In Review
Assessment and Management of Chronic Pain in
Individuals Seeking Treatment for Opioid
Dependence Disorder
Michael R Clark, MD, MPH1; Kenneth B Stoller, MD2; Robert K Brooner, PhD3
496 La Revue canadienne de psychiatrie, vol 53, no 8, août 2008
Objective: To review the problem of chronic pain in patients with substance use disorders, focusing on the
prevalence of chronic pain in patients with substance dependence disorders, especially prescription opioid
dependence, associated comorbidities, and the impact on drug abuse treatment response.
Method: We identified relevant articles using PubMed from 1987 to 2008. Additional articles were
obtained from the reference lists of key reviews of relevant topics. Studies were included if they
investigated the relation between chronic pain and substance use disorders. Of particular interest were
articles that proposed integrated treatment for both problems.
Results: The high prevalence of chronic pain syndromes was only recently explored in patients seeking
treatment for drug abuse. The presence of chronic pain increases the risk of poor response to substance
abuse treatment and an increased likelihood of multiple comorbidities that further add to the negative impact
experienced by patients with substance dependence disorders. Substance abuse treatment programs offering
integrated medical and psychiatric care for these comorbidities improve outcomes, with stepped care
approaches offering the best treatment by tailoring the level of care to the individual patient’s needs.
Conclusions: Substance abuse treatment programs should expand their services to address the
comorbidities likely to pose barriers to successful drug rehabilitation. Given the high prevalence and
negative impact of chronic pain, new pain management services should be integrated within the drug
treatment program and adapted as patients demonstrate the need for more intensive treatment. If applied to
the problem of chronic pain, a model substance abuse treatment program of integrated stepped care would
improve outcomes for patients with both devastating disorders.
Can J Psychiatry 2008;53(8):496–508
Clinical Implications
Chronic pain is a common problem in patients seeking treatment for substance dependence disorders, especially
prescription opioid dependence.
Similar to other important comorbidities, without appropriate treatment, chronic pain has a negative impact on
patients’ response to drug abuse treatment.
Integrating treatment for medical and psychiatric disorders with substance abuse treatment improves outcomes;
novel approaches for providing chronic pain treatment in substance abuse treatment programs would enhance the
care of these high-risk patients and improve outcomes.
Limitations
Currently, treating chronic pain in patients with substance dependence disorders assumes patients are drug
seeking and without legitimate need for pain treatment.
Pain management resources are limited and avoid patients with known substance dependence disorders.
Integrating chronic pain treatment modalities into substance abuse treatment programs would require additional
costs in time, personnel, and medications.
Further research is needed to investigate the efficacy and effectiveness of novel approaches that would offer
integrated and (or) stepped care paradigms to patients with both chronic pain and substance abuse.
Key Words: chronic pain, addiction, dependence, substance
abuse, treatment, stepped care, integrated services
Chronic pain and substance abuse are independently recognized
as complex problems growing in scope and
severity. Each has its own unique difficulties that contribute to
poor outcomes and partial response to treatment.Asubstantial
and very unfortunate number of patients have both of these
devastating problems and constitute a highly stigmatized and
plainly underserved population who would benefit from additional
scientific and clinical attention. Practical guidance is
needed for the assessment, formulation, and treatment of
patients with chronic pain and substance dependence disorder.
Identifying opportunities and directions for additional
research are important elements to advancing our understanding
of these problems and their critically important
interrelations.
Patients with a partial and poor response to standard treatments
for chronic pain are at increased risk of being labelled a
drug addict when they request more aggressive pain therapy.
Whether they specifically ask for opioid analgesics or not,
practitioners will often assume the worst. In patients with
known substance use disorder, continuing complaints of pain
are routinely regarded simply as drug-seeking behaviour that
is undermining their recovery plan. Common approaches to
evaluating this complex set of problems often focus on determining
whether the patient has a real pain problem or is simply
an addict engaged in drug-seeking behaviours. This deliberation
has some clear and compelling features; however, the
dichotomy is usually oversimplified. The result is an inadvertent
underrecognition and undertreatment of chronic pain.
