Prevalence and Characteristics of Chronic Pain in Patients Admitted to an Outpatient Drug and Alcohol Treatment Program

Nociplastic Pain and Pain-Motivated Drinking in Alcohol Use Disorder

Heavy chronic alcohol use may produce pain amplification through neurochemical and neuroplastic changes at multiple levels of the nervous system. Similar changes are thought to underlie nociplastic pain. The American College of Rheumatology Fibromyalgia Survey has been used as a surrogate for nociplastic pain, including among individuals with alcohol use disorder (AUD). However, studies linking nociplastic pain to pain-motivated drinking are lacking. The present study aimed to determine if nociplastic pain is associated with pain-motivated drinking in AUD. To achieve this aim, a new scale-the Pain-Motivated Drinking Scale (PMDS)-was developed to measure how often participants were motivated by pain to drink alcohol. Measurement properties of this new scale were determined, including its factor structure, internal consistency reliability, and construct validity. In this cross-sectional observational study, participants with AUD (n = 138) were consecutively recruited from the patient pool at an academic addiction treatment facility. Seventy-two percent (95, 72.0%) reported they drank alcohol "to get relief from physical pain" at least some of the time, and over forty-two percent (56, 42.4%) reported pain relief motivated their drinking at least half of the time. PMDS had a single-factor structure, strong internal consistency reliability, and construct validity. A multiple hierarchical linear regression was run to determine if nociplastic pain was associated with pain-motivated drinking. Nociplastic pain was associated with PMDS even after controlling for potential confounders and pain severity. These findings suggest nociplastic pain is uniquely associated with pain-motivated drinking in AUD. PERSPECTIVE: Nociplastic pain is independently associated with pain-motivated drinking in alcohol use disorder (AUD). The Pain-Motivated Drinking Scale (PMDS) is a new scale to measure how often people drink to cope with pain. PMDS has promising psychometric properties. Nociplastic pain may be uniquely associated with pain-motivated drinking in AUD.

Alcohol Use Disorder and Chronic Pain: An Overlooked Epidemic

Alcohol use disorder (AUD) and chronic pain disorders are pervasive, multifaceted medical conditions that often co-occur. However, their comorbidity is often overlooked, despite its prevalence and clinical relevance. Individuals with AUD are more likely to experience chronic pain than the general population. Conversely, individuals with chronic pain commonly alleviate their pain with alcohol, which may escalate into AUD. This narrative review discusses the intricate relationship between AUD and chronic pain. Based on the literature available, the authors present a theoretical model explaining the reciprocal relationship between AUD and chronic pain across alcohol intoxication and withdrawal. They propose that the use of alcohol for analgesia rapidly gives way to acute tolerance, triggering the need for higher levels of alcohol consumption. Attempts at abstinence lead to alcohol withdrawal syndrome and hyperalgesia, increasing the risk of relapse. Chronic neurobiological changes lead to preoccupation with pain and cravings for alcohol, further entrenching both conditions. To stimulate research in this area, the authors review methodologies to improve the assessment of pain in AUD studies, including self-report and psychophysical methods. Further, they discuss pharmacotherapies and psychotherapies that may target both conditions, potentially improving both AUD and chronic pain outcomes simultaneously. Finally, the authors emphasize the need to manage both conditions concurrently, and encourage both the scientific community and clinicians to ensure that these intertwined conditions are not overlooked given their clinical significance.

Alcohol consumption and opioid craving among chronic pain patients prescribed long-term opioid therapy

BACKGROUND

Concurrent use of alcohol with opioids is common among chronic pain patients, heightening the risk for disordered opioid use and overdose, yet the relationship between alcohol consumption and opioid craving among chronic pain patients remains largely unexplored. Here we examined the relationship between alcohol consumption and opioid craving among chronic pain patients on long-term opioid therapy.

METHODS

A cross-sectional study was conducted with 335 chronic pain patients on long-term opioid therapy. Participants completed the Timeline Followback to assess alcohol consumption, as well as measures of opioid craving, pain severity, and pain interference. Linear regression analyses examined the relationship between alcohol consumption and opioid craving, controlling for pain severity, pain interference, and opioid misuse severity.

RESULTS

Alcohol consumption (total number of drinks and amount consumed in one sitting) was positively associated with opioid craving (p < 0.001 and p = 0.005, respectively). Pain severity did not predict opioid craving. The relationship between alcohol consumption and opioid craving remained significant after controlling for pain severity, pain interference, and opioid misuse severity.

CONCLUSION

Alcohol consumption is linked with more severe opioid craving among chronic pain patients prescribed long-term opioid therapy. Patients receiving opioid analgesics should be carefully screened for co-use of alcohol.

Deficits in proactive avoidance and neural responses to drinking motives in problem drinkers

Physical pain and negative emotions represent two distinct drinking motives that contribute to harmful alcohol use. Proactive avoidance which can reduce problem drinking in response to these motives appears to be impaired in problem drinkers. However, proactive avoidance and its underlying neural deficits have not been assessed experimentally. How these deficits inter-relate with drinking motives to influence alcohol use also remains unclear. The current study leveraged neuroimaging data collected in forty-one problem and forty-one social drinkers who performed a probabilistic learning go/nogo task that involved proactive avoidance of painful outcomes. We characterized the regional brain responses to proactive avoidance and identified the neural correlates of drinking to avoid physical pain and negative emotions. Behavioral results confirmed problem drinkers' proactive avoidance deficits in learning rate and performance accuracy, both which were associated with greater alcohol use. Imaging findings in problem drinkers showed that negative emotions as a drinking motive predicted attenuated right insula activation during proactive avoidance. In contrast, physical pain motive predicted reduced right putamen response. These regions' activations as well as functional connectivity with the somatomotor cortex also demonstrated a negative relationship with drinking severity and positive relationship with proactive avoidance performance. Path modeling further delineated the pathways through which physical pain and negative emotions, along with alcohol use severity, influenced the neural and behavioral measures of proactive avoidance. Taken together, the current findings provide experimental evidence for proactive avoidance deficits in problem drinkers and establish the link between their neural underpinnings and alcohol misuse.

Somatosensory profiling of patients undergoing alcohol withdrawal: Do neuropathic pain and sensory loss represent a problem?

INTRODUCTION

Chronic heavy alcohol use is known to cause neurological complications such as peripheral neuropathy. Concerning the pathophysiology, few sural nerve and skin biopsy studies showed that small fibers might be selectively vulnerable to degeneration in alcohol-related peripheral neuropathy. Pain has rarely been properly evaluated in this pathology. The present study aims at assessing pain intensity, potential neuropathic characteristics as well as the functionality of both small and large nerve sensitive fibers.

METHODS

In this observational study, 27 consecutive adult patients, hospitalized for alcohol withdrawal and 13 healthy controls were recruited. All the participants underwent a quantitative sensory testing (QST) according to the standardized protocol of the German Research Network Neuropathic Pain, a neurological examination and filled standardized questionnaires assessing alcohol consumption and dependence as well as pain characteristics and psychological comorbidities.

RESULTS

Nearly half of the patients (13/27) reported pain. Yet, pain intensity was weak, leading to a low interference with daily life, and its characteristics did not support a neuropathic component. A functional impairment of small nerve fibers was frequently described, with thermal hypoesthesia observed in 52% of patients. Patients with a higher alcohol consumption over the last 2 years showed a greater impairment of small fiber function.

DISCUSSION

Patients report pain but it is however unlikely to be caused by peripheral neuropathy given the non-length-dependent distribution and the absence of neuropathic pain features. Chronic pain in AUD deserves to be better evaluated and managed as it represents an opportunity to improve long-term clinical outcomes, potentially participating to relapse prevention.

Longitudinal associations between pain and substance use disorder treatment outcomes

INTRODUCTION

Pain is commonly reported among those in treatment for substance use disorders (SUD) and is associated with poorer SUD treatment outcomes. The current study examined the trajectory of pain over the course of SUD treatment and associations with substance use outcomes.

METHODS

This observational study included adults seeking treatment for alcohol, cannabis, or opioid use disorders (N = 811). Participants completed a battery of assessments at treatment admission, 30 days post admission, and at discharge, including measures of demographics, pain, quality of life, abstinence self-efficacy, and craving.

