Painful medical conditions and alcohol use: a prospective study among older adults

Sex-specific biobehavioral regulation of persistent inflammatory pain by alcohol

BACKGROUND

Although a large percentage of chronic pain patients consume alcohol to manage their pain, there is a significant gap in knowledge regarding the mechanisms underlying the antinociceptive effects of alcohol.

METHODS

To determine the longitudinal analgesic effects of alcohol, we utilized the complete Freund's adjuvant (CFA) model of inflammatory pain in adult female and male Wistar rats. Both somatic and negative motivational aspects of pain were measured using the electronic von Frey (mechanical nociception) system, thermal probe test (thermal nociception), and mechanical conflict avoidance task (pain avoidance-like behavior). Tests were conducted at baseline and 1 and 3 weeks following intraplantar CFA or saline administration. At both time points post-CFA, animals were treated with each of three doses of alcohol (intraperitoneal; 0, 0.5, and 1.0 g/kg) over separate days in a Latin square design.

RESULTS

Alcohol produced dose-dependent mechanical analgesia and antihyperalgesia in females but only antihyperalgesia in males. Although alcohol continued to attenuate CFA-induced decreases in both thermal and mechanical nociceptive thresholds between 1 and 3 weeks post-CFA, it appeared less effective at increasing thresholds 3 weeks after CFA induction.

CONCLUSIONS

These data suggest that individuals may develop tolerance to alcohol's ability to alleviate both somatic and negative motivational symptoms of chronic pain over time. We also discovered sex-specific neuroadaptations in protein kinase A-dependent phosphorylation of GluR1 subunits and extracellular signal-regulated kinase (ERK 1/2) phosphorylation in nociceptive brain centers of animals receiving an alcohol challenge 1 week post-CFA. Together, these findings illustrate a sex-specific regulation of behavioral and neurobiological indices of persistent pain by alcohol.

Pain as a causal motivator of alcohol consumption: Associations with gender and race

Despite accumulating evidence indicating reciprocal interrelations between pain and alcohol consumption, no prior work has examined pain as a proximal antecedent of drinking. The goal of the current study was to test the effects of experimental pain induction on ad-lib alcohol consumption among moderate-to-heavy drinkers without chronic pain (N = 237; 42% female; 37% Black; M = 3.26daily drinks). Participants were randomized to either pain-induction (capsaicin + thermal heat paradigm) or no-pain-control conditions. Experimental pain induction lasted for 15 minutes, during which ad-lib alcohol consumption was assessed using an established taste test paradigm. As hypothesized, results indicated that participants randomized to the pain-induction condition poured and consumed more alcohol and reached a higher peak blood alcohol concentration than those randomized to the no-pain condition (ps < 0.05; ηp² range = 0.018-0.021). Exploratory analyses revealed the effects of pain on alcohol consumption to be most pronounced among participants who self-identified as male or Black (relative to female or White, respectively). These findings indicate that the experience of pain serves as a causal, situational motivator for alcohol consumption, and suggest that current drinkers may be susceptible to escalating their consumption of alcohol in the context of pain. Future research is needed to explicate observed differences in the effects of pain on drinking as a function of gender and race, and to extend this work to individuals with chronic pain and varying levels of alcohol use. Collectively, these findings may help inform the development of integrated treatments to address co-occurring pain and alcohol use. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Clusters of older adults with and without experience of alcohol-related harms based on affective motivations for drinking

Aim: This cross-sectional study explores profiles of community-residing Norwegian older adults (aged 62–95 years) in relation to their personally expressed motives for alcohol use. It specifically investigates drinking motives as they uniquely characterise alcohol consumers reporting problem and non-problem drinking assessed using the Drinking Problem Index (DPI). Methods: Two-step cluster analysis was used to delineate subgroups of alcohol consumers on seven drinking motivation variables, together with DPI score. The clusters were evaluated by gender, physical health and psychological health status. Results: Four clusters of alcohol consumers were identified in relation to drinking motives: Low motivated drinkers, Ambivalent drinkers, Enhancement drinkers, and Coping drinkers. For one subgroup, a strong reliance on alcohol to cope with negative feelings was most relevant to both non-problem and problem drinkers. For another subgroup, enjoying the effects of alcohol, but non-reliance on alcohol to cope with negative mood were associated with reporting drinking problems. Ambivalent drinkers reported overall low satisfaction with mental health. Very poor physical and mental health were more prevalent in men than in women characterised as Coping drinkers. Predominantly mental health status supported distinctiveness of delineated clusters. Conclusion: This study demonstrates that the classification approach to profiling of characteristics of alcohol consumers based on their motivations to drink may have a potential utility in human care settings to identify individuals who incur or may be at risk of developing alcohol-related problems in later life, and those who are not.

Does Gender Moderate the Relationship Between Chronic Pain and Substance Use Disorder? Insights From a National Canadian Population Survey

BACKGROUND

Though it has been shown that men have a higher lifetime prevalence of substance use disorder and a lower prevalence of chronic pain than women, there is little research to date focusing on gender differences in the relationship between chronic pain and substance use disorder. This study examined whether gender moderates the relationship of chronic pain and substance use disorder. We also sought to examine the gender differences in the associations between specific pain types-arthritis, migraine, and back pain, and substance use disorder.

METHODS

The data were drawn from the 2012 Canadian Community Health Survey-Mental Health (CCHS-MH 2012) with individuals aged 20 years and older living in the 10 Canadian provinces (N = 23,089). A two-level logistic mixed effects model was used to account for provincial differences.

