Pain and Substance Use — A Reciprocal Model

By Lindsey Getz

Pain and substance use can interact in a cycle that can ultimately worsen and maintain both chronic pain and substance use and misuse, according to new research. This is important information for social workers to keep in mind as they work with clients who face these challenges.

In the research, recently published in the Annual Review of Clinical Psychology, researchers Joseph W. Ditre, PhD; Emily L. Zale, PhD; and Lisa R. LaRowe, MS, examined results from more than 100 studies on pain and substance use. The team then integrated these findings to propose a reciprocal model in which pain and substance use interact in the manner of a positive feedback loop, resulting in greater pain and continued substance use.

“Research studies usually examine either how substance use affects pain or how pain affects substance use,” explains Zale, an assistant professor in the department of psychology and director of the Substance Use, Pain, and Health Research Lab at New York’s Binghamton University. “But our reciprocal model puts these two different types of research together to understand how pain and substance use affect each other.”

On one hand, substance use can be a risk factor for chronic pain and may worsen pain over time. On the other hand, experiencing pain can motivate people to use substances and might make it harder to quit, Zale adds.

“We propose that the two conditions interact in the manner of a positive feedback loop, which means that they can increase each other over time,” she says. “Another way to think about this relationship is as a vicious cycle—substance use can worsen pain, pain can motivate escalations in substance use or make it harder to quit—and these repeated cycles can result in more severe pain and worsening addiction.”

“Neither patients nor providers tend to be aware of how pain and substance use can interact in this reciprocal way,” adds lead author Ditre, an associate professor in the department of psychology and director of the Pain and Addiction Research Lab at New York’s Syracuse University. “But this is important when it comes to better understanding why some individuals have a harder time quitting substances than others. One goal of our research program is to examine understudied factors that might be contributing to not only their use but their ability to stop. The role of acute and chronic pain in the onset and maintenance of substance addiction warrants additional consideration.”

Zale adds that while it is easy to think of pain in terms of opioid use, their research looked at other substances, including alcohol, cannabis, and cigarettes.

“When you think of someone drinking alcohol in greater quantities than would be healthy or someone who is smoking, it is quite likely that these individuals may be experiencing pain—and that is likely to both motivate their substance use as well as serve as a barrier to quitting,” Zale says.

An Altered Approach to Treatment
As a result of these findings, clinicians who treat substance use disorders should assess their patients for chronic pain, and consider addressing pain during their treatment, Ditre and Zale say.

“Social workers are often looking at the wholistic vision of what is going on with someone who is using substances—and the factors that might contribute to their quitting,” Zale says. “Pain absolutely needs to be something on the roadmap to consider. Just like any other trigger—such as the proximity to a bar or someone else in the home who smokes—pain should be looked at as a risk factor in the assessment of their substance use and the ability to potentially quit.”

Of course, given the reciprocal link, Ditre says that social workers must also bear in mind that pain can also be a motivation to quit.

“In the field of psychology, we often talk about opportunities to address the attitudes that individuals have toward substance use,” Ditre adds. “It’s possible that because pain is such a big part of peoples’ lives—and something that they very much want to reduce—that if we’re able to tie their substance use to their pain, this could provide them with a novel reason to stop using substances.”

Ditre says that people already know that drinking too much—or smoking—is bad for their health. So, messaging that is primarily focused on those facts does not always resonate strongly; they already understand that. But if you can tie the messaging to their pain, Ditre says this could be a factor that tips the scale; this could potentially be a reason they ultimately quit.

“Of course, there is a level of complexity here and as much as their pain experience could give them a reason to quit, our research also indicates that they may experience increased sensitivity to pain during the withdrawal period,” Ditre continues. “This is why it’s so important that this is recognized and addressed by clinicians. It can be explained that increased pain is a short-term result but that the long-term result will be better-managed pain in the future.”

“Addressing adaptive pain coping strategies will be important,” Zale adds. “Social workers must make sure that if their client was using substances to cope with pain, that you are replacing it with other pain coping strategies.”

In terms of healthy coping strategies, the research strongly points in the direction of cognitive behavioral strategies such as acceptance and commitment therapy that looks to change the relationship one has to pain.

Looking Ahead
Ditre and Zale are pursuing multiple avenues of research, including studies to better understand the reasons that pain and substance use get caught in a cycle, and studies to develop treatments that can help break the cycle. Both say that the need for additional research is important.

“This is such an important area of research and we are currently developing and testing treatments focused on educating people as to what emerging science is telling us about the role that pain plays in substance use,” Ditre says.

Even in just the context of smoking cessation, addressing pain presents a lot of opportunity, Ditre adds.

“Nicotine may reduce pain in the short term and though nicotine patches are widely used to help cope with withdrawal symptoms, we never really think about them in the context of offsetting pain,” he says. “That could create a whole different reason to use them. If an individual is living with a painful condition for which they might be smoking to cope, then the ability to use nicotine patches to address that pain in the short term could be one of the most compelling reasons they’ve heard. By presenting this option, you might also increase adherence.”

Zale has established the Substance Use, Pain, and Health Research Lab and is currently collaborating with other Binghamton researchers to better understand the development of pain and substance use in adolescents and young adults.

“With more than 100 million people in the United States who experience chronic pain, this is an issue that needs to remain at the forefront,” she says. “If you’ve struggled to find something that has worked for your clients in the past, then it’s time to consider that there is likely a good portion of your clientele who are also experiencing pain—and determine whether this link could impact their ability to quit.”

Ditre agrees. “Pain is such an important contributor to substance use and one that should be increasingly acknowledged,” he adds. “Given our findings related to its reciprocal nature, it is something that social workers could benefit from including in not only their assessment toolbox but also their treatment toolbox.”

— Lindsey Getz is a Royersford, PA–based freelance writer.