Skip to main content

Recommendations for Substance Abuse and Pain Control in Patients with Chronic Pain

Current Pain and Headache Reports volume 22, Article number: 25 (2018) Cite this article

Abstract

Purpose of Review

In the present investigation, current literature on the relationship between substance abuse and pain is evaluated in order to improve clinical management and its implications on the increasingly challenging chronic pain and substance abuse epidemic. The relationship between substance abuse and chronic pain are evaluated, and this review provides recommendations on the management of this special patient population.

Recent Findings

Currently, there are limited guidelines for prescribing opioids and other analgesics in the chronic pain population. As this field of practice continues to evolve, it is essential for clinicians to serve as the gatekeepers to monitor for misuse and safety. Multiple studies have indicated that illicit drug use and opioid abuse affect over 9% of patients. Although there are numerous reasons for seeking illicit drugs and abusing them, it is essential that clinicians identify factors which place certain patients at high risk and accordingly, to screen these patients in order to optimize their management.

Summary

The high prevalence of patients with chronic pain who also screen positive for drug use emphasizes the importance and increasingly pressing need to evaluate and to manage chronic pain in this population.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

References

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

  1. Gaskin D, Richard P. Relieving pain in America: a blueprint for transforming prevention, care, education, and research Appendix C, The Economic Costs of Pain in the United States. Washington DC: National Academies Press (US); 2011.

    Google Scholar 

  2. Katz NP, Sherburne S, Beach M, Rose RJ, Vielguth J, Bradley J, et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. 2003;97(4):1097–102.

    CAS  PubMed  Article  Google Scholar 

  3. Barry DT, Savant JD, Beitel M, Cutter CJ, Moore BA, Schottenfeld RS, et al. Pain and associated substance use among opioid dependent individuals seeking office-based treatment with buprenorphine–naloxone: a needs assessment study. Am J Addict. 2013;22(3):212–7.

    PubMed  PubMed Central  Article  Google Scholar 

  4. Jamison RN, Kauffman J, Katz NP. Characteristics of methadone maintenance patients with chronic pain. J Pain Symptom Manag. 2000;19(1):53–62.

    CAS  Article  Google Scholar 

  5. Rosenblum A, Joseph H, Fong C, Kipnis S, Cleland C, Portenoy RK. Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities. JAMA. 2003;289(18):2370–8.

    PubMed  Article  Google Scholar 

  6. Trafton JA, Oliva EM, Horst DA, Minkel JD, Humphreys K. Treatment needs associated with pain in substance use disorder patients: implications for concurrent treatment. Drug Alcohol Depend. 2004;73(1):23–31.

    PubMed  Article  Google Scholar 

  7. Manchikanti L, Cash KA, Damron KS, Manchukonda R, Pampati V, McManus CD. Controlled substance abuse and illicit drug use in chronic pain patients: an evaluation of multiple variables. Pain Physician. 2006;9(3):215–25.

    PubMed  Google Scholar 

  8. Manchikanti L, Manchukonda R, Damron K, Brandon D, McManus C, Cash K. Does adherence monitoring reduce controlled substance abuse in chronic pain patients? Pain Physician. 2006;9(1):57–60.

    PubMed  Google Scholar 

  9. Manchikanti L, Pampati V, Damron K, Beyer C, Barnhill R, Fellows B. Prevalence of prescription drug abuse and dependency in patients with chronic pain in western Kentucky. J Ky Med Assoc. 2003;101(11):511–7.

    PubMed  Google Scholar 

  10. Alford DP, German JS, Samet JH, Cheng DM, Lloyd-Travaglini CA, Saitz R. Primary care patients with drug use report chronic pain and self-medicate with alcohol and other drugs. J Gen Intern Med. 2016;31(5):486–91.

    PubMed  PubMed Central  Article  Google Scholar 

  11. Harris KM, Edlund MJ. Self-medication of mental health problems: new evidence from a national survey. Health Serv Res. 2005;40(1):117–34.

    PubMed  PubMed Central  Article  Google Scholar 

  12. Mariani JJ, Khantzian EJ, Levin FR. The self-medication hypothesis and psychostimulant treatment of cocaine dependence: an update. Am J Addict. 2014;23(2):189–93.

    PubMed  Article  Google Scholar 

  13. Kahan M, Srivastava A, Wilson L, Gourlay D, Midmer D. Misuse of and dependence on opioids: study of chronic pain patients. Can Fam Physician. 2006;52(9):1081–7.