RESULTS

Our findings indicated gender moderated the association between arthritis as well as migraine, and substance use disorder. However, no moderation effect of gender on the relationship between back pain and substance use disorder was found. Specifically, the strength of the association between arthritis and substance use disorder was stronger among men (OR_interaction = 0.62, 95% CI: 0.53 to 0.73), whereas the strength of the association between migraine and substance use disorder was stronger among women (OR_interaction = 1.45, 95% CI: 1.18 to 1.79). In addition, geographical location was found to explain a small proportion (2.3%-2.4%) of the overall variance in SUD.

CONCLUSIONS

The results suggest that gender moderated the relations between arthritis as well as migraine, and substance use disorder, respectively. Treatment programs for pain and substance misuse might benefit from an approach tailored to gender differences.

Examining Sex Differences in Associations between Pain and Alcohol Use among College Student-Athletes

Background: College student-athletes are a high-risk population for both pain and alcohol use. Although a growing literature indicates that pain motivates alcohol consumption, no studies have tested associations between pain and alcohol in college student-athletes. Methods and Results: Among National Collegiate Athletic Association Division I student-athletes at a large public university (N = 65; 48% Female), nearly all student-athletes (97%) reported alcohol use and 65% reported pain due to an athletic injury. Pain intensity was positively associated with greater motivation to reduce drinking prior to receiving a brief alcohol intervention. Among females, pain intensity was associated with lower self-reported alcohol consumption. Among male athletes, pain-related interference was associated with greater alcohol-related problems and lower perceived ability to deal with alcohol-related situations. Conclusion: Results provide initial evidence that pain may be important to consider when addressing alcohol use among student-athletes.

Distinct health-related risk profiles among middle-aged and older adults with risky alcohol use from the Danish general population

BACKGROUND

Knowledge is lacking on distinct health-related risk profiles among the substantial group of middle-aged and older adults with risky alcohol use (AU). Such profiles could inform the planning of interventions and prevention.

AIMS

To 1) identify distinct health-related profiles based on different types of health-related functioning limitations and distress and 2) assess associations between these profiles and age, sex, and health-relevant behaviors (e.g., smoking).

METHODS

Cross-sectional nation-wide Danish health survey with n = 6630 adults aged 55-64 and n = 7605 aged 65-74 with at least risky AU (>84 g ethanol/week in women, >168 in men). Health-related risk profiles were identified with Latent Class Analysis (LCA). Multinomial regression was applied for the association between risk profiles and auxiliary variables.

RESULTS

A six-class LCA solution was found among 55-64 year-olds (classes: 'Normative' [61%], 'Distress' [6%], 'Mental health limitations [5%]', 'Pain-related distress [10%]', 'Broad limitations and pain distress [7%]', 'High overall burden' [11%]) and a five-class solution among 65-74 year-olds. Most classes were comparable across age groups. The 'Distress'-class characterized by pain-distress, tiredness-distress, and sleep-related distress (6%) only showed in the younger group. In both age groups, auxiliary covariates (high-risk AU, possible alcohol use disorder, weekly smoking) were positively associated with problematic profile membership (vs. normative class membership).

CONCLUSION

Middle-aged and older adults with risky AU have distinct health-related profiles relevant for the form and content of prevention and interventions. Despite their distinct features, almost all problematic health profiles warrant careful attention regarding high-risk AU and probable alcohol use disorder.

Why do patients with chronic hepatitis C drink alcohol? An examination of pain, depression and drinking motives

Alcohol consumption in the setting of chronic HCV is associated with accelerated progression towards cirrhosis, increased risk of hepatocellular carcinoma and higher mortality. This analysis contextualizes how sociodemographic factors, chronic pain and depression relate to the motivations of individuals with chronic HCV to consume alcohol. We conducted a secondary analysis of baseline data from the Hep ART trial of behavioural interventions on alcohol use among patients with HCV. Alcohol consumption was measured using the Drinking Motives Questionnaire and a novel 6-item measure of pain-related drinking motives. Statistical analyses performed included ANOVA for bivariate analyses and multivariable ordinary least-squares linear regression. At study baseline, 181 participants had an average age of 55 years; the majority (66.7%) reported beyond-minor pain; and a third (37%) met criteria for depression; drinking motives were higher for individuals with beyond-minor pain (means 9.9 vs. 4.6, p < .001) and who met criteria for depression (means 10.9 vs. 6.4, p < .001) when using the pain-related drinking motives items. Average pain(coef = 1.0410067141 < .001) was significantly associated with increased motives to drink to relieve pain in the full baseline model specification controlling for all covariates using ordinary at least squares; depression (coef = 7.06; 95% CI 1.32, 12.81; p = .016) was significantly associated with increased non-pain-related motives to drink. From baseline to 3-month follow-up, compared to participants who had mean average pain scores among the sample, motives to drink to relieve pain decreased in participants who had higher average pain scores (coef = -0.30; 95% CI -0.59, -0.01; p = .40). Physical pain and depression are associated with increased motives to consume alcohol. Patients with chronic liver disease should be screened for chronic pain and depression and, if present, referred to pain specialists or co-managed in partnership with pain specialists in hepatology clinics.

Pain catastrophizing predicts alcohol craving in heavy drinkers independent of pain intensity

BACKGROUND

Chronic pain and alcohol use disorder (AUD) are often co-occurring conditions. Pain catastrophizing, an emotional component of pain, and pain intensity are related to alcohol use as a coping mechanism; however, how pain interacts with tonic alcohol craving is an understudied area. This study sought to determine the unique and independent effects of pain intensity and pain catastrophizing on alcohol craving in heavy drinkers.

METHOD

Non-treatment seeking heavy drinkers (n = 128) completed self-report measures of pain (both intensity and catastrophizing), depression, alcohol use and problems, and reasons for heavy drinking. A hierarchical regression examined the unique contribution of pain intensity to alcohol craving. Depression, pain catastrophizing, and alcohol use measures were added to the hierarchical model in sequential blocks.

