Pain in Patients with Substance Use Disorder

Pain in patients with substance use disorder concerns the assessment and treatment of pain in people who have, or are at elevated risk for, a disorder involving the use of opioids, alcohol, or other substances. It is a distinct topic within pain medicine because these patients may experience pain differently, because tolerance and altered drug responses change how analgesics behave, and because the use of opioid analgesics carries particular risks that must be weighed against the obligation to treat pain.

Definition

Pain in patients with substance use disorder refers to the recognition and treatment of acute or chronic pain in individuals with a current, past, or high-risk substance use disorder, in whom altered drug tolerance and the risks of analgesic misuse complicate the balance between adequate pain relief and harm.

Scope

This entry covers the bidirectional relationship between chronic pain and substance use, altered analgesic response in the context of tolerance, the framing of risk-benefit and monitoring in opioid prescribing guidelines, and the public-health context of opioid misuse. It is a reference topic and does not provide dosing, prescribing, or individualized treatment advice.

Core questions

• How are chronic pain and substance use disorder related to one another?
• How does tolerance alter the response to opioid and other analgesics?
• How do prescribing guidelines frame the balance between treating pain and limiting risk?
• What is the public-health context of opioid misuse that shapes this topic?

Key concepts

• Bidirectional pain and substance use relationship
• Tolerance and altered analgesic response
• Risk-benefit balance in opioid prescribing
• Monitoring and risk-mitigation strategies
• Undertreatment versus overprescribing tension
• Public-health context of opioid misuse

Mechanisms

Pain and substance use disorder interact in both directions: chronic pain can contribute to substance use, and substance use can in turn affect pain perception and treatment. Tolerance, particularly to opioids, alters the relationship between a given dose and its effect, complicating analgesic decisions. Opioid analgesics, while effective for some pain, carry risks of misuse, opioid use disorder, and harm, which is why prescribing guidelines emphasize assessing risk, weighing benefit against harm, and monitoring (Chou et al., 2009; Dowell, Haegerich & Chou, 2016). Systematic review evidence has examined how often long-term opioid use for chronic pain is associated with misuse or addiction (Martell et al., 2007), situating clinical decisions within a documented tension between undertreatment and overprescribing.

Clinical relevance

This topic is central to safe and equitable pain care, because patients with substance use disorder are at risk both of having their pain undertreated and of harm from analgesics. The entry is descriptive reference material about how this balance is conceptualized in the literature and guidelines; it is not a guide to prescribing, dosing, or individualized management.

Epidemiology

Substance use disorders, including opioid use disorder, are common in the general population, and national survey data document substantial prescription opioid use, misuse, and use disorder among adults (Han et al., 2017). Chronic pain frequently co-occurs with substance use, and the rise in opioid-related harm in several countries provided the public-health backdrop for prescribing guidelines (Dowell, Haegerich & Chou, 2016).

History

Concern about pain in patients with substance use disorder intensified as long-term opioid prescribing for chronic non-cancer pain expanded and as evidence accumulated on misuse and addiction (Martell et al., 2007). Professional and public-health guidelines were issued to structure risk assessment and monitoring (Chou et al., 2009; Dowell, Haegerich & Chou, 2016), reflecting an ongoing effort to reconcile the duty to relieve pain with the imperative to limit harm.

Debates

How should opioids be used for chronic non-cancer pain in patients at risk for substance use disorder?

Guidelines weigh limited evidence of long-term benefit against documented risks of misuse and harm, and emphasize risk assessment, monitoring, and caution; balancing adequate analgesia against these risks remains a central and contested judgement.

Key figures

• Roger Chou
• Deborah Dowell
• David Fiellin
• Jane Ballantyne

Seminal works

• chou-2009
• dowell-2016
• martell-2007

Frequently asked questions

Why is pain treatment more complex in patients with substance use disorder?

These patients may have altered tolerance that changes how analgesics work, and opioid analgesics carry particular risks of misuse and harm, so clinicians must balance the duty to treat pain against the need to limit risk. The entry describes this balance rather than prescribing how to manage it.

Does having a substance use disorder mean a patient's pain should not be treated?

No. The literature stresses that patients with substance use disorder are at risk of having pain undertreated, and that pain should be assessed and managed; the added complexity concerns choosing approaches that balance relief against the risk of harm.