    PubMed  PubMed Central  Google Scholar 

  14. Weaver M, Schnoll S. Abuse liability in opioid therapy for pain treatment in patients with an addiction history. Clin J Pain. 2001;18(4 Suppl):S61–9.

    Google Scholar 

  15. Conroy DA, Kurth ME, Strong DR, Brower KJ, Stein MD. Marijuana use patterns and sleep among community-based young adults. J Addict Dis. 2016;35(2):135–43.

    PubMed  PubMed Central  Article  Google Scholar 

  16. Vadivelu N, Mitra S, Kaye AD, Urman RD. Perioperative analgesia and challenges in the drug-addicted and drug-dependent patient. Best Pract Res Clin Anaesthesiol. 2014;28(1):91–101.

    PubMed  Article  Google Scholar 

  17. Ghuran A, Nolan J. Recreational drug misuse: issues for the cardiologist. Heart. 2000;83(6):627–33.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  18. Dowling K, Storr CL, Chilcoat HD. Potential influences on initiation and persistence of extramedical prescription pain reliever use in the US population. Clin J Pain. 2006;22(9):776–83.

    PubMed  Article  Google Scholar 

  19. Dabu-Bondoc S, Shah AA, Effraim PR. Prescription drug abuse. Subst Abuse: Springer; 2015. 127–41.

  20. Bingham CR, Shope JT, Tang X. Drinking behavior from high school to young adulthood: differences by college education. Alcohol Clin Exp Res. 2005;29(12):2170–80.

    PubMed  PubMed Central  Article  Google Scholar 

  21. Vadivelu N, Lumermann L, Zhu R, Kodumudi G, Elhassan AO, Kaye AD. Pain control in the presence of drug addiction. Curr Pain Headache Rep. 2016;20(5):1–8.

    Article  Google Scholar 

  22. Warner M, Trinidad JP, Bastian BA, Minino AM, Drugs HH. Most frequently involved in drug overdose deaths: United States, 2010-2014. Natl Vital Stat Rep: Cent Dis Control Prev, Nat Cent Health Stat, Natl Vital Stat Syst. 2016;65(10):1–15.

    Google Scholar 

  23. Vadivelu N, Lumermann L, Zhu R, Kodumudi G, Elhassan AO, Kaye AD. Pain Control in the presence of drug addiction. Curr Pain Headache Rep. 2016;20(5):35.

    PubMed  Article  Google Scholar 

  24. Whitby LG, Hertting G, Axelrod J. Effect of cocaine on the disposition of noradrenaline labelled with tritium. Nature. 1960;187:604–5.

    CAS  PubMed  Article  Google Scholar 

  25. Foltin RW, Ward AS, Haney M, Hart CL, Collins ED. The effects of escalating doses of smoked cocaine in humans. Drug Alcohol Depend. 2003;70(2):149–57.

    CAS  PubMed  Article  Google Scholar 

  26. Pavarin R, Lugoboni F, Mathewson S, Ferrari AM, Guizzardi G, Quaglio G. Cocaine-related medical and trauma problems: a consecutive series of 743 patients from a multicentre study in Italy. Eur J Emerg Med: Off J Eur Soc Emerg Med. 2011;18(4):208–14.

    Article  Google Scholar 

  27. • Cicero TJ, Ellis MS, Harney J. Shifting patterns of prescription opioid and heroin abuse in the United States. N Engl J Med. 2015;373(18):1789–90. A review of the development of heroin abuse and prescription opioid abuse in the United States.

    PubMed  Article  Google Scholar 

  28. Vadivelu N, Urman RD, Hines UR. Essentials of Pain Management: Springer: 2011. 671–697.

  29. Isbell H, Vogel VH. The addiction liability of methadon (amidone, dolophine, 10820) and its use in the treatment of the morphine abstinence syndrome. Am J Psychiatr. 1949;105(12):909–14.

    CAS  PubMed  Article  Google Scholar 

  30. Oslin, David W. “Addictions.” Psychiatry for Neurologists. Humana Press, 2006. 93–104.

  31. Strang J, Hall W, Hickman M, Bird SM. Impact of supervision of methadone consumption on deaths related to methadone overdose (1993–2008): analyses using OD4 index in England and Scotland. BMJ (Clin Res Ed). 2010;341:c4851.

    Article  Google Scholar 

  32. Jasinski DR, Pevnick JS, Griffith JD. Human pharmacology and abuse potential of the analgesic buprenorphine: a potential agent for treating narcotic addiction. Arch Gen Psychiatry. 1978;35(4):501–16.