RESULTS

The final model of the hierarchical regression demonstrated that pain catastrophizing has an independent effect on alcohol craving over and above demographic, pain intensity, depression, and alcohol measures. Exploratory analyses suggest that individuals in the high intensity pain grade have higher levels of depression symptomology, pain catastrophizing, alcohol use and problems, as well as engaging in heavy drinking to "feel normal" compared to the no pain and low intensity pain grades.

CONCLUSIONS

These results demonstrate that pain catastrophizing predicts alcohol craving independent of self-reported chronic pain intensity. Individuals with high intensity chronic pain have more severe alcohol use and mood-related symptomology. Upon replication in clinical samples, these findings can inform clinical care for pain management.

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.

Neurobiological aspects of pain in the context of alcohol use disorder

Alcohol is an effective and widely utilized analgesic. However, the chronic use of alcohol can actually facilitate nociceptive sensitivity over time, a condition known as hyperalgesia. Excessive and uncontrollable alcohol drinking is also a hallmark feature of alcohol use disorder (AUD). Both AUD and chronic pain are typically accompanied by negative affective states that may underlie reinforcement mechanisms contributing to AUD maintenance or progression. Frequent utilization of alcohol to relieve pain in individuals suffering from AUD or other chronic pain conditions may thus represent a powerful negative reinforcement construct. This chapter will describe ties between alcohol-mediated pain relief and potential exacerbation of AUD. We describe neurobiological systems engaged in alcohol analgesia as well as systems recruited in the development and maintenance of AUD and hyperalgesia. Although few effective therapies exist for either chronic pain or AUD, the common interaction of these conditions will likely lead the way for promising new discoveries of more effective and even simultaneous treatment of AUD and co-morbid hyperalgesia. An abundance of neurobiological findings from multiple laboratories has implicated a potentiation of central amygdala (CeA) signaling in both pain and AUD, and these data also suggest that attenuation of stress-related systems (including corticotropin-releasing factor, vasopressin, and glucocorticoid receptor activity) would be particularly effective and comprehensive therapeutic strategies targeting the critical intersection of somatic and motivational mechanisms driving AUD, including alcohol-induced hyperalgesia.

The role of depression course on life functioning and coping outcomes from baseline through 23-year follow-up

BACKGROUND

Although studies have examined how depressed patients' baseline characteristics predict depression course, still needed are studies of how depression course is associated with modifiable long-term outcomes.

AIMS

This study examined six outcomes of three groups representing distinct depression courses (low baseline severity, rapid decline; moderate baseline severity, rapid decline; and high baseline severity, slow decline): medical functioning, coping patterns, family functioning, social functioning, employment, and work functioning.

METHOD

Adults with depression at baseline (N = 382; 56% women) were followed for 23 years on self-reported outcomes (79% response rate). Data from the baseline assessment and follow-ups (1, 4, 10, and 23 years) were used in a longitudinal analysis to examine associations between depression course and outcomes.

RESULTS

All depression course groups declined on medical and social functioning and employment over follow-up. The high- and moderate-severity depression course groups reported poorer coping patterns than the low-severity group. The high-severity depression course group reported poorer family functioning than the moderate-severity group, and had the poorest work functioning outcome, followed by the moderate-severity and then the low-severity groups.

CONCLUSIONS

Patients with a high- or moderate-severity depression course may benefit from treatment that manages coping patterns and improves family and work functioning.

Alcohol and Drug Overdose and the Influence of Pain Conditions in an Addiction Treatment Sample

PURPOSE

Overdose from alcohol and/or drugs kills tens of thousands of Americans annually, with a large number of deaths attributed to opioid pain medications. Addiction treatment patients are known to be at high risk for overdose; however, the relationship between pain and overdose history within this group is understudied, especially in relation to alcohol overdoses. In the present study, we evaluated whether nonfatal overdose history was more likely among addiction treatment patients with pain, and examined the characteristics of overdoses among those with and without pain.

METHODS

We analyzed cross-sectional data from 739 patients at a large residential addiction treatment center (median age 37, 25.7% female). We used 2-stepped binary regression models to evaluate whether demographics, pain type (chronic, acute, or both), depression symptoms, and opioid misuse were associated with lifetime history of nonfatal (1) alcohol and (2) drug overdose (lifetime yes/no), and conducted follow-up analyses examining overdose characteristics.

RESULTS

In adjusted analyses, history of chronic pain (odds ratio [OR] 2.60, 95% confidence interval [CI] 1.59, 4.27) and illicit drug use (OR 1.99, 95% CI 1.07, 3.68) were associated with an increased likelihood of nonfatal alcohol overdose. Opioid misuse (OR 3.11, 95% CI 2.51, 3.86), depression symptoms (OR 1.33, 95% CI 1.14, 1.55), and younger age (OR 0.96, 95% CI 0.94, 0.97) were associated with increased likelihood of drug overdose. Those with pain reported a higher number of lifetime alcohol overdoses and were more likely to combine numerous drugs with alcohol before overdose.

CONCLUSIONS

Pain conditions may play an under-recognized role in the overdose epidemic, particularly alcohol-related overdose. Addiction treatment and overdose prevention interventions should incorporate appropriate assessment and treatment of pain including education about the risks of polysubstance use, particularly combining alcohol with sedatives and prescription pain relievers.