RESULTS

Analyses indicated linear reductions in pain intensity and interference over time. Significant interactive effects were observed for opioid use disorder (OUD) and time, such that participants with OUD had greater reductions in pain intensity and interference over time compared to those without OUD. Elevated pain intensity was associated with negative treatment outcomes, including reduced quality of life and abstinence self-efficacy, and greater craving and negative affect.

CONCLUSIONS

Reductions in pain occur over the course of SUD treatment, particularly for those with OUD. Greater pain was also associated with adverse SUD treatment outcomes. Results suggest that treatment and associated abstinence may be beneficial for those with co-occurring pain and SUD, highlighting an additional benefit of improving access to SUD treatment for patients and health care systems. Future research should replicate these findings among diverse samples and further characterize the trajectory of pain during and after SUD treatment.

Post-Combat-Injury Opioid Prescription and Alcohol Use Disorder in the Military

INTRODUCTION

Previous studies have identified combat exposure and combat traumatic experience as problematic drinking risk factors. Increasing evidence suggests that opioid use increases the risk of alcohol use disorder. This study investigated the association between opioid prescription use after injury and (1) alcohol use disorder and (2) severity of alcohol use disorder among deployed military servicemembers.

METHODS

Deidentified health records data of 9,029 deployed servicemembers from a retrospective cohort study were analyzed. Data were randomly selected from the Department of Defense Trauma Registry and included servicemembers with combat injuries during deployment in Iraq or Afghanistan (2002-2016). Pharmacy records and International Classification of Diseases, Ninth and Tenth Revision diagnosis codes were used. Three groups were identified (no opioid prescription use, nonpersistent opioid prescription use, and persistent opioid prescription use) and were compared on the basis of alcohol use disorder risk using Cox proportional hazard models. Data analyses were performed in 2021.

RESULTS

Of the 9,029 servicemembers with combat injury, 2,262 developed alcohol use disorder (1,322 developed severe alcohol use disorder). Compared with no opioid prescription use, increased alcohol use disorder risk was associated with persistent opioid prescription use, with a hazard ratio of 1.13 (95% CI=1.02, 1.26). After covariate adjustment, increased risk remained statistically significant (hazards ratio=1.24; 95% CI=1.10, 1.39). There was no significant difference in alcohol use disorder risk between no opioid prescription use and nonpersistent opioid prescription use. The risk of severe alcohol use disorder did not vary by opioid use among servicemembers with alcohol use disorder diagnosis.

CONCLUSIONS

The findings of the study suggest that the incidence of alcohol use disorder was higher among injured servicemembers with persistent opioid prescription use than among those without opioid use. If replicated in prospective studies, the findings highlight the need for clinicians to consider the current and history of alcohol use of patients in initiating treatment involving opioids.

Mindfulness-Oriented Recovery Enhancement for Addictive Behavior, Psychiatric Distress, and Chronic Pain: A Multilevel Meta-Analysis of Randomized Controlled Trials

Objectives

Methods

Results

Conclusions

Meta-analysis Pre-registration: PROSPERO #CRD42022319006

Supplementary Information

A history of depression in patients attending a chronic pain management clinic in South Africa: A retrospective chart review

Background: Chronic pain and depression are closely related conditions, which commonly exist as comorbid disorders. Understanding the prevalence of depression in patients presenting with chronic pain is vital for effective pain management.Aim: Our study aimed to establish the prevalence of a history of depression in patients presenting with chronic pain to a chronic pain management clinic at a tertiary academic hospital and to describe the characteristics of patients with both conditions.Setting: Groote Schuur Hospital, Chronic Pain Management Clinic, Cape Town, South Africa.Method: A retrospective review of 665 medical charts of consecutive patients accessing the clinic over a 7-year period was conducted. Baseline, patient-centred data were collected.Results: Of the 665 charts, 623 were analysed. The median age of patients was 53 years. The prevalence of depression in patients presenting with chronic pain was 32%, three times higher than the national life-time prevalence in South Africa. The majority (77%) of patients with chronic pain and depression were female (p  0.01). Overall, 51% of the patients assessed were unemployed with low levels of education. The majority of our study patients had received a tricyclic antidepressant at some time prior to presentation.Conclusion: The high prevalence of a history of depression in patients presenting with chronic pain in our study, emphasises the importance of looking for and understanding the interrelation of the physiological, psychiatric, psychological and socio-economic factors that are common to both depression and chronic pain. Pain relief alone is insufficient to ensure optimal rehabilitation of these patients and integrating the management of their depression should improve patient outcomes and overall well-being.

Cognitive-Affective Transdiagnostic Factors Associated With Vulnerability to Alcohol and Prescription Opioid Use in the Context of Pain

The use of alcohol and prescription opioids is common among people in pain and poses significant public health burdens. This review identifies factors associated with motivation to use alcohol and prescription opioids in the context of pain. Pain-relevant, cognitive-affective, transdiagnostic vulnerability factors-expectancies/motives, pain catastrophizing, pain-related anxiety, distress intolerance, anxiety sensitivity, and perceived interrelations-were selected from theoretical conceptualizations of pain and substance use. Searches conducted in PubMed, PsycINFO, and Embase returned 25 studies that examined associations between identified variables of interest and the use of alcohol and prescription opioids in the context of pain. Consistent with a larger literature on pain and substance use, the studies included in this review demonstrated that people with chronic pain are motivated to use alcohol and opioids in response to negative affect and hold expectancies/motives for coping with pain. Vulnerabilities that engender difficulty managing aversive internal states (distress intolerance and anxiety sensitivity) and maladaptive responses to pain (pain-related anxiety and pain catastrophizing) also were implicated in motivation for alcohol and opioid use. Although one study found that pain-related anxiety was associated with co-use of alcohol and opioids, no studies examined simultaneous use. Future research directions that can explicate causal associations, identify patterns of alcohol and opioid co-use, clarify the role of pain in cessation processes, and inform treatment development are discussed.

A measure of expectancies for alcohol analgesia: Preliminary factor analysis, reliability, and validity

Rates of alcohol consumption are substantially higher among persons with pain, and recent research has focused on elucidating bidirectional pain-alcohol effects. Expectancies for alcohol analgesia could influence the degree to which alcohol confers acute pain-relieving effects, and may amplify the propensity to respond to pain with drinking behavior. However, no validated measures of expectancies for alcohol analgesia are available. Therefore, we developed a five-item measure of Expectancies for Alcohol Analgesia (EAA), which assesses the perceived likelihood that alcohol will reduce pain. The goal of this project was to examine psychometric properties of the EAA among a sample of 273 current alcohol users with chronic pain (M_age = 32.9; 34% female) who completed an online survey of pain and substance use. Confirmatory factor analysis (CFA) results indicated that the hypothesized single-factor structure of the EAA provided good model fit (Bollen-Stine bootstrap p = .13). The EAA also showed excellent internal consistency (α = 0.97), and scores were positively associated with quantity/frequency of alcohol use, alcohol outcome expectancies, coping-related drinking motives, and pain severity (ps < 0.01). These findings provide initial support regarding the single-factor structure, reliability, and validity of the EAA. Examination of predictive utility and further validation are important next steps.

Sex moderates the effects of experimentally induced musculoskeletal pain on alcohol demand in healthy drinkers

BACKGROUND

Pain may serve as an antecedent for alcohol use, increasing risk for hazardous drinking and associated consequences. Delayed onset muscle soreness (DOMS) induction produces clinically relevant but time-limited musculoskeletal pain. This study was conducted to determine whether DOMS induction on the dominant elbow flexors influenced alcohol demand using the Alcohol Purchase Task (APT). We hypothesized DOMS would increase alcohol demand relative to a sham control. Based on existing studies of pain self-medication, we expected DOMS-related increases in alcohol demand would be greatest in men.

METHODS

Participants (N = 53; 57 % women) were randomly assigned to a DOMS (eccentric exercise) or sham condition (concentric exercise). Participants completed the APT pre-exercise and 48 -hs post-exercise. Repeated measures GLM was used to characterize group by sex by time interactions on APT indices, including intensity, breakpoint, essential value (EV), O_max, and P_max.