    CAS  PubMed  Article  Google Scholar 

  33. Marsch LA, Stephens MA, Mudric T, Strain EC, Bigelow GE, Johnson RE. Predictors of outcome in LAAM, buprenorphine, and methadone treatment for opioid dependence. Exp Clin Psychopharmacol. 2005;13(4):293–302.

    PubMed  Article  Google Scholar 

  34. Weiss RD, Potter JS, Fiellin DA, Byrne M, Connery HS, Dickinson W, et al. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial. Arch Gen Psychiatry. 2011;68(12):1238–46.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  35. Magnani B, Kwong T. Urine drug testing for pain management. Clin Lab Med. 2012;32(3):379–90.

    PubMed  Article  Google Scholar 

  36. •• Kaye AD, Marshall ZJ, Lambert SM, Trescot AM, Prabhakar A, Elhassan AO, et al. Ethical perspectives on urine drug screening for pain physicians. Pain Physician. 2014;17(5):E559–64. (excellent review on urine drug screening for pain physicians).

    PubMed  Google Scholar 

  37. Barclay JS, Owens JE, Blackhall LJ. Screening for substance abuse risk in cancer patients using the Opioid Risk Tool and urine drug screen. Support Care Cancer: Off J Multinatl Assoc Support Care Cancer. 2014;22(7):1883–8.

    Article  Google Scholar 

  38. Childers JW, King LA, Arnold RM. Chronic pain and risk factors for opioid misuse in a palliative care clinic. Am J Hosp Palliat Care. 2015;32(6):654–9.

    PubMed  Article  Google Scholar 

  39. Rauenzahn S, Sima A, Cassel B, Noreika D, Gomez TH, Ryan L, et al. Urine drug screen findings among ambulatory oncology patients in a supportive care clinic. Support Care Cancer: Off Multinatl Assoc Support Care Cancer. 2017;25:1859–64.

    Article  Google Scholar 

  40. Arthur JA, Edwards T, Lu Z, Reddy S, Hui D, Wu J, et al. Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic. Cancer. 2016;122(23):3732–9.

    CAS  PubMed  Article  Google Scholar 

  41. Dickerson DM. Acute pain management. Anesthesiol Clin. 2014;32(2):495–504.

    PubMed  Article  Google Scholar 

  42. Carroll IR, Angst MS, Clark JD. Management of perioperative pain in patients chronically consuming opioids. Reg Anesth Pain Med. 2004;29(6):576–91.

    PubMed  Article  Google Scholar 

  43. de Leon-Casasola O. New concepts in postoperative pain management: is there more beyond pain control? J Fla Med Assoc. 1996;83(10):695–700.

    PubMed  Google Scholar 

  44. Kelly JP, Cook SF, Kaufman DW, Anderson T, Rosenberg L, Mitchell AA. Prevalence and characteristics of opioid use in the US adult population. Pain. 2008;138(3):507–13.

    Article  Google Scholar 

  45. • Feldman MD. Chronic pain and prescription drug use and abuse: emerging research in general internal medicine. J Gen Intern Med. 2016;31(5):451–2. A review of the current research regarding prescription drug use and chronic pain.

    PubMed  PubMed Central  Article  Google Scholar 

  46. Glajchen M. Chronic pain: treatment barriers and strategies for clinical practice. J Am Board Fam Pract. 2001;14(3):211–8.

    CAS  PubMed  Google Scholar 

  47. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107–12.

    PubMed  Article  Google Scholar 

  48. •• Califf RM, Woodcock J, Ostroff S. A proactive response to prescription opioid abuse. N Engl J Med. 2016;374(15):1480–5. A special report regarding the increasingly pressing importance in assessing the current epidemic and the need for improvements on appropriate opioid use and pain management.

    CAS  PubMed  Article  Google Scholar 

  49. Johnson NB, Hayes LD, Brown K, Hoo EC, Ethier KA. CDC National Health Report: leading causes of morbidity and mortality and associated behavioral risk and protective factors—United States, 2005-2013. MMWR Suppl. 2014;63(4):3–27.

    PubMed  Google Scholar 

  50. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999--2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487–92.

  51. Larson MJ, Paasche-Orlow M, Cheng DM, Lloyd-Travaglini C, Saitz R, Samet JH. Persistent pain is associated with substance use after detoxification: a prospective cohort analysis. Addiction. 2007;102(5):752–60.

    PubMed  Article  Google Scholar 

  52. Potter JS, Chakrabarti A, Domier CP, Hillhouse MP, Weiss RD, Ling W. Pain and continued opioid use in individuals receiving buprenorphine-naloxone for opioid detoxification: secondary analyses from the Clinical Trials Network. J Subst Abus Treat. 2010;38(Suppl 1):S80–6.