The Association Between Alcohol Consumption and Pain Interference in a Nationally Representative Sample: The Moderating Roles of Gender and Alcohol Use Disorder Symptomatology

BACKGROUND

Prior research on alcohol consumption and pain has yielded inconsistent results regarding the directionality of effects for both consumption-to-pain and pain-to-consumption relations. The present study sought to examine directionality of these relations by testing bidirectional longitudinal associations between consumption and pain interference, a crucial aspect of pain that captures pain-related disability and has been regarded as a valuable measure of treatment outcome. In addition, this study explored possible moderation of these bidirectional longitudinal associations by gender and alcohol use disorder (AUD) symptomatology.

METHODS

Analyses included 29,989 current/former drinkers who were interviewed at both waves (2001 and 2004) of the U.S. National Epidemiological Survey on Alcohol and Related Conditions (NESARC). Analyses used self-report data from both waves on past-year average daily volume of alcohol consumed and past-month pain interference (1 item from the Medical Outcomes Study 12-item Short-Form Health Survey [MOS-SF-12]). AUDADIS-IV data from Wave 1 were used to index baseline AUD symptomatology (i.e., symptom count). Cross-lagged panel modeling and multigroup analyses were employed.

RESULTS

Regarding the consumption-to-pain-interference relation, in general, higher baseline alcohol consumption was associated with lower subsequent pain interference at follow-up. However, among men with higher AUD-symptom counts, the opposite pattern emerged, with higher baseline alcohol consumption being significantly related to higher subsequent pain interference at follow-up. Regarding the pain-interference-to-consumption relation, higher baseline pain interference was significantly associated with lower subsequent alcohol consumption at follow-up, and no moderating effects were observed.

CONCLUSIONS

The distinctive patterns of the consumption-to-pain-interference relation observed among men with elevated AUD symptomatology suggest that this relation might be driven by different mechanisms across different groups of individuals. Specifically, the detrimental effect of alcohol on pain interference might emerge at relatively advanced stages of AUD among men, consistent with Koob's Dark Side of Alcohol Addiction theory in human research.

Interactive Effects of Quality of Life and Related Factors on Alcohol Use Outcomes

This investigation derives its impetus from public health concerns around detecting, mitigating, and preventing the deleterious effects that alcohol use can cause particularly in advanced age. We aim to complement gerontological research by exploring the interactive effects of quality of life and related factors on alcohol use outcomes assessed by the Drinking Problem Index. The study is based on cross-sectional data collected from questionnaires mailed to a randomly drawn sample of 6,000 Norwegian adults aged 62 and older (participation rate: 32%). According to the Chi-square Automatic Interaction Detection (CHAID) analysis, constellations of interactive factors emerged differently for women and men, and, between non-problem and problem drinkers. For women, drinking outcomes were related to intra-psychic functioning, and for men, to physical health and social situation. An ongoing quality-of-life assessment may be very important in the comprehensive assistance provided to those older people who are vulnerable to undergoing alcohol-related harms.

Alcohol and Pain: A Translational Review of Preclinical and Clinical Findings to Inform Future Treatment Strategies

Alcohol use disorder (AUD) and chronic pain are enduring and devastating conditions that share an intersecting epidemiology and neurobiology. Chronic alcohol use itself can produce a characteristic painful neuropathy, while the regular analgesic use of alcohol in the context of nociceptive sensitization and heightened affective pain sensitivity may promote negative reinforcement mechanisms that underlie AUD maintenance and progression. The goal of this review was to provide a broad translational framework that communicates research findings spanning preclinical and clinical studies, including a review of genetic, molecular, behavioral, and social mechanisms that facilitate interactions between persistent pain and alcohol use. We also consider recent evidence that will shape future investigations into novel treatment mechanisms for pain in individuals suffering from AUD.

Gender differences in associations between pain-related anxiety and alcohol use among adults with chronic pain

Background: Over 100 million Americans live with chronic pain, and adults with chronic pain may be more likely to experience alcohol-related problems or Alcohol Use Disorder. An evolving conceptual model posits that bidirectional effects between pain and alcohol exacerbate both pain and drinking. Pain has been shown to motivate alcohol urge and consumption, and drinking for pain-coping predicts escalations in alcohol use over time. Pain-related anxiety is a transdiagnostic vulnerability factor that has been implicated in both pain and substance-related (i.e., tobacco, opioids, cannabis) outcomes, but has not yet been studied in relation to alcohol use. Objective: We sought to conduct the first test of cross-sectional associations between pain-related anxiety, gender, and alcohol use. Methods: Adults with chronic pain (N = 234; M_age = 29.54, 67% Female) self-reported pain-related anxiety, gender, and alcohol use (i.e., consumption frequency/quantity, alcohol-related consequences, and dependence symptoms measured with the Alcohol Use Disorders Identification Test; AUDIT). Hierarchical regression and conditional effects models were used to test associations between pain-related anxiety, gender, and alcohol use. Results: Pain-related anxiety was positively associated with alcohol-related consequences and alcohol dependence symptoms measured by the AUDIT among males, but not females. Pain-related anxiety was not associated with the frequency/quantity of alcohol consumption in our sample. Conclusions: These findings are consistent with prior research, which has demonstrated associations between pain-related anxiety and deleterious substance use outcomes. Results provide initial evidence that pain-related anxiety may be a relevant factor to consider in the context of alcohol research and treatment among male drinkers.