RESULTS

The DOMS procedure significantly increased pain ratings at the elbow flexors. Men had significantly higher demand intensity than women across groups and time points. Significant interactive effects were detected for breakpoint and EV. From pre- to post-test, breakpoint significantly increased in men in the DOMS group. However, breakpoint and EV significantly decreased in women in the DOMS group.

CONCLUSIONS

Increased alcohol demand in men in the DOMS group was consistent with epidemiological data suggesting men are at higher risk for self-medicating pain with alcohol than women. However, decreased demand in women was unexpected. Taken together, results indicate DOMS induction may be a useful means to characterize pain as an antecedent for alcohol use.

Prevalence, Characteristics, and Management of Chronic Noncancer Pain Among People Who Use Drugs: A Cross-Sectional Study

INTRODUCTION

Most studies on chronic noncancer pain (CNCP) in people who use drugs (PWUD) are restricted to people attending substance use disorder treatment programs. This study assessed the prevalence of CNCP in a community-based sample of PWUD, identified factors associated with pain, and documented strategies used for pain relief.

METHODS

This was a cross-sectional study nested in an ongoing cohort of PWUD in Montreal, Canada. Questionnaires were administered to PWUD seen between February 2017 and January 2018. CNCP was defined as pain lasting three or more months and not associated with cancer.

RESULTS

A total of 417 PWUD were included (mean age = 44.6 ± 10.6 years, 84% men). The prevalence of CNCP was 44.8%, and the median pain duration (interquartile range) was 12 (5-18) years. The presence of CNCP was associated with older age (>45 years old; odds ratio [OR] = 1.8, 95% CI = 1.2-2.7), male sex (OR = 2.3, 95% CI = 1.2-4.2), poor health condition (OR = 1.9, 95% CI = 1.3-3.0), moderate to severe psychological distress (OR = 2.9, 95% CI = 1.8-4.7), and less frequent cocaine use (OR = 0.5, 95% CI = 0.3-0.9). Among CNCP participants, 20.3% used pain medication from other people, whereas 22.5% used alcohol, cannabis, or illicit drugs to relieve pain. Among those who asked for pain medication (N = 24), 29.2% faced a refusal from the doctor.

CONCLUSIONS

CNCP was common among PWUD, and a good proportion of them used substances other than prescribed pain medication to relieve pain. Close collaboration of pain and addiction specialists as well as better pain assessment and access to nonpharmacological treatments could improve pain management in PWUD.

Pain severity and anxiety sensitivity interact to predict drinking severity among hazardous drinking college students

Background: Hazardous alcohol use among college students is a growing problem. Alcohol is commonly used in the context of pain due to acute analgesic effects, although the role of pain among hazardous drinkers has not been examined. Little is known regarding factors that may moderate pain-alcohol relations. One factor is anxiety sensitivity, which reflects the fear of physiological sensations. Pain severity and anxiety sensitivity may interact such that those with high anxiety sensitivity may have stronger pain-alcohol relations.Objectives: The current study examined interactive associations of pain severity and anxiety sensitivity in relation to hazardous drinking severity, alcohol consumption, and alcohol problems among hazardous drinking college students (n = 370; 78.1% female).Methods: Self report measures of alcohol use, pain severity, and anxiety sensitivity were collected and moderation analyses were conducted.Results: There was a significant interaction of pain severity and anxiety sensitivity in relation to hazardous drinking severity (β = 0.25, p = .037); pain severity was significantly related to hazardous drinking for high (β = 0.28, p < .001) but not low (β = 0.09, p = .202) anxiety sensitivity. There was a similar interaction for alcohol consumption (β = 0.35, p = .008). For alcohol problems, there was no significant interaction, but there were unique main effects of both pain severity (β = 0.23, p < .001) and anxiety sensitivity (β = 0.34, p < .001).Conclusions: These findings suggest that drinkers with high anxiety sensitivity may use alcohol hazardously (and in greater quantities) in the context of pain. If replicated with longitudinal samples, the findings may inform clinical practice in terms of screening for and treatment of anxiety sensitivity.

Pain-related anxiety, sex, and co-use of alcohol and prescription opioids among adults with chronic low back pain

BACKGROUND

Both alcohol and prescription opioid use/misuse are highly prevalent among individuals with chronic pain. Co-use of alcohol and prescription opioids is also common, despite contraindications due to increased risk of negative health effects and mortality. There is evidence that pain-related anxiety (i.e., the tendency to respond to pain with anxiety or fear) may be associated with heavier drinking and prescription opioid use/co-use, and that these associations may be especially salient among men.

METHODS

This study is the first examination of pain-related anxiety in relation to hazardous alcohol use, prescription opioid use/misuse, and alcohol-opioid co-use. Participants included 1812 adults with chronic low back pain (69 % female, Mage = 43.95) who completed an online survey assessing health behaviors.

RESULTS

Pain-related anxiety was positively associated with indices of alcohol (i.e., alcohol-related consequences) and opioid use (i.e., prescription opioid use/misuse, daily opioid consumption). Of note, sex moderated associations between pain-related anxiety and both alcohol-related consequences and prescription opioid misuse. In addition to being associated with alcohol and prescription opioid use, independently, pain-related anxiety was also associated with greater likelihood of endorsing co-use of alcohol and opioids and engaging in concurrent hazardous drinking and prescription opioid misuse.

CONCLUSIONS

These findings contribute to a growing literature suggesting that pain-related anxiety is an important transdiagnostic factor in pain and alcohol and prescription opioid use/co-use, perhaps especially among males.

Pain-induced alterations in the dynorphinergic system within the mesocorticolimbic pathway: Implication for alcohol addiction

Latest studies have revealed that pain negatively impacts on reward processing and motivation leading to negative affective states and stress. These states not only reduce quality of life of patients by increasing the appearance of psychiatric comorbidities, but also have an important impact on vulnerability to drug abuse, including alcohol. In fact, clinical, epidemiological but also preclinical studies have revealed that the presence of pain is closely related to alcohol use disorders (AUDs). All this evidence suggests that pain is a factor that increases the risk of suffering AUD, predicting heavy drinking behavior and relapse drinking in those patients with a previous history of AUD. The negative consequences of chronic pain and its impact on stress and AUD are likely mediated by alterations in the central nervous system, especially in the stress and reward systems. Therefore, pain and stress impact on dopaminergic mesolimbic pathway can lead to an increase in drug abuse liability. In this mini review we analyze the interaction between pain, stress, and alcohol addiction, and how dynamic changes in the kappa opioid system might play a crucial role in the development of compulsive alcohol drinking in chronic pain patients.

From Pleasure to Pain, and Back Again: The Intricate Relationship Between Alcohol and Nociception

AIMS

A close and bidirectional relationship between alcohol consumption and pain has been previously reported and discussed in influential reviews. The goal of the present narrative review is to provide an update on the developments in this field in order to guide future research objectives.

METHODS

We evaluated both epidemiological and neurobiological literature interrogating the relationship between alcohol use and pain for the presence of significant effects. We outlined studies on interactions between alcohol use and pain using both self-reports and objective experimental measures and discussed potential underlying mechanisms of these interactions.

RESULTS

Epidemiological, preclinical and clinical literature point to three major interactions between alcohol use and pain: (a) alcohol use leading to hyperalgesia, (b) alcohol use moderating pain and hyperalgesia and (c) chronic pain as a risk factor predisposing to alcohol relapse. Neurobiological studies using animal models to assess these interactions have transitioned from mostly involuntary modes of experimenter-controlled alcohol administration to self-administration procedures, and increasingly indicate that neuronal circuits implicated in both withdrawal and anticipation stages of alcohol use disorder also have a role in chronic pain. Mechanistically, alterations in GABA, glutamate, the corticotropin-releasing factor system, endogenous opioids and protein kinase C appear to play crucial roles in this maladaptive overlap.

CONCLUSIONS

Many of the principles explaining the interactions between alcohol and pain remain on a strong foundation, but continuing progress in modeling these interactions and underlying systems will provide a clearer basis for understanding, and ultimately treating, the damaging aspects of this interaction.

