Patients with Chronic Pain and a Substance Use Disorder May Have Better Pain Outcomes with More Intensive Treatments

Many patients with chronic pain have a current or past substance use disorder (SUD). This study included patients recruited from Veterans Administration primary-care clinics for a clinical trial comparing treatment as usual (TAU) with a collaborative care initiative (CCI) for management of chronic pain. The initiative included collaboration between a psychologist case manager and an internist to develop treatment recommendations. The primary outcome was pain disability as self-reported on the Roland-Morris Disability Questionnaire. A 30% improvement was considered clinically significant. Among those patients who completed baseline and 12-month follow-up evaluations (n=362), 20% had a history of SUD.

• Patients assigned to CCI were more likely to have improvement in pain-related disability than those assigned to TAU (22% versus 14%, respectively).

• Patients with an SUD were younger, less likely to be married or cohabitating, reported greater pain-related disability, and were more likely to be prescribed an opioid. They were also more likely to have current major depression or post-traumatic stress disorder.

• In the TAU group, patients with an SUD were less likely to have improvement in pain-related function (adjusted odds ratio [AOR], 0.30; 95% CI, 0.11–0.82).

• In contrast, no difference in improvement was detected between those with and without an SUD in the CCI group (although the confidence interval was wide) (AOR, 1.06; 95% CI, 0.37–3.01).

Comments:

This study reinforces the challenges of treating chronic pain in patients with a coexisting SUD, but it also provides hope that more intensive treatment models may be effective for this population. In fact, it appears that in the CCI group, having an SUD no longer decreased the likelihood of a good outcome. This was not true for the TAU group. This finding stresses the need for additional studies specifically targeting this population.

Darius A. Rastegar, MD

Reference:

Morasco BJ, Corson K, Turk DC, et al. Association between substance use disorder status and painrelated function following 12 months of treatment in primary care patients with musculoskeletal pain. J Pain. September 16, 2010 (E-pub ahead of print).