Characterizing chronic pain and alcohol use trajectory among treatment-seeking alcoholics

Accumulating evidence indicates pain may be an important risk factor for development of alcohol use disorder (AUD) and risk of relapse for people recovering from AUD. This study was conducted to characterize the prevalence and severity of significant recurrent pain and various chronic pain conditions in treatment-seeking alcoholics. In addition, we sought to examine associations between alcohol use trajectory and pain presence/severity. Four hundred fifty-one treatment-seeking alcoholics were recruited for this study. Participants completed a battery of assessments, including measures of demographics, affect, alcohol and other drug use, presence/absence of significant recurrent pain, recent pain severity, and chronic pain type. Analyses indicated significant recurrent pain was highly prevalent in the study sample (53.66%), and was significantly more common among women (62.57%) than men (47.35%; p = 0.001). Typical drinking prior to treatment did not differ by pain status, but participants with pain were more likely to report current opioid use. Individuals with pain reported greater depression and anxiety than those without (p < 0.0008), and pain tended to be more severe among women than men (p = 0.035). Both men and women with pain indicated that pain had affected their substance use. In addition, both later age of first treatment and longer transition time from alcohol dependence to treatment were associated with greater pain severity, especially among men. These data suggest chronic pain is highly prevalent among treatment-seeking alcoholics, especially women, and that delays to first treatment are associated with pain presence and intensity. These results highlight the importance of effective pain management for the subset of treatment seekers with pain.

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.

Pain and alcohol: a comparison of two cohorts of 60 year old women and men: findings from the Good Aging in Skåne study

Background and aims Pain, use of painkillers and alcohol are highly prevalent in the general population. Aims of the study were to describe differences in pain, alcohol consumption and use of painkillers among two 60 year old birth cohorts stratified by gender. Methods Participants were recruited from the Skåne centre of The Swedish National study on Aging and Care, a multicentre, prospective, longitudinal study. The sample comprised 60 year old men and women born between 1941 and 1943 and recruited to the study between 2001 and 2004 (n=663) and 60 year old men and women born in the period 1952-1954 and recruited to the study between 2013 and 2015 (n=924). Specially trained research staff conducted the interviews. For descriptive statistics the variables were presented in total numbers, percentages, mean and standard deviation, and 1st and 3rd quartile are also shown. The sample was divided into four groups: men and women born in the period 1941-1943, men and women born in the period 1952-1954, respectively. Results No difference in alcohol intake was detected between the two birth cohorts. All participants, regardless of pain or not, reported alcohol use below the specified risk level for both sexes. Teetotallers were more common in the 1952-1954 male cohort, 128 (29%), p<0.029. Two hundred and eighty one Men born between 1952 and 1954 reported pain (59.0%), compared to 173 men born between 1941 and 1943 (51.6%), p<0.034. There was no difference between the male cohorts in use of painkillers, p<0.062. No difference was found between the two female cohorts in terms of pain, p<0.144. One hundred and ten women in the 1941-43 cohort used painkillers (53.1%) compared to 119 women born between 1952 and 1954 (40.1%), p<0.004. When comparing men and women with pain born between 1941 and 1942, men with moderate pain use more alcohol, 157 g/month (q1 10, q3 365) than women, 44 g/month (q1 0, q3 134), p<0.001. Men with severe pain also use more alcohol, 96 g/month (q1 17, q3 324) than women, 27 g/month (q1 0, q1 118), p<0.030, and when those with pain were merged into a group, men use more alcohol, 175 g/month (q1 31, q3 356), than women, 68 g/month (q1 1, q3 207), p<0.001. This also applies to the later cohort; men, 132 g/month (q1 22, q3 270), compared to women, 76 g/month (q1 8, q3 182), p<0.001. When merging all pain into one group women use more painkillers both in the 1941-43 cohort, men (39.9%) compared to women (53.1%), p<0.010 and in the 1952-54 cohort, men (18.5%) compared to women (26.6%), p<0.003. Use of analgesics and alcohol is common but the highest percentage is among women born between 1941 and 1943, 45 (48.9%). Conclusions Pain and alcohol use are common among 60 year old women and men. A gender difference is that women use more painkillers. In the 1941-43 cohort almost every second woman with moderate pain who took painkillers also consumed alcohol. Implications It is time to alert prescribers that a large section of the population uses alcohol combined with painkillers. More research is needed to better understand the long-term perspective on health when using both painkillers and alcohol.

'I take my tablets with the whiskey': A qualitative study of alcohol and medication use in mid to later life

Background

Concurrent alcohol and medication use can result in significant problems especially in mid to later life. Alcohol is often used instead of medication for a number of health-related conditions. This novel qualitative study explored concurrent alcohol and medication use, as well as the use of alcohol for medicinal purposes, in a sample of individuals in mid to later life.

Methods

Twenty-four interviews (12 men/12 women, ages 51–90 years) and three focus groups (n = 27, 6 men/21 women, ages 50–95 years) from three branches of Age UK and two services for alcohol problems in North East England.

Results

Older people in this study often combined alcohol and medication, frequently without discussing this with their family doctor. However, being prescribed medication could act as a motivating factor to stop or reduce alcohol consumption. Participants also used alcohol to self-medicate, to numb pain, aid sleep or cope with stress and anxiety. Some participants used alcohol to deal with depression although alcohol was also reported as a cause of depression. Women in this study reported using alcohol to cope with mental health problems while men were more likely to describe reducing their alcohol consumption as a consequence of being prescribed medication.

Conclusions

As older people often combine alcohol and medication, health professionals such as family doctors, community nurses, and pharmacists should consider older patients’ alcohol consumption prior to prescribing or dispensing medication and should monitor subsequent drinking. In particular, older people should be informed of the dangers of concurrent alcohol and medication use.