Association between alcohol consumption and osteoarthritis prevalence in Korea as assessed by the alcohol use disorders identification test (AUDIT): a cross-sectional study

Background

Osteoarthritis (OA) holds significance as a highly prevalent disorder in elderly populations. Various studies have been conducted on the association between alcohol consumption and OA, but the results have often been conflicting. The aim of this study was to investigate the relationship between alcohol consumption and OA in a large-scale sample representative of the Korean population.

Methods

Among the 25,534 participants surveyed in the fifth Korean National Health and Nutrition Examination Survey (2010–2012), 7165 individuals aged ≥50 who responded to drinking-related items were analyzed. The Alcohol Use Disorders Identification Test (AUDIT) grade was calculated, and radiologic examination analysis included the Kellgren-Lawrence (KL) grade of the lumbar spine, hip, and knee joints. Logistic regression analysis was performed to evaluate the association between AUDIT grades and OA through estimation of odds ratios (ORs).

Results

In crude analyses, OA (KL grade ≥ 2) of the lumbar spine and knee was more prevalent towards Zone I, but following adjustment, knee OA prevalence significantly increased in Zone III and IV compared to Zone I (Zone III: OR 1.464, 95% confidence interval (CI) 1.027–2.088; Zone IV: OR 1.543, 95% CI 1.028–2.317, respectively). Meanwhile, adjusted hip and lumbar OA values showed positive associations towards Zone IV, but did not reach statistical significance. Additional analyses of the association between alcohol consumption and pain severity of knee OA patients were nonsignificant.

Conclusions

These results imply that radiological knee OA, rather than symptomatic knee OA, is associated with alcohol consumption.

At the intersection of alcohol use disorder and chronic pain

OBJECTIVE

Alcohol use disorder (AUD) and chronic pain are widespread conditions with extensive public health burden. This review seeks to describe neuroanatomical links and major mediating influences between AUD and chronic pain, in the service of identifying factors that predict the risk of chronic pain in precipitating or facilitating AUD.

METHOD

We review the neural bases of pain and the influence of AUD on processes involved in pain perception. We propose potential mechanisms involved in the development of chronic pain in AUD, and we consider implications for pain management in recovery from AUD.

RESULTS

Pain is a multidimensional and subjective experience that, in its acute form, is essential for survival, but in chronic form, pain is a disorder that negatively impacts quality of life. Neural substrates involved in initiating and maintaining chronic pain include dysfunction in descending pain pathways and reward network circuitry. AUD involves preoccupation or craving, intoxication, withdrawal, and negative affect. Neural substrates of AUD involve widespread mesocorticolimbic and cerebrocerebellar networks. Both conditions involve dysfunction of extended reward and oversight circuitry, particularly prefrontal cortex.

CONCLUSIONS

The interrelationship between chronic pain and AUD resides in the intersection of etiological influences, mental experiences, and neurobiological processes. Characterization of the connection between brain and behavioral abnormalities in AUD's precipitation of chronic pain-and vice versa-allows for early detection and treatment of patients at risk for developing either or both of these conditions and for preemptive interventional approaches to reduce the risk of consequent vulnerabilities and harm. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Reduced sensitivity to ethanol and excessive drinking in a mouse model of neuropathic pain

The co-occurrence of chronic pain and alcohol use disorders (AUDs) involves complex interactions between genetic and neurophysiological aspects, and the research has reported mixed findings when they both co-occur. There is also an indication of a gender-dependent effect; males are more likely to use alcohol to cope with chronic pain problems than females. Recently, a new conceptualization has emerged, proposing that the negative affective component of pain drives and maintains alcohol-related behaviors. We studied in a longitudinal fashion alterations in alcohol drinking patterns and pain thresholds in a mouse model of chronic neuropathic pain in a sex-dependent manner. Following partial denervation (spared nerve injury [SNI]), stimulus-evoked pain responses were measured before chronic alcohol consumption, during drinking, during a deprivation phase, and following an episode of excessive drinking. During the course of alcohol drinking, we observed pronounced sex differences in pain thresholds. Male mice showed a strong increase in pain thresholds, suggesting an analgesic effect induced by alcohol over time, an effect that was not observed in female mice. SNI mice did not differ from sham-operated controls in baseline alcohol consumption. However, following a deprivation phase and the reintroduction of ethanol, male SNI mice but not female mice showed more pronounced excessive drinking than controls. Finally, we observed decreased central ethanol sensitivity in male SNI mice but not in females. Together with our finding, that ethanol is able to decrease a pain-induced negative affective memory we come to following conclusion. We propose that a lower sensitivity to the intoxicating effects of alcohol together with the ability of alcohol to reduce the negative affective component of pain may explain the higher co-occurrence of AUD in male chronic pain patients.

Effects of acute pain and pain-related fear on risky decision-making and effort during cognitive tests

Introduction: The experience of acute pain and pain-related fear negatively impact cognition and behavior; however, little research has examined their impacts on risky decision-making and effort. The present study investigated the effects of acute pain and pain-related fear on risky decision-making and effort during cognitive tests. Method: Levels of pain-related fear were assessed. Healthy participants (n = 146) experienced acute pain induced via cold pressor task, and then were randomly assigned to one of the four conditions to induce pain-related fear: Pain Threat (n = 36), Pain Threat with Control (n = 39), Cognitive Threat with Control (n = 34), and Control (n = 36). Participants then completed measures of effort (Word Memory Test [WMT], self-reported effort) and risky decision-making (Iowa Gambling Task [IGT], Balloon Analogue Risk Task [BART]). Results: Collapsed across condition, participants did not learn to decide advantageously on the IGT following an acute pain experience. During the early trials (1-40) on the IGT, participants in the Pain Threat condition made riskier decisions. Higher levels of pain during the cold pressor task predicted less risky decisions on the BART, and participants in the Cognitive Threat with Control condition made less risky decisions. Participants in the Pain Threat with Control condition self-reported lower effort on cognitive tests, yet no group-based differences were seen in WMT performance. Greater pain-related fear predicted greater self-reported effort and better WMT performance, but no effects were seen on decision-making task performance. Conclusions: The experience of pain and the threat of additional pain can lead to changes in risky decision-making and effort on cognitive tasks. This threat of additional pain could activate underlying pain-related fear, creating hypervigilance to and avoidance of pain that affects subsequent task performance. Implications for research and clinical evaluation of acute pain and pain-related fear are discussed.

Chronic pain management among people who use drugs: A health policy challenge in the context of the opioid crisis

BACKGROUND

In Canada, the rise in prescription opioid (PO) overdoses and addiction is a major public health concern. Various health authorities have recently recommended that physicians use caution when prescribing opioids, especially to people with histories of substance use. As a result, fewer therapeutic options are available for people who use drugs (PWUD) and suffer from chronic non-cancer pain (CNCP). This paper examines how PWUD describe their experiences with CNCP management in the context of the opioid crisis.

METHODS

This qualitative study is based on in-depth interviews with Montreal (Canada) PWUD experiencing CNCP for 3 months or more.

RESULTS

Most of the 25 participants (27-61 years; 10 women, 15 men) were polysubstance users (cocaine, opioids, amphetamine, etc.) suffering from CNCP for several years, with multiple additional health and social problems. The majority were unsatisfied with their CNCP management. They felt labelled as "addicts" and stigmatized within the healthcare system. Many participants had been denied PO, even those with severe CNCP and those who were not opioid-dependent. Participants expressed a desire to access non-pharmacological CNCP therapies, but these were often too expensive. Some PWUD were offered methadone to relieve CNCP and found this inappropriate. As a last resort several participants reported self-medicating CNCP with street drugs, increasingly known to be laced with fentanyl.

CONCLUSION

PWUD with CNCP are affected by two opioid crises: the PO crisis and the street-opioid crisis. The lack of a coherent policy that addresses their pain management produces reoccurring problems when seeking CNCP relief. Restrictive prescription measures implemented in response to the PO crisis may have consequences similar to prohibitionist policies: they heighten overdose risks for PWUD by increasing exposure to street drugs laced with fentanyl. Improving access to diverse CNCP management options for PWUD can help reduce harms related to street-opioid use.

