extent does a cohort of new users of weak opioids develop persistent or probable problematic opioid use? Pain. 2011;152:1555–61. This study demonstrates low risk of addiction in low dose acute opioid treatment. PubMedCrossRefGoogle Scholar
  20. 20.
    Gentilello LM, Rivara FP, Donovan DM, et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg. 1999;230:473–80. discussion 480–473.PubMedCrossRefGoogle Scholar
  21. 21.
    Mitra S, Sinatra RS. Perioperative management of acute pain in the opioid-dependent patient. Anesthesiology. 2004;101:212–27.PubMedCrossRefGoogle Scholar
  22. 22.
    Neighbor ML, Dance TR, Hawk M, Kohn MA. Heightened pain perception in illicit substance-using patients in the ED: implications for management. Am J Emerg Med. 2011;29:50–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Barry DT, Goulet JL, Kerns RK, et al. Nonmedical use of prescription opioids and pain in veterans with and without HIV. Pain. 2011;152:1133–8.PubMedCrossRefGoogle Scholar
  24. 24.
    •• Edlund MJ, Martin BC, Fan MY, et al. Risks for opioid abuse and dependence among recipients of chronic opioid therapy: results from the TROUP study. Drug Alcohol Depend. 2010;112:90–8. This study demonstrates the phenomena of “adverse selection” and high-risk opioid prescribing. PubMedCrossRefGoogle Scholar
  25. 25.
    Morasco BJ, Corson K, Turk DC, Dobscha SK. Association between substance use disorder status and pain-related function following 12 months of treatment in primary care patients with musculoskeletal pain. J Pain. 2011;12:352–9.PubMedGoogle Scholar
  26. 26.
    Morasco BJ, Duckart JP, Dobscha SK. Adherence to clinical guidelines for opioid therapy for chronic pain in patients with substance use disorder. J Gen Intern Med. 2011;26:965–71.PubMedCrossRefGoogle Scholar
  27. 27.
    Carroll CP, Haythornthwaite J. Maladaptive opioid use behaviors and psychiatric illness: what should we do with what we know? Curr Pain Headache Rep. 2011;15:91–3.PubMedCrossRefGoogle Scholar
  28. 28.
    Goebel JR, Compton P, Zubkoff L, et al. Prescription sharing, alcohol use, and street drug use to manage pain among veterans. J Pain Symptom Manage. 2011;41:848–58.PubMedCrossRefGoogle Scholar
  29. 29.
    Chan BK, Tam LK, Wat CY, et al. Opioids in chronic non-cancer pain. Expert Opin Pharmacother. 2011;12:705–20.PubMedCrossRefGoogle Scholar
  30. 30.
    Fitzcharles MA, Ste-Marie PA, Gamsa A, et al. Opioid use, misuse, and abuse in patients labeled as fibromyalgia. Am J Med. 2011;124:955–60.PubMedCrossRefGoogle Scholar
  31. 31.
    Morasco BJ, Duckart JP, Carr TP, et al. Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain. Pain. 2010;151:625–32.PubMedCrossRefGoogle Scholar
  32. 32.
    Silverberg MJ, Ray GT, Saunders K, et al. Prescription long-term opioid use in HIV-infected patients. Clin J Pain. 2012;28:39–46.PubMedCrossRefGoogle Scholar
  33. 33.
    Sullivan MD, Edlund MJ, Fan MY, et al. Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and medicaid insurance plans: The TROUP Study. Pain. 2010;150:332–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Clark MR, Treisman GJ. Optimizing treatment with opioids and beyond. In: Clark MR, Treisman GJ, editors. Chronic Pain and Addiction. 2011. pp. 92–112.Google Scholar
  35. 35.
    Hwang SW, Wilkins E, Chambers C, et al. Chronic pain among homeless persons: characteristics, treatment, and barriers to management. BMC Fam Pract. 2011;12:73.PubMedCrossRefGoogle Scholar
  36. 36.
    Heiwe S, Lonnquist I, Kallmen H. Potential risk factors associated with risk for drop-out and relapse during and following withdrawal of opioid prescription medication. Eur J Pain. 2011;15:966–70.PubMedCrossRefGoogle Scholar
  37. 37.
