Chronic Pain Associated with Substance Use, Self-Medication in Primary Care

Chronic pain is among the most common chief complaints in primary care and many patients treated for substance use disorder report it. This cross-sectional secondary analysis of baseline data from a randomized brief counseling trial included 589 adults in a hospital primary care practice who screened positive for illicit drug use or non-medical use of prescription drugs (NMUPD) based on the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) for past 3 month use (scores range 0–39).

• 50% reported severe chronic pain, 24% moderate, and 13% mild, based on scores on the validated Graded Chronic Pain Scale (scores: none [0], mild [1–3], moderate [4–6] and severe [7–10]). Similar proportions of those with high-risk drug use (ASSIST ≥ 27) and lower to moderate-risk drug use (ASSIST 2–26) had severe pain. Three-quarters reported pain-related dysfunction.
• Those with severe pain were more likely to be older, Latino, less educated, less healthy, unemployed, more depressed or anxious, and have lower overall health status. They were less likely to report alcohol use and more likely to have had a hospitalization and emergency department visit in the prior 3 months.
• Of the 121 with NMUPD, 81% reported substance use to treat pain.
• Of the 576 who reported marijuana, cocaine, or heroin use in the prior 3 months, 51% reported use to treat pain.
• Of the 57 who had high-risk alcohol use (ASSIST ≥ 27), 79% drank to treat pain, compared with only 38% of the 265 with any unhealthy alcohol use in the prior 3 months.

Comments:

This study affirms the well-described associations among substance use, chronic pain, mental health problems, poor health, and socioeconomic vulnerability. Notably, the association between substance use and chronic pain held true regardless of severity of use, which suggests that “self-medication” for pain contributes to continued substance use and return to use even among those with mild substance use problems. Empirical research is needed to demonstrate the study’s implication that the assessment and management of chronic pain might improve the impact of treatments to reduce substance use in primary care settings.

Peter D. Friedmann, MD, MPH

Reference:

Alford DP, German JS, Samet JH, et al. Primary care patients with drug use report chronic pain and self-medicate with alcohol and other drugs. J Gen Intern Med. 2016;31(5):486–491.