An integrative review of personalized feedback interventions for pain and alcohol

Interrelations between pain and alcohol consumption are considered to be bidirectional in nature, leading to greater pain and increased drinking over time. Personalized feedback interventions (PFIs), which typically aim to motivate behavior change via presentation of personalized and normative feedback, hold great promise for integrated treatment. There has been no previous review of PFIs for pain, and limited work has focused on examining the utility of PFIs for more established, adult drinkers. Our review of the literature revealed that brief, computer-based PFIs can improve pain outcomes and decrease problematic alcohol consumption. Future research would likely benefit from developing integrated, computer-based PFIs for pain and alcohol misuse. Such approaches offer potential for broad impact, while simultaneously reducing patient and healthcare provider burden.

A Reciprocal Model of Pain and Substance Use: Transdiagnostic Considerations, Clinical Implications, and Future Directions

Pain and substance use are highly prevalent and co-occurring conditions that continue to garner increasing clinical and empirical interest. Although nicotine and tobacco, alcohol, and cannabis each confer acute analgesic effects, frequent or heavy use may contribute to the development and progression of chronic pain, and pain may be heightened during abstinence. Additionally, pain can be a potent motivator of substance self-administration, and it may contribute to escalating use and poorer substance-related treatment outcomes. We integrated converging lines of evidence to propose a reciprocal model in which pain and substance use are hypothesized to interact in the manner of a positive feedback loop, resulting in the exacerbation and maintenance of both conditions over time. Theoretical mechanisms in bidirectional pain-substance use relations are reviewed, including negative reinforcement, social cognitive processes, and allostatic load in overlapping neural circuitry. Finally, candidate transdiagnostic factors are identified, and we conclude with a discussion of clinical implications and future research directions.

Substance misuse in patients who have comorbid chronic pain in a clinical population receiving methadone maintenance therapy for the treatment of opioid dependence

AIMS

To compare specific substance misuse in treatment-seeking, opioid-dependent patients with and without comorbid chronic pain, and to assess the respective value of urinalysis and patient reports in assessing substance misuse.

METHODS

Participants comprised a clinical population in a regional NHS Substance Misuse Service in the East of Scotland (N = 521). The Brief Pain Inventory - Short Form was used to assess pain, and the Maudsley Addiction Profile and urinalysis were used to assess substance misuse at study inception. Urinalysis was used to assess substance misuse during the 5-year follow-up period. Data were hosted, linked, anonymized and analyzed within a national Safe Haven.

RESULTS

Compared with opioid-dependent patients with no pain, a significantly higher proportion of treatment-seeking, opioid-dependent patients with chronic pain were engaged in non-medical benzodiazepine use (69% versus 58%; p = 0.016) and illicit cannabinoid use (84% versus 65%; p = 0.025) at study inception. Furthermore, a significantly higher proportion of this group was shown to continue non-medical benzodiazepine use (70% versus 42%; p = 0.037) and illicit cannabinoid use (100% versus 31%; p = 0.002) during the 5-year follow-up period. There were significant correlations between drug screen results and patient-reported use of opioids (Tetrachoric ϱ = 0.4944; p < 0.001), benzodiazepines (Tetrachoric ϱ = 0.2641; p = 0.001) and cannabinoids (Tetrachoric ϱ = 0.8384; p < 0.001).

CONCLUSIONS

Whilst gaining control of illicit opioid use during treatment, opioid-dependent patients with comorbid chronic pain demonstrated persistent problematic use of benzodiazepines and cannabinoids. This pattern of misuse was shown to persist during the 5-year follow-up period.

Pain and Addiction: An Integrative Therapeutic Approach

The current opioid crisis highlights an urgent need for better paradigms for prevention and treatment of chronic pain and addiction. Although many approach this complex clinical condition with the question, "Is this pain or is this addiction?," it is more than the sum of its parts. Chronic pain among those with dependence and addiction often evolves into a complex disabling condition with pain at multiple sites, psychosocial dysfunctions, medical and psychiatric disorders, polypharmacy, and polysubstance use, all interacting with each other in complex ways (multimorbidity). The authors offer an integrative therapeutic approach to manage this complex clinical scenario.

Acute alcohol effects on facial expressions of emotions in social drinkers: a systematic review

Background

As known from everyday experience and experimental research, alcohol modulates emotions. Particularly regarding social interaction, the effects of alcohol on the facial expression of emotion might be of relevance. However, these effects have not been systematically studied. We performed a systematic review on acute alcohol effects on social drinkers' facial expressions of induced positive and negative emotions.

Materials and methods

With a predefined algorithm, we searched three electronic databases (PubMed, PsycInfo, and Web of Science) for studies conducted on social drinkers that used acute alcohol administration, emotion induction, and standardized methods to record facial expressions. We excluded those studies that failed common quality standards, and finally selected 13 investigations for this review.

Results

Overall, alcohol exerted effects on facial expressions of emotions in social drinkers. These effects were not generally disinhibiting, but varied depending on the valence of emotion and on social interaction. Being consumed within social groups, alcohol mostly influenced facial expressions of emotions in a socially desirable way, thus underscoring the view of alcohol as social lubricant. However, methodical differences regarding alcohol administration between the studies complicated comparability.

Conclusion

Our review highlighted the relevance of emotional valence and social-context factors for acute alcohol effects on social drinkers' facial expressions of emotions. Future research should investigate how these alcohol effects influence the development of problematic drinking behavior in social drinkers.

Prevalence of pain and its socio-demographic and clinical correlates among heroin-dependent patients receiving methadone maintenance treatment

To date there have been no studies investigating the characteristics of pain in Chinese heroin-dependent patients (HDPs) receiving methadone maintenance treatment (MMT). This study examined the frequency and socio-demographic and clinical correlates of pain in HDPs under MMT. A consecutive sample of 603 HDPs was recruited from three MMT clinics in Wuhan, China. These patients completed a standardized questionnaire concerning socio-demographic and clinical data. Pain intensity was assessed with the 5-point Verbal Rating Scale (“Overall, how intense is your pain now?”) with responses of: 1 = none, 2 = mild, 3 = moderate, 4 = severe, 5 = very severe. A pain score of three or higher was used to denote clinical significant pain (CSP). The prevalence of CSP in HDPs receiving MMT was 53.6%. Factors significantly associated CSP in multiple logistics regression analysis were old age, marital status of “non-married”, unemployment, having religious beliefs, a history of injecting heroin, a high dose of methadone, and more depressive symptoms. Over a half of Chinese HDPs receiving MMT have CSP. Services for HDPs in MMT settings should include periodic screening for pain, psychosocial supports, and professional treatment for pain.

Pain in methadone patients: Time to address undertreatment and suicide risk (ANRS-Methaville trial)

Background

Pain in opioid-dependent patients is common but data measuring the course of pain (and its correlates) using validated scales in patients initiating methadone treatment are sparse. We aimed to assess pain and its interference in daily life, associated correlates, and undertreatment before and during methadone treatment.

Methods

This is a secondary analysis using longitudinal data of a randomized trial comparing two methadone initiation models. We assessed the effect of methadone initiation and other correlates on pain intensity and interference (using the Brief Pain Inventory) at months 0, 6 and 12 using a mixed multinomial logistic regression model.

Results

The study group comprised 168 patients who had data for either pain intensity or interference for at least one visit. Moderate to severe pain was reported in 12.9% of patients at M0, 5.4% at M6 and 7.3% at M12. Substantial interference with daily functioning was reported in 36.0% at M0, 14.5% at M6 and 17.1% at M12. Of the 98 visits where patients reported moderate to severe pain or substantial interference, 55.1% reported no treatment for pain relief, non-opioid analgesics were reported by 34.7%, opioid analgesics by 3.1% and both opioid and non-opioid analgesics by 7.1%. Methadone was associated with decreased pain intensity at 6 months (OR = 0.29, p = 0.04) and 12 months (OR = 0.30, p = 0.05) of follow-up and tended to be associated with substantial pain interference. Suicide risk was associated with both pain intensity and pain interference.

Conclusions

Methadone in opioid-dependent patients can reduce pain. However, undertreatment of pain in methadone patients remains a major clinical concern. Patients with pain are at higher risk of suicide. Adequate screening and management of pain in this population is a priority and needs to be integrated into routine comprehensive care.