    Ilgen MA, Haas E, Czyz E, et al. Treating chronic pain in veterans presenting to an addictions treatment program. Cogn Behav Pract. 2011;18:149–60.CrossRefGoogle Scholar
  38. 38.
    Manchikanti L, Singh V, Caraway DL, Benyamin RM. Breakthrough pain in chronic non-cancer pain: fact, fiction, or abuse. Pain Physician. 2011;14:E103–17.PubMedGoogle Scholar
  39. 39.
    • Simone CB, Vapiwala N, Hampshire MK, Metz JM. Cancer patient attitudes toward analgesic usage and pain intervention. Clin J Pain. 2012;28:157–62. The concerns of typical cancer pain patients are studied, including both undertreatment and addiction. PubMedCrossRefGoogle Scholar
  40. 40.
    Dev R, Parsons HA, Palla S, et al. Undocumented alcoholism and its correlation with tobacco and illegal drug use in advanced cancer patients. Cancer. 2011;117:4551–6.PubMedCrossRefGoogle Scholar
  41. 41.
    Kircher S, Zacny J, Apfelbaum SM, et al. Understanding and treating opioid addiction in a patient with cancer pain. J Pain. 2011;12:1025–31.PubMedCrossRefGoogle Scholar
  42. 42.
    Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6:107–12.PubMedCrossRefGoogle Scholar
  43. 43.
    Becker WC, Starrels JL, Heo M, et al. Racial differences in primary care opioid risk reduction strategies. Ann Fam Med. 2011;9:219–25.PubMedCrossRefGoogle Scholar
  44. 44.
    Vijayaraghavan M, Penko J, Guzman D, et al. Primary care providers' judgments of opioid analgesic misuse in a community-based cohort of HIV-infected indigent adults. J Gen Intern Med. 2011;26:412–8.PubMedCrossRefGoogle Scholar
  45. 45.
    McGeary DD, McGeary CA, Gatchel RJ. A comprehensive review of telehealth for pain management: where we are and the way ahead. Pain Pract. 2012.Google Scholar
  46. 46.
    Meltzer EC, Rybin D, Saitz R, et al. Identifying prescription opioid use disorder in primary care: diagnostic characteristics of the Current Opioid Misuse Measure (COMM). Pain. 2011;152:397–402.PubMedCrossRefGoogle Scholar
  47. 47.
    Moore T, Jones T, Browder J, et al. A comparison of common screening methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain management. Pain Med. 2009;10:1426–33.PubMedCrossRefGoogle Scholar
  48. 48.
    Bohn TM, Levy LB, Celin S, et al. Screening for abuse risk in pain patients. In: Clark MR and Treisman GJ, editors. Chronic pain and addiction. 2011. pp. 113–24.Google Scholar
  49. 49.
    Katz NP, Sherburne S, Beach M, et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. 2003;97:1097–102.PubMedCrossRefGoogle Scholar
  50. 50.
    Christo PJ, Manchikanti L, Ruan X, et al. Urine drug testing in chronic pain. Pain Physician. 2011;14:123–43.PubMedGoogle Scholar
  51. 51.
    Gupta A, Patton C, Diskina D, Cheatle M. Retrospective review of physician opioid prescribing practices in patients with aberrant behaviors. Pain Physician. 2011;14:383–9.PubMedGoogle Scholar
  52. 52.
    •• Starrels JL, Becker WC, Alford DP, et al. Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010;152:712–20. This study demonstrates the benefits and limitations of these treatment practices. PubMedGoogle Scholar
  53. 53.
    Jones JD, Sullivan MA, Manubay J, et al. The subjective, reinforcing, and analgesic effects of oxycodone in patients with chronic, non-malignant pain who are maintained on sublingual buprenorphine/naloxone. Neuropsychopharmacology. 2011;36:411–22.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Daniel Krashin
    • 1
  • Natalia Murinova
    • 2
  • Jane Ballantyne
    • 1
  1. 1.Anesthesiology and Pain MedicineUniversity of Washington Medical CenterSeattleUSA
  2. 2.NeurologyUniversity of Washington Medical CenterSeattleUSA

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