    Article  Google Scholar 

  53. •• Kaye AD, Jones MR, Kaye AM, Ripoll JG, Galan V, Beakley BD, et al. Prescription opioid abuse in chronic pain: an updated review of opioid abuse predictors and strategies to curb opioid abuse: part 1. Pain Physician. 2017;20(2s):S93–s109. (excellent review on opioid abuse predictors and strategies for pain physicians).

    PubMed  Google Scholar 

  54. •• Kaye AD, Jones MR, Kaye AM, Ripoll JG, Jones DE, Galan V, et al. Prescription opioid abuse in chronic pain: an updated review of opioid abuse predictors and strategies to curb opioid abuse (part 2). Pain Physician. 2017;20(2s):S111–s33. (excellent review on opioid abuse predictors and strategies for pain physicians).

    PubMed  Google Scholar 

  55. Cheatle MD, Gallagher RM. Chronic pain and comorbid mood and substance use disorders: a biopsychosocial treatment approach. Curr Psychiatry Rep. 2006;8(5):371–6.

    PubMed  Article  Google Scholar 

  56. Kennedy J, Roll JM, Schraudner T, Murphy S, McPherson S. Prevalence of persistent pain in the US adult population: new data from the 2010 national health interview survey. J Pain. 2014;15(10):979–84.

    PubMed  Article  Google Scholar 

  57. Gore M, Sadosky A, Stacey BR, Tai KS, Leslie D. The burden of chronic low back pain: clinical comorbidities, treatment patterns, and health care costs in usual care settings. Spine. 2012;37(11):E668–77.

    PubMed  Article  Google Scholar 

  58. Poleshuck EL, Green CR. Socioeconomic disadvantage and pain. Pain. 2008;136(3):235–8.

    PubMed  PubMed Central  Article  Google Scholar 

  59. Paulozzi LJ, Strickler GK, Kreiner PW, Koris CM. Controlled substance prescribing patterns—prescription behavior surveillance system, eight states, 2013. Morb Mortal Wkly Rep Surveill Summ. 2015;64(9):1–14.

    Google Scholar 

  60. Jones CM, Logan J, Gladden RM, Bohm MK. Vital signs: demographic and substance use trends among heroin users—United States, 2002-2013. MMWR Morb Mortal Wkly Rep. 2015;64(26):719–25.

    PubMed  PubMed Central  Google Scholar 

  61. Chou R, Fanciullo GJ, Fine PG, Miaskowski C, Passik SD, Portenoy RK. Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain: Off J Am Pain Soc. 2009;10(2):131–46.

    CAS  Article  Google Scholar 

  62. Edlund MJ, Martin BC, Fan MY, Devries A, Braden JB, Sullivan MD. Risks for opioid abuse and dependence among recipients of chronic opioid therapy: results from the TROUP study. Drug Alcohol Depend. 2010;112(1–2):90–8.

    PubMed  PubMed Central  Article  Google Scholar 

  63. Rice JB, White AG, Birnbaum HG, Schiller M, Brown DA, Roland CL. A model to identify patients at risk for prescription opioid abuse, dependence, and misuse. Pain Med. 2012;13(9):1162–73.

    PubMed  Article  Google Scholar 

  64. Nielsen S, Hillhouse M, Thomas C, Hasson A, Ling W. A comparison of buprenorphine taper outcomes between prescription opioid and heroin users. J Addict Med. 2013;7(1):33–8.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  65. Potter JS, Marino EN, Hillhouse MP, Nielsen S, Wiest K, Canamar CP, et al. Buprenorphine/naloxone and methadone maintenance treatment outcomes for opioid analgesic, heroin, and combined users: findings from starting treatment with agonist replacement therapies (START). J Stud Alcohol Drugs. 2013;74(4):605–13.

    PubMed  PubMed Central  Article  Google Scholar 

  66. Stumbo SP, Yarborough BJ, McCarty D, Weisner C, Green CA. Patient-reported pathways to opioid use disorders and pain-related barriers to treatment engagement. J Subst Abus Treat. 2017;73:47–54.

    Article  Google Scholar 

  67. Weiss RD, Potter JS, Griffin ML, McHugh RK, Haller D, Jacobs P, et al. Reasons for opioid use among patients with dependence on prescription opioids: the role of chronic pain. J Subst Abus Treat. 2014;47(2):140–5.