Alcohol and Opioid Use, Co-Use, and Chronic Pain in the Context of the Opioid Epidemic: A Critical Review

The dramatic increase in opioid misuse, opioid use disorder (OUD), and opioid-related overdose deaths in the United States has led to public outcry, policy statements, and funding initiatives. Meanwhile, alcohol misuse and alcohol use disorder (AUD) are a highly prevalent public health problem associated with considerable individual and societal costs. This study provides a critical review of alcohol and opioid misuse, including issues of prevalence, morbidity, and societal costs. We also review research on interactions between alcohol and opioid use, the influence of opioids and alcohol on AUD and OUD treatment outcomes, respectively, the role of pain in the co-use of alcohol and opioids, and treatment of comorbid OUD and AUD. Heavy drinking, opioid misuse, and chronic pain individually represent significant public health problems. Few studies have examined co-use of alcohol and opioids, but available data suggest that co-use is common and likely contributes to opioid overdose-related morbidity and mortality. Co-use of opioids and alcohol is related to worse outcomes in treatment for either substance. Finally, chronic pain frequently co-occurs with use (and co-use) of alcohol and opioids. Opioid use and alcohol use are also likely to complicate the treatment of chronic pain. Research on the interactions between alcohol and opioids, as well as treatment of the comorbid disorders is lacking. Currently, most alcohol research excludes patients with OUD and there is lack of measurement in both AUD and OUD research in relation to pain-related functioning. Research in those with chronic pain often assesses opioid use, but rarely assesses alcohol use or AUD. New research to examine the nexus of alcohol, opioids, and pain, as well as their treatment, is critically needed.

Late-Life Drinking Problems: The Predictive Roles of Drinking Level vs. Drinking Pattern

OBJECTIVE

Research on late-middle-aged and older adults has focused primarily on average level of alcohol consumption, overlooking variability in underlying drinking patterns. The purpose of the present study was to examine the independent contributions of an episodic heavy pattern of drinking versus a high average level of drinking as prospective predictors of drinking problems.

METHOD

The sample comprised 1,107 adults ages 55-65 years at baseline. Alcohol consumption was assessed at baseline, and drinking problems were indexed across 20 years. We used prospective negative binomial regression analyses controlling for baseline drinking problems, as well as for demographic and health factors, to predict the number of drinking problems at each of four follow-up waves (1, 4, 10, and 20 years).

RESULTS

Across waves where the effects were significant, a high average level of drinking (coefficients of 1.56, 95% CI [1.24, 1.95]; 1.48, 95% CI [1.11, 1.98]; and 1.85, 95% CI [1.23, 2.79] at 1, 10, and 20 years) and an episodic heavy pattern of drinking (coefficients of 1.61, 95% CI [1.30, 1.99]; 1.61, 95% CI [1.28, 2.03]; and 1.43, 95% CI [1.08, 1.90] at 1, 4, and 10 years) each independently increased the number of drinking problems by more than 50%.

CONCLUSIONS

Information based only on average consumption underestimates the risk of drinking problems among older adults. Both a high average level of drinking and an episodic heavy pattern of drinking pose prospective risks of later drinking problems among older adults.

Spinal AMPA Receptor GluA1 Ser831 Phosphorylation Controls Chronic Alcohol Consumption-Produced Prolongation of Postsurgical Pain

Previous studies have shown that excessive alcohol drinking is associated with chronic pain development; however, the molecular mechanism underlying this association is poorly understood. In this study, we investigated the effect of chronic alcohol consumption on plantar incision-induced postsurgical pain. We observed that 4-week ethanol drinking significantly prolonged plantar incision-induced mechanical pain, but not thermal pain. The chronic alcohol consumption enhanced plantar incision-produced α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor GluA1 phosphorylation at the Ser831 site in the spinal cord. The targeted mutation of the GluA1 phosphorylation site in GluA1 S831A mutant mice significantly inhibited the incisional pain prolongation produced by chronic alcohol consumption. Moreover, chronic alcohol consumption combined with plantar incision markedly increased AMPA receptor-mediated miniature excitatory postsynaptic currents in the spinal dorsal horn neurons, and this effect was diminished significantly in the GluA1 S831A mutant mice. Our results suggest that chronic alcohol consumption may promote the development of persistent postsurgical pain by enhancing AMPA receptor GluA1 Ser831 phosphorylation. We identified chronic alcohol consumption as a risk factor for pain chronification after surgery.

Chronic pain causes a persistent anxiety state leading to increased ethanol intake in CD1 mice

Mood disorders and chronic pain are closely linked, but limited progress has been made in understanding the role of chronic and neuropathic pain in the aetiopathogenesis of depression. To explore the pathological mechanisms that mediate the association between pain and depressive-like behaviours, we studied the time-dependent effect of neuropathic pain on the development of anxiety-like and despair behaviours in CD1 mice. We analysed behavioural data, neuroinflammation reactions and changes in neurotransmitter (glutamate and serotonin) levels in the mouse prefrontal cortex. Sciatic-operated mice displayed long-lasting anxiety-like and despair behaviours, starting 5 and 20 days after partial sciatic nerve ligation, respectively. Glutamatergic neurotransmission and IL-1β cytokine expression were enhanced in the prefrontal cortex of mice with neuropathic pain. We found no change in serotonin metabolism, cytokine IL-6 or brain-derived neurotrophic factor levels. While sciatic-operated mice exposed to intermittent ethanol intake (20% v/v) using the drinking in the dark procedure consumed higher amounts of ethanol than sham-operated mice, thermal allodynia and despair behaviour were not attenuated by ethanol consumption. Our findings reveal an association between glutamatergic neurotransmission and pain-induced mood disorders, and indicate that moderate ethanol consumption does not relieve nociceptive and depressive behaviours associated with chronic pain in mice.

Alcohol Use as Risk Factors for Older Adults' Emergency Department Visits: A Latent Class Analysis

INTRODUCTION

Late middle-aged and older adults' share of emergency department (ED) visits is increasing more than other age groups. ED visits by individuals with substance-related problems are also increasing. This paper was intended to identify subgroups of individuals aged 50+ by their risk for ED visits by examining their health/mental health status and alcohol use patterns.