Chronic Pain and the Opioid Conundrum

Opioids prescribed for chronic cancer and noncancer pain have been embroiled in public policy debates as to effectiveness and potential for contributing to society's problem with misuse, addiction, and overdose mortality. The conundrum of opioid prescribing is to determine who will most likely benefit from opioids and how medical practitioners may safely provide chronic opioid therapy, while also identifying patients who are unlikely to benefit or could divert illicit pharmaceuticals into society. Risk assessment and monitoring are essential to meet the standard of care, as is compliance with federal controlled substances law as well as state regulations.

Alcohol treatment outcomes following discharge from a partial hospital program

Background

Thousands of individuals in the United States seek alcohol treatment each year, typically in outpatient settings. Partial hospital programs provide a high level of structured, individualized outpatient care for individuals who are in treatment for alcohol use disorder. Previous research in other outpatient and inpatient settings has found that psychological distress, pain, and aftercare utilization are associated with treatment outcomes.

Objectives

The current study evaluates baseline characteristics and aftercare utilization predictors of alcohol use outcomes of individuals in a week-long partial hospital program.

Methods

The 113 participants (59.3% male) were interviewed during their time in the program and then were reassessed one month post-discharge.

Results

Results indicated that a greater number of mental health provider visits and 12-step attendance were associated with abstinence at follow-up such, while baseline characteristics did not consistently predict outcomes.

Conclusions

Findings highlight the importance of aftercare planning, particularly in our more severe, clinical sample.

Risks associated with borrowing and sharing of prescription analgesics among patients observed by pain management physicians in Croatia: a qualitative study

Background

Understanding and improving patient safety is a key issue in medicine. One of the potential threats to patient safety is the sharing of medication among patients, which is a form of self-medication. This study analyzed experiences and attitudes of pain management physicians (PMPs) about sharing prescription analgesics among patients.

Methods

This qualitative study was conducted by semi-structured interviews among PMPs employed in Croatian pain clinics. The study involved two researchers and 15 PMPs.

Results

Among PMPs, 80% have seen patients who share their prescription analgesics with other patients for whom prescription is not intended. Most PMPs consider prescription analgesics sharing a risky and negative behavior. Some of them, however, found certain positive aspects associated to it, such as being a benevolent behavior, helping patients to get medications when they need them, and helping them cope with pain.

Conclusion

The majority of physicians specialized in pain management encountered patients sharing prescription analgesics. Most of them considered this as risky behavior with a number of potential consequences. It has been noted that this problem is neglected and that physicians should inquire about medication sharing. Direct-to-consumers advertising was perceived as a factor contributing to such behavior. Patient education and more involvement of physicians in identifying this behavior were cited as potential remedies for preventing sharing of prescription analgesics.

Inhibition of Reinforcing, Hyperalgesic, and Motor Effects of Morphine by Buspirone in Rats

Morphine and other opioids are among the most effective prescription medications for the treatment of pain. Addiction and hyperalgesia associated with their long-term use limits the clinical utility of these drugs. In view of a role of somatodendritic serotonin-1A receptors in addiction and analgesic effects of morphine, the present study concerns effects of co-use of buspirone, a partial agonist at the serotonin-1A receptor, on reinforcing, hyperalgesic, and motor effects of morphine in rats. A dose of morphine (7.5 mg/kg) producing moderate effects on motor activity and analgesia, and buspirone (doses of 0, 1.0, and 2.0 mg/kg) were injected intraperitoneally. Reinforcing effects were monitored in a conditioned place preference (CPP) paradigm and associated changes in motor activity were monitored during a drug conditioning phase. The hot plate test was used to monitor nociceptive response. Acute administration of morphine decreased motor activity and reduced pain perception. Repeated administration was reinforcing in the CPP paradigm and was associated with hyperalgesia and tolerance in motor depressant effects of morphine. These effects of repeated morphine administration were blocked in rats cotreated with buspirone. Pain perception was also slightly reduced in rats repeatedly treated with higher doses of buspirone. The findings are important for improving and extending therapeutic medications for pain.

PERSPECTIVE

The present study shows an important role of serotonin-1A receptors in morphine-induced hyperalgesia and addiction. It shows that buspirone, a prescription medicine for anxiety and depression can block addictive and hyperalgesic effects of morphine. Clinicians should consider buspirone as adjunctive therapy with morphine to improve therapeutic medications in pain.

Chronic pain, craving, and illicit opioid use among patients receiving opioid agonist therapy

AIMS

In a sample of patients receiving opioid agonist therapy, we evaluated whether having chronic pain was associated with (a) craving for opioids and (b) illicit opioid use.

METHODS

In a cross-sectional study of adults on buprenorphine or methadone maintenance recruited from an urban medical center, we examined any craving for opioids (primary dependent variable) in the past week and recent illicit opioid use (secondary dependent variable). Illicit opioid use was defined as a positive urine drug test (UDT) for opiates and chronic pain was defined as bodily pain that had been present for at least 3 months. Multivariable logistic regression models were fit for each outcome, adjusting for age, sex, and non-white race. Additional models adjusted for depression (PHQ-9) and anxiety (STAI).

RESULTS

The sample included 105 adults on methadone or buprenorphine maintenance. Mean age was 43.8 (SD ±9.4)years; 48% were female and 32% non-white; 19% were on methadone. Chronic pain was present in 68% of the sample, 51% reported craving opioids in the past week, and 16% had a positive UDT. Chronic pain was associated with 3-fold higher odds of reporting craving in the past week (aOR=3.10; 95% CI: 1.28-7.50, p-value=0.01). The relative odds for having a positive UDT were not statistically significant (aOR=2.52; 95% CI: 0.64-9.90, p=0.18).

CONCLUSION

In this sample of patients treated with opioid agonist therapy, those with chronic pain had higher odds of reporting craving for opioids. Chronic pain with associated opioid craving potentially places this population at risk for relapse.

Pain and alcohol consumption among older adults: findings from the World Health Organization Study on global AGEing and adult health, Wave 1

OBJECTIVE

To investigate cross-sectional associations between self-reported recent pain and alcohol use/abstinence, and previous-day pain and previous-week alcohol consumption in adults aged 50 + in six low- and middle-income countries (LMICs).

METHODS

The WHO Study on global AGEing and adult health (SAGE) Wave 1 (2007-2010) in China, Ghana, India, Mexico, Russia and South Africa is the data source. Prevalence of alcohol use/abstinence is reported by previous-day and previous-month pain. Multinomial logistic regressions (crude and adjusted for sex and country) tested associations between recent pain and alcohol use in the pooled multicountry sample.

RESULTS

Across the six SAGE countries, about one-third of respondents reported alcohol use, being highest in Russia (74%) and lowest in India (16%). Holding the effects of sex and country constant, compared with abstainers, people with previous-day pain were more likely to be previous-day or other users. With regard to the quantity and frequency of alcohol use, people with previous-day pain were more likely to be non-heavy drinkers.

CONCLUSION

Overall, we found that, in this population of older adults in six LMICs, recent pain was associated with moderate use of alcohol, although there were differences between countries. The findings provide a platform for country-specific research to better understand bi-directional associations between pain and alcohol in older adults.

Pain, alcohol use disorders and risky patterns of drinking among people with chronic non-cancer pain receiving long-term opioid therapy

BACKGROUND

The utilisation of pharmaceutical opioids has increased internationally, and there is evidence of increasing risky alcohol consumption with ageing. This study examines the patterns and correlates of risky drinking among people with chronic non-cancer pain (CNCP) prescribed opioids, and the associations between alcohol consumption and pain.

METHODS

The Pain and Opioids IN Treatment cohort comprises 1514 people in Australia prescribed pharmaceutical opioids for CNCP. Participants reported lifetime, past year and past month alcohol use, as well as mental and physical health, other substance use, pain characteristics, and current opioid dose.

RESULTS

Less than one-tenth of the sample were 'lifetime abstainers' (7%); 34% were 'former drinkers'; 34% were 'non-risky drinkers' (i.e., past 12 month use ≤4 standard drinks); 16% were 'occasional risky drinkers'; and 8% were 'regular risky drinkers' (i.e., ≥weekly use of >4 standard drinks). Males reported greater levels of alcohol use, and a third (33%) of the total sample reported a lifetime alcohol use disorder. Controlling for demographics, mental health, physical health and substance use disorder history, 'former drinkers' (cf. 'non-risky drinkers') reported higher pain severity and interference ratings, and lower pain coping. 'Occasional risky drinkers' and 'regular risky drinkers' (cf. 'non-risky drinkers') reported higher levels of pain interference.