    Article  Google Scholar 

  68. Winstock AR, Lintzeris N, Lea T. “Should I stay or should I go?” Coming off methadone and buprenorphine treatment. Int J Drug Policy. 2011;22(1):77–81.

    PubMed  Article  Google Scholar 

  69. Bonn-Miller MO, Boden MT, Bucossi MM, Babson KA. Self-reported cannabis use characteristics, patterns and helpfulness among medical cannabis users. Am J Drug Alcohol Abuse. 2014;40(1):23–30.

    PubMed  Article  Google Scholar 

  70. Ilgen MA, Bohnert K, Kleinberg F, Jannausch M, Bohnert AS, Walton M, et al. Characteristics of adults seeking medical marijuana certification. Drug Alcohol Depend. 2013;132(3):654–9.

    PubMed  Article  Google Scholar 

  71. Nunberg H, Kilmer B, Pacula RL, Burgdorf J. An analysis of applicants presenting to a medical marijuana specialty practice in California. J Drug Policy Anal. 2011;4(1).

  72. Potter JS, Prather K, Weiss RD. Physical pain and associated clinical characteristics in treatment-seeking patients in four substance use disorder treatment modalities. Am J Addict. 2008;17(2):121–5.

    PubMed  Article  Google Scholar 

  73. Price AM, Ilgen MA, Bohnert AS. Prevalence and correlates of nonmedical use of prescription opioids in patients seen in a residential drug and alcohol treatment program. J Subst Abus Treat. 2011;41(2):208–14.

    Article  Google Scholar 

  74. Caldeiro RM, Malte CA, Calsyn DA, Baer JS, Nichol P, Kivlahan DR, et al. The association of persistent pain with out-patient addiction treatment outcomes and service utilization. Addiction. 2008;103(12):1996–2005.

    PubMed  Article  Google Scholar 

  75. Ashrafioun L, Bohnert KM, Jannausch M, Ilgen MA. Characteristics of substance use disorder treatment patients using medical cannabis for pain. Addict Behav. 2015;42:185–8.

    PubMed  Article  Google Scholar 

  76. Vadivelu N, Singh-Gill H, Kodumudi G, Kaye AJ, Urman RD, Kaye AD. Practical guide to the management of acute and chronic pain in the presence of drug tolerance for the healthcare practitioner. Ochsner J. 2014;14(3):426–33.

    PubMed  PubMed Central  Google Scholar 

  77. Abrecht CR, Brovman EY, Greenberg P, Song E, Rathmell JP, Urman RD. A contemporary medicolegal analysis of outpatient medication management in chronic pain. Anesth Analg. 2017;125(5):1761–8.

    PubMed  Article  Google Scholar 

Download references

Author information

Affiliations

  1. Yale University, TMP3 333, Cedar Street, New Haven, CT, 06520, USA

    Nalini Vadivelu & Dan Haddad

  2. Department of Internal Medicine, NYU-Winthrop Hospital, 259 First St., Mineola, NY, 11501, USA

    Alice M. Kai

  3. California Northstate School of Medicine, 9700 West Taron Dr., Elk Grove, CA, 95757, USA

    Gopal Kodumudi

  4. University of Connecticut School of Medicine, 263 Farmington Ave., Farmington, CT, 06030, USA

    Vijay Kodumudi

  5. Department of Anesthesiology, Austin Health, Level 2 Austin Tower, 145 Studley Road, Heidelberg, VIC, 3084, USA

    Niketh Kuruvilla

  6. Department of Anesthesiology, Louisiana State University Health Sciences Center, 1542 Tulane Ave, Suite 656, New Orleans, LA, 70112, USA

    Alan David Kaye

  7. Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, 02115, USA

    Richard D. Urman

Authors
  1. Nalini Vadivelu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alice M. Kai
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Gopal Kodumudi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Dan Haddad
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Vijay Kodumudi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Niketh Kuruvilla
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Alan David Kaye
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Richard D. Urman
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nalini Vadivelu.

Ethics declarations

Conflict of Interest

Nalini Vadivelu, Alice M. Kai, Gopal Kodumudi, Dan Haddad, Vijay Kodumudi, Niketh Kuruvilla, Alan David Kaye, and Richard D. Urman declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Other Pain

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Vadivelu, N., Kai, A.M., Kodumudi, G. et al. Recommendations for Substance Abuse and Pain Control in Patients with Chronic Pain. Curr Pain Headache Rep 22, 25 (2018). https://doi.org/10.1007/s11916-018-0679-3

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11916-018-0679-3

Keywords

  • Substance abuse
  • Pain control
  • Chronic pain
  • Opioid
  • Addiction
  • Prescription