METHODS

Data came from the 2013 National Health Interview Survey's Sample Adult file (n=15,713). Following descriptive analysis of sample characteristics by alcohol use patterns, latent class analysis (LCA) modeling was fit using alcohol use pattern (lifetime abstainers, ex-drinkers, current infrequent/light/moderate drinkers, and current heavy drinkers), chronic health and mental health status, and past-year ED visits as indicators.

RESULTS

LCA identified a four-class model. All members of Class 1 (35% of the sample; lowest-risk group) were infrequent/light/moderate drinkers and exhibited the lowest probabilities of chronic health/mental health problems; Class 2 (21%; low-risk group) consisted entirely of lifetime abstainers and, despite being the oldest group, exhibited low probabilities of health/mental health problems; Class 3 (37%; moderate-risk group) was evenly divided between ex-drinkers and heavy drinkers; and Class 4 (7%; high-risk group) included all four groups of drinkers but more ex-drinkers. In addition, Class 4 had the highest probabilities of chronic health/mental problems, unhealthy behaviors, and repeat ED visits, with the highest proportion of Blacks and the lowest proportions of college graduates and employed persons, indicating significant roles of these risk factors.

CONCLUSION

Alcohol nonuse/use (and quantity of use) and chronic health conditions are significant contributors to varying levels of ED visit risk. Clinicians need to help heavy-drinking older adults reduce unhealthy alcohol consumption and help both heavy drinkers and ex-drinkers improve chronic illnesses self-management.

Alcohol Use Predicts 10-Year Depressive Symptom Trajectories in the Health and Retirement Study

OBJECTIVE

To determine effects of late-middle-aged adults' baseline drinking behavior on their subsequent 10-year depressive symptom trajectories.

METHOD

Health and Retirement Study participants (N = 7,939) were assessed on baseline demographic, health, and drinking characteristics, and biennially assessed for the next 10 years on their depressive symptoms.

RESULTS

Growth mixture modeling generated four classes of depressive symptom trajectories: Consistently low (72%), consistently elevated (6%), increasing (12%), and decreasing (10%). Baseline abstinence from alcohol, possibly enforced by poorer health and a history of drinking problems, and heavier drinking, "binge" drinking, and having a history of drinking problems, raised risk of membership in the "consistently elevated" class. Abstinence by participants without history of drinking problems-and light, moderate, and heavier drinking-protected against membership in the "increasing" class. Abstinence by participants without history of drinking problems elevated-and moderate drinking reduced-likelihood of membership in the "decreasing" class.

DISCUSSION

Late-middle-aged adults' alcohol use is associated with the subsequent long-term course of their depressive symptoms.

Approach to the pharmacological management of chronic pain in patients with an alcohol use disorder

This paper provides an overview of research, guidelines, and clinical considerations for the use of medications for chronic pain in the management of patients with an alcohol use disorder. A review of the literature identified randomized controlled trials, epidemiological cohort studies, consensus guidelines, and one systematic review and meta-analysis. Where gaps in the literature existed, clinical experience of the authors is included. Use of nonopioid medications should be given priority and may offer a more favorable risk profile as well as benefits beyond pain management, such as improvement in anxiety, depression, or insomnia. Pregabalin and gabapentin have additional benefits to decrease alcohol cravings or time to relapse after a period of abstinence from alcohol. Drug interactions between selected analgesics and alcohol, disulfiram, or naltrexone require careful consideration.

Primary Care Management of Alcohol Misuse

More than one in four American adults consume alcohol in quantities exceeding recommended limits. One in 12 have an alcohol use disorder marked by harmful consequences. Both types of alcohol misuse contribute to acute injury and chronic disease, making alcohol the third largest cause of preventable death in the United States. Alcohol misuse alters the management of common conditions from insomnia to anemia. Primary care providers should screen adult patients to identify the full spectrum of alcohol misuse. A range of effective treatments are available - from brief counselling interventions and mutual help groups to medications and behavioral therapies.

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.

Smoking Status and Pain Intensity Among OEF/OIF/OND Veterans

OBJECTIVE

Pain and smoking are highly prevalent among Veterans. Studies in non-Veteran populations have reported higher pain intensity among current smokers compared with nonsmokers and former smokers. We examined the association of smoking status with reported pain intensity among Veterans of Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND).

DESIGN

The sample consisted of OEF/OIF/OND Veterans who had at least one visit to Veterans Affairs (2001-2012) with information in the electronic medical record for concurrent smoking status and pain intensity. The primary outcome measure was current pain intensity, categorized as none to mild (0-3); moderate (4-6); or severe (≥7); based on a self-reported 11-point pain numerical rating scale. Multivariable logistic regression analyses were used to assess the association of current smoking status with moderate to severe (≥4) pain intensity, controlling for potential confounders.

RESULTS

Overall, 50,988 women and 355,966 men Veterans were examined. The sample mean age was 30 years; 66.3% reported none to mild pain; 19.8% moderate pain; and 13.9% severe pain; 37% were current smokers and 16% former smokers. Results indicated that current smoking [odds ratio (OR) = 1.29 (95% confidence intervals (CI) = 1.27-1.31)] and former smoking [OR = 1.02 (95% CI = 1.01-1.05)] were associated with moderate to severe pain intensity, controlling for age, service-connected disability, gender, obesity, substance abuse, mood disorders, and Post Traumatic Stress Disorder.

CONCLUSIONS

We found an association between current smoking and pain intensity. This effect was attenuated in former smokers. Our study highlights the importance of understanding reported pain intensity in OEF/OIF/OND Veterans who continue to smoke.

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.