CONCLUSIONS

Among people with CNCP, those who abstained from alcohol or drank at risky levels reported poorer pain outcomes compared with moderate drinkers. Early identification and intervention for risky drinking among people is critical, particularly given the risks associated with co-administration of alcohol and opioids.

Hepatitis C virus infection and pain sensitivity in patients on methadone or buprenorphine maintenance therapy for opioid use disorders

BACKGROUND

Patients with opioid use disorders on opioid agonist therapy (OAT) have lower pain tolerance compared to controls. While chronic viral infections such as HCV and HIV have been associated with chronic pain in this population, no studies have examined their impact on pain sensitivity.

METHODS

We recruited 106 adults (41 uninfected controls; 40 HCV mono-infected; and 25 HCV/HIV co-infected) on buprenorphine or methadone to assess whether HCV infection (with or without HIV) was associated with increased experimental pain sensitivity and self-reported pain. The primary outcome was cold pain tolerance assessed by cold-pressor test. Secondary outcomes were cold pain thresholds, wind-up ratios to repetitive mechanical stimulation (i.e., temporal summation) and acute and chronic pain. Multivariable regression models evaluated associations between viral infection status and outcomes, adjusting for other factors.

RESULTS

No significant differences were detected across groups for primary or secondary outcomes. Adjusted mean cold pain tolerance was 25.7 (uninfected controls) vs. 26.8 (HCV mono-infection) vs. 25.3 (HCV/HIV co-infection) seconds (global p-value=0.93). Current pain appeared more prevalent among HCV mono-infected (93%) compared to HCV/HIV co-infected participants (76%) and uninfected controls (80%), as did chronic pain (77% vs. 64% vs. 61%, respectively). However, differences were not statistically significant in multivariable models.

CONCLUSION

This study did not detect an association between HCV infection and increased sensitivity to pain among adults with and without HIV who were treated with buprenorphine or methadone for opioid use disorders. Results reinforce that pain and hyperalgesia are common problems in this population.

Pain as a predictor of heavy drinking and any drinking lapses in the COMBINE study and the UK Alcohol Treatment Trial

AIMS

To test the association between pain and heavy drinking lapses during and following treatment for alcohol use disorders (AUD).

DESIGN

Secondary data analysis of data from two clinical trials for AUD.

SETTING AND PARTICIPANTS

Participants included 1383 individuals from the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) Study in the United States [69.0% male, 76.8% non-Hispanic White average age=44.4, standard deviation (SD) = 10.2] and 742 individuals from the UK Alcohol Treatment Trial (UKATT) in the United Kingdom [74.1% male, 95.6% White, average age=41.6 (SD=10.1)].

MEASUREMENTS

Form-90 (a structured assessment interview) was used to assess the primary outcome: time to first heavy drinking day. The Short Form Health Survey and Quality of Life measures were used to assess pain interference and pain intensity.

FINDINGS

Pain was a significant predictor of heavy drinking lapses during treatment in UKATT [odds ratio (OR)=1.19, 95% confidence interval (CI)=1.08, 1.32, P=0.0003] and COMBINE (OR=1.12, 95% CI=1.03, 1.21, P=0.009), and was a significant predictor of heavy drinking lapses following treatment in COMBINE (OR=1.163, 95% CI=1.15, 1.17, P<0.00001). After controlling for other relapse risk factors (e.g. dependence severity, self-efficacy, temptation, psychiatric distress), pain remained a significant predictor of heavy drinking lapses during treatment in UKATT (OR=1.19, 95% CI=1.06, 1.34, P=0.004) and following treatment in COMBINE (OR=1.44, 95% CI=1.07, 1.92, P=0.01).

CONCLUSIONS

Among people treated for alcohol use disorder, being in physical pain appears to predict heavy drinking lapses during or after treatment.

Chronic pain and depression among primary care patients treated with buprenorphine

BACKGROUND

Pain and depression are each prevalent among opioid dependent patients receiving maintenance buprenorphine, but their interaction has not been studied in primary care patients.

OBJECTIVE

We set out to examine the relationship between chronic pain, depression, and ongoing substance use, among persons maintained on buprenorphine in primary care settings.

DESIGN

Between September 2012 and December 2013, we interviewed buprenorphine patients at three practice sites.

PARTICIPANTS

Opioid dependent persons at two private internal medicine offices and a federally qualified health center participated in the study.

MAIN MEASURES

Pain was measured in terms of chronicity, with chronic pain being defined as pain lasting at least 6 months; and in terms of severity, as measured by self-reported pain in the past week, measured on a 0-100 scale. We defined mild chronic pain as pain severity between 0 and 39 and lasting at least 6 months, and moderate/severe chronic pain as severity ≥ 40 and lasting at least 6 months. To assess depression, we used the Center for Epidemiologic Studies Depression (CESD) ten-item symptom scale and the two-item Patient Health Questionnaire (PHQ-2).

KEY RESULTS

Among 328 participants, 169 reported no chronic pain, 56 reported mild chronic pain, and 103 reported moderate/severe chronic pain. Participants with moderate/severe chronic pain commonly used non-opioid pain medications (56.3%) and antidepressants (44.7%), yet also used marijuana, alcohol, or cocaine (40.8%) to help relieve pain. Mean CESD scores were 7.1 (±6.8), 8.3 (±6.0), and 13.6 (±7.6) in the no chronic, mild, and moderate/severe pain groups, respectively. Controlling for covariates, higher CESD scores were associated with a higher likelihood of moderate/severe chronic pain relative to both no chronic pain (OR = 1.09, p < 0.001) and mild chronic pain (OR = 1.06, p = 0.04).

CONCLUSION

Many buprenorphine patients are receiving over-the-counter or prescribed pain medications, as well as antidepressants, and yet continue to have significant and disabling pain and depressive symptoms. There is a clear need to address the pain-depression nexus in novel ways.

Association between physical pain and alcohol treatment outcomes: The mediating role of negative affect

OBJECTIVE

Physical pain and negative affect have been described as risk factors for alcohol use following alcohol treatment. The current study was a secondary analysis of 2 clinical trials for alcohol use disorder (AUD) to examine the associations between pain, negative affect and AUD treatment outcomes.

METHOD

Participants included 1,383 individuals from the COMBINE Study (COMBINE Pharmacotherapies and Behavioral Interventions for Alcohol Dependence; COMBINE Study Research Group, 2003; 31% female, 23% ethnic minorities, average age = 44.4 [SD = 10.2]), a multisite combination pharmacotherapy and behavioral intervention study for AUD in the United States, and 742 individuals from the United Kingdom Alcohol Treatment Trial (UKATT Research Team, 2001; 25.9% female, 4.4% ethnic minorities, average age = 41.6 [SD = 10.1]) a multisite behavioral intervention study for AUD in the United Kingdom. The Form-90 was used to collect alcohol use data, the Short Form Health Survey and Quality of Life measures were used to assess pain, and negative affect was assessed using the Brief Symptom Inventory (COMBINE) and the General Health Questionnaire (UKATT).

RESULTS

Pain scores were significantly associated with drinking outcomes in both datasets. Greater pain scores were associated with greater negative affect and increases in pain were associated with increases in negative affect. Negative affect significantly mediated the association between pain and drinking outcomes and this effect was moderated by social behavior network therapy (SBNT) in the UKATT study, with SBNT attenuating the association between pain and drinking.

CONCLUSION

Findings suggest pain and negative affect are associated among individuals in AUD treatment and that negative affect mediated pain may be a risk factor for alcohol relapse.

The effect of nonrecurring alcohol administration on pain perception in humans: a systematic review

Purpose

Alcohol is believed to have pain-dampening effects and is often used as self-medication by persons with pain problems; however, experimental evidence confirming this effect is scarce. We conducted a systematic review of experimental studies on the effects of nonrecurring alcohol administration on pain perception in healthy human subjects and the underlying mechanisms.

Method

Three databases (PubMed, PsycINFO, and Web of Science) were searched for relevant studies using a predefined algorithm. In a next step, irrelevant articles were excluded by screening titles and abstracts. Finally, articles were checked regarding a set of methodological criteria; only publications meeting these criteria were selected for this review. A total of 14 experimental studies were identified.

Results

Overall, most of the studies were able to show a pain-dampening effect of alcohol. However, many of them had methodological shortcomings (eg, lack of placebo control, insufficient blinding, or very small sample sizes). In addition, comparability is limited due to considerable variations in alcohol administration and pain measurement. More importantly, potential mechanisms of action and moderating variables have scarcely been investigated.

Conclusion

Despite the frequent use of alcohol as self-medication by persons with pain problems, there are to date only a few experimental investigations of alcohol effects on pain perceptions. The results of these studies suggest that alcohol does in fact have pain-dampening effects. However, the mechanisms implicated in these effects are still unknown, and experimental research has been limited to pain-free subjects. Future research should provide more knowledge about alcohol effects on pain, especially in chronic pain patients.

Longitudinal analysis of pain and illicit drug use behaviors in outpatients on methadone maintenance

BACKGROUND

Little is known about the experience of chronic pain and the occurrence of illicit drug use behaviors in the population enrolled in methadone maintenance treatment (MMT) programs.

METHODS

This is a secondary analysis of longitudinal data from two MMT samples enrolled in a randomized controlled trial of hepatitis care coordination. Patients completed pain, illicit drug use, and other questionnaires at baseline and 3, 9, and 12 months later. Associations were sought over time between the presence or absence of clinically significant pain (average daily pain ≥ 4 or mean pain interference ≥ 4 during the past week) and current illicit drug use (i.e., non-therapeutic opioid, cocaine or amphetamine use identified from self-report or urine drug screening).

RESULTS

Of 404 patients providing complete data, within-patient variability in pain and illicit drug use was high across the four assessment periods. While 263 denied pain at baseline, 118 (44.9%) later experienced clinically significant pain during ≥ 1 follow-up assessments. Of 180 patients (44.6%) without evidence of illicit drug use at baseline, only 109 (27.0%) had similar negative drug use at all follow-up assessments. Across four assessment periods, there was no significant association between pain group status and current illicit drug use.

CONCLUSIONS

This one-year longitudinal analysis did not identify a significant association between pain and illicit drug use in MMT populations. This finding conflicts with some earlier investigations and underscores the need for additional studies to clarify the complex association between pain and substance use disorders in patients in MMT program settings.

Interrelations between pain and alcohol: An integrative review

Pain and alcohol use are both highly prevalent in the general population, and pain-alcohol interrelations are of increasing empirical interest. Previous research has identified associations between pain and alcohol dependence, and the current review provides novel contributions to this emerging domain by incorporating studies that have tested relations between pain and low-to-moderate alcohol consumption, and by identifying potential psychosocial mechanisms of action. Specifically, we sought to integrate evidence of pain-alcohol relations derived from two directions of empirical inquiry (i.e., effects of alcohol on pain and effects of pain on alcohol use) across psychological, social, and biological literatures. We observed converging evidence that associations between alcohol consumption and pain may be curvilinear in nature. Whereas moderate alcohol use was observed to be associated with positive pain-related outcomes (e.g., greater quality of life), excessive drinking and alcohol use disorder appear to be associated with deleterious pain-related outcomes (e.g., greater pain severity). We also observed evidence that alcohol administration confers acute pain-inhibitory effects, and that situational pain may motivate alcohol consumption (e.g., drinking for pain-coping). Future research can inform theoretical and clinical applications through examination of temporal relations between pain and alcohol consumption, tests of hypothesized mechanisms, and the development of novel interventions.

Massage Impact on Pain in Opioid-dependent Patients in Substance Use Treatment

Background:

Chronic pain is a common cause of health care utilization and high levels of pain are pronounced in individuals engaged in methadone maintenance treatment. Although massage has been demonstrated to alleviate chronic pain symptoms, its use as an adjunctive therapy to modify pain during opioid-replacement treatment is absent from the literature.

Purpose:

To consider the efficacy of Swedish massage in reducing pain in opioid-dependent patients with chronic pain receiving methadone treatment.

Setting:

Trial was conducted at a nonprofit methadone treatment center serving low-income patients.

Research Design:

A randomized clinical trial with randomized to either 1) massage plus treatment-as-usual (TAU) (n = 27) or 2) TAU (n = 24). Durability of treatment effect was evaluated at Week 12.

Intervention:

Eight weekly 50-minute Swedish massage sessions plus TAU or TAU alone.

Main Outcome Measures:

Pain, anxiety, depression, physical functioning, decreased substance use, and improvement in treatment engagement.

Results:

Randomized participants were comparable at Baseline for demographic, pain, physical, and emotional variables. Massage group reported improved pain scores; worst pain had a clinically significant 2-point improvement while the other pain scores did not. Overall improvements were not observed in treatment engagement or levels of anxiety, depression, or physical functioning. A subgroup of the participants, who felt they could be pain-free, consistently reported improvements in pain from Baseline to Week 8, and this was most pronounced and clinically significant in the massage group.

Conclusions:

These preliminary findings do not support an overall clinically significant positive effect of Swedish massage on reduction in pain ratings or improvement in anxiety, depression, or treatment engagement in a substance-using, opioid-dependent population with chronic pain. Future nonpharmacologic pain research in marginalized substance-using populations may wish to consider some of the challenges and limitations faced in this project.

Pain and emotional distress among substance-use patients beginning treatment relative to a representative comparison group

OBJECTIVES

A secondary analysis assessed health-related quality-of-life (HRQOL) characteristics (ie, anxiety, depression, fatigue, and types of pain) among patients entering substance-use treatment and identified characteristics specific to treatment modalities relative to a representative comparison group.

METHODS

As part of a larger alcohol bank assessment, substance-use patients (n = 406) beginning methadone treatment (n = 170) or other outpatient treatment (n = 236) and a comparison group representative of the general population (n = 1000) completed a survey measuring anxiety, depression, fatigue, pain interference, and pain in the last 7 days. Previous studies lacked comparable and concurrent assessments across these 3 groups.

RESULTS

Patients entering substance-use treatment had relatively high levels of emotional distress and poorer HRQOL relative to the general population. Among treatment modalities, patients beginning methadone treatment reported the highest levels of pain interference and pain behavior and the poorest physical functioning. Before the potentially modifying effects of methadone maintenance, patients beginning agonist therapy reported the greatest levels of compromised quality of life.

CONCLUSIONS

These data present the magnitude of differences in HRQOL characteristics between treatment and comparison groups using the same assessment rubric and may help inform the design and timing of treatment modalities, thereby enhancing treatment efficacy for patients.

Pain and associated substance use among opioid dependent individuals seeking office-based treatment with buprenorphine-naloxone: a needs assessment study

BACKGROUND AND OBJECTIVES

A paucity of studies has examined the pain experiences of opioid dependent individuals seeking office-based buprenorphine-naloxone treatment (BNT). We set out to examine, among those seeking BNT: (a) the prevalence of pain types (i.e., recent pain, chronic pain), (b) the characteristics of pain (intensity, frequency, duration, interference, location, and genesis), and (c) substance use to alleviate pain.

METHOD

We surveyed 244 consecutive individuals seeking office-based BNT for opioid dependence about physical pain and associated substance use.

RESULTS

Thirty-six percent of respondents reported chronic pain (CP) (i.e., pain lasting at least 3 months) and 36% reported "some pain" (SP) (i.e., past week pain not meeting the threshold for CP). In comparison to SP respondents, those with CP were, on average, older; reported greater current pain intensity, pain frequency, typical pain duration, typical pain intensity, and typical pain interference; were more likely to report shoulder or pelvis and less likely to report stomach or arms as their most bothersome pain location; and were more likely to report accident or nerve damage and less likely to report opioid withdrawal as the genesis of their pain. Both pain subgroups reported similarly high rates of past-week substance use to alleviate pain.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

The high rates of pain and self-reported substance use to manage pain suggest the importance of assessing and addressing pain in BNT patients.