Peripheral systems: neuropathy

Long-term, excessive consumption of alcoholic beverages produces a peripheral neuropathy with symptoms of decreased superficial sensation, hyperalgesia, and weakness. Alcoholic neuropathy is characterized by axonal degeneration with reduced density of both small and large fibers and axonal sprouting. Electrophysiologic studies reveal a marked reduction in the amplitude of sensory potentials and moderate slowing of nerve conduction, mainly in the lower extremities. Dietary deficiency of vitamins, which are often associated with chronic alcoholism, can contribute to the pathogenesis. Recent studies using animal models have identified several mechanisms by which ethanol impacts peripheral nerve function. Ethanol can exert direct neurotoxic effects on peripheral nerves via its metabolite acetaldehyde and by enhancing oxidative stress. Ethanol activation of protein kinase Cε signaling in primary afferent nociceptors plays an important role in lowering nociceptive threshold. Further, ethanol causes cytoskeletal dysfunction and inhibits both anterograde and retrograde axonal transport. Alcoholic neuropathy is potentially reversible and treatments include abstinence from alcoholic beverages and consumption of a nutritionally balanced diet supplemented with B vitamins. However, response to these treatment strategies can be variable, which underscores the need for novel therapeutic strategies. In this review, we provide an overview of the clinical findings and insights on molecular mechanisms from animal models.

Life stressors and resources and the 23-year course of depression

BACKGROUND

Life stressors and personal and social resources are associated with depression in the short-term, but little is known about their associations with the long-term course of depression. The current paper presents results of a 23-year study of community adults who were receiving treatment for depression at baseline (N=382).

METHODS

Semi-parametric group-based modeling was used to identify depression trajectories and determine baseline predictors of belonging to each trajectory group.

RESULTS

There were three distinct courses of depression: high severity at baseline with slow decline, moderate severity at baseline with rapid decline, and low severity at baseline with rapid decline. At baseline, individuals in the high-severity group had less education than those in the moderate-severity group, and more medical conditions than those in the moderate- and low-severity groups. Individuals in the high- and moderate-severity groups evidenced less psychological flexibility, and relied more on avoidance coping than individuals in the low-severity group.

LIMITATIONS

Results are limited by use of self-report and lack of information about depression status and life events in the periods between follow-ups.

CONCLUSIONS

These results assist in identifying groups at high risk for a long-term course of depression, and will help in selecting appropriate interventions that target depression severity, coping skills and management of stressors.

A qualitative study of alcohol, health and identities among UK adults in later life

Increasing alcohol consumption among older individuals is a public health concern. Lay understandings of health risks and stigma around alcohol problems may explain why public health messages have not reduced rates of heavy drinking in this sector. A qualitative study aimed to elucidate older people's reasoning about drinking in later life and how this interacted with health concerns, in order to inform future, targeted, prevention in this group. In 2010 a diverse sample of older adults in North East England (ages 50–95) participated in interviews (n = 24, 12 male, 12 female) and three focus groups (participants n = 27, 6 male, 21 female). Data were analysed using grounded theory and discursive psychology methods. When talking about alcohol use older people oriented strongly towards opposed identities of normal or problematic drinker, defined by propriety rather than health considerations. Each of these identities could be applied in older people's accounts of either moderate or heavy drinking. Older adults portrayed drinking less alcohol as an appropriate response if one experienced impaired health. However continued heavy drinking was also presented as normal behaviour for someone experiencing relative wellbeing in later life, or if ill health was construed as unrelated to alcohol consumption. Older people displayed scepticism about health advice on alcohol when avoiding stigmatised identity as a drinker. Drinking patterns did not appear to be strongly defined by gender, although some gendered expectations of drinking were described. Identities offer a useful theoretical concept to explain the rises in heavy drinking among older populations, and can inform preventive approaches to tackle this. Interventions should engage and foster positive identities to sustain healthier drinking and encourage at the community level the identification of heavy drinking as neither healthy nor synonymous with dependence. Future research should test and assess such approaches.

Pain and use of alcohol in later life: prospective evidence from the health and retirement study

OBJECTIVE

To determine whether (a) late-life pain predicts growth in older adults' use of alcohol, and elevated risk of drinking problems; and (b) sociodemographic characteristics moderate these relationships.

METHOD

Five times over an 8-year interval, N = 5,446 Health and Retirement Study (HRS) participants provided information about their pain and alcohol use. Two-part latent growth modeling and logistic regression were used to analyze these data.

RESULTS

Participants with more pain at baseline had lower initial levels and a faster rate of decline over the next 8 years in alcohol consumption, but they also were at elevated risk of having drinking problems. Income and African American background interacted with pain to predict 8-year change in alcohol consumption and presence of drinking problems.

DISCUSSION

Late-life pain does not predict growth in older adults' alcohol consumption, but is nonetheless linked to elevated risk of drinking problems, especially among African Americans.

Alcohol dependence as a chronic pain disorder

Dysregulation of pain neurocircuitry and neurochemistry has been increasingly recognized as playing a critical role in a diverse spectrum of diseases including migraine, fibromyalgia, depression, and PTSD. Evidence presented here supports the hypothesis that alcohol dependence is among the pathologies arising from aberrant neurobiological substrates of pain. In this review, we explore the possible influence of alcohol analgesia and hyperalgesia in promoting alcohol misuse and dependence. We examine evidence that neuroanatomical sites involved in the negative emotional states of alcohol dependence also play an important role in pain transmission and may be functionally altered under chronic pain conditions. We also consider possible genetic links between pain transmission and alcohol dependence. We propose an allostatic load model in which episodes of alcohol intoxication and withdrawal, traumatic stressors, and injury are each capable of dysregulating an overlapping set of neural substrates to engender sensory and affective pain states that are integral to alcohol dependence and comorbid conditions such as anxiety, depression, and chronic pain.