A third situation can arise when patients with unquestionable
chronic pain develop an independent substance use disorder
despite the most sincere, understandable efforts to seek pain
relief. The rush to judgment, often reflected in the evaluation
phase, can lead to the emphasis on only one dimension of the
presentation (for example, substance abuse or pain) that minimizes
the other dimension (pain or substance abuse). One
important element in the successful management of these
patients who present with features of both problems is tolerating
the ambiguity that can dominate the initial evaluation and
accepting that the question can be resolved with sufficient
time in treatment.
The remaining sections of this article review the background
relevant to appreciating the epidemiology of these problems,
continuing uncertainties and challenges in the evaluation and
treatment of chronic pain and substance use disorder, strategies
for the initial management of these patients’ treatment
while sufficient information is obtained to clarify the extent
and severity of these problems and their resulting therapeutic
concerns, and concludes with an overview of a promising
adaptive evaluation and treatment approach for patients with
complaints of chronic pain in the context of known opioid
dependence.
Defining Chronic Pain
Chronic pain is an internationally common problem. In the
general population, estimates of the point prevalence of
chronic pain in the United States range from 10% to 50%.1–5
The prevalence rates observed across these studies reflect
variations in the definition of chronic pain.6–9 Chronic pain
has numerous causes, produces profoundly detrimental
effects on physical, psychological, and social functioning,
and complicates the evaluation, diagnosis, and treatment of
related and unrelated medical and psychiatric disorders.10–14
The negative impact of chronic pain on the evaluation and
treatment of so many problems unfortunately extends to and
is amplified in people with opioid dependence and other drug
use disorders.
Important questions remain about how best to define and
measure chronic pain. The syndrome is defined using critical
cut-off values across relevant domains of duration, intensity,
and quality of the pain, combined with the effects of pain on
specific areas of physical and psychosocial functioning.1,3–5
Originally, the International Association for the Study of
Pain distinguished chronic pain from acute pain15,16 by defining
it as “pain without apparent biological value that has persisted
beyond the normal tissue healing time (usually 3
months).”15, p 18 Subsequent definitions of chronic pain have
proposed variations in the thresholds for duration, intensity,
impact on usual functioning, and expanded into other relevant
domains of the patients’ illness experience (for example,
use of rescue analgesics or rates of health care use).17
Numerous best practice recommendations were made in
recent years to guide clinical practice and research on chronic
pain.18,19 Relevant domains of the experience of chronic pain
include assessments of pain intensity and quality, physical
and emotional functioning, patient satisfaction and global
improvement, and changes specifically attributable to the
treatment of pain. In conjunction, the definition of chronic
pain used in numerous recent epidemiologic studies and recommended
by the World Health Organization now includes
the expanded criteria: pain should be present for most of the
time during at least 6 consecutive months; moderate-tosevere
pain intensity should occur during the course of the
episode; and impairment of functioning should be sufficient
to warrant discussion of the problem with a health care professional
or to motivate use of medication.2,6–9,20
Chronic Pain in Opioid-Dependent Patients
Numerous recent studies have turned attention to determining
the prevalence of chronic pain in individuals with opioid
Assessment and Management of Chronic Pain in Individuals Seeking Treatment for Opioid Dependence Disorder
The Canadian Journal of Psychiatry, Vol 53, No 8, August 2008 497
dependence and other substance use disorders. Similar to
findings in the general population, differences in the definition
of chronic pain have contributed to variability in prevalence
rates. For example, using a narrow definition that
required pain for at least 6 months and moderate or greater
intensity, or that significantly interfered with daily activities,
Rosenblum et al21 showed that 37% of patients in methadone
treatment programs met criteria for severe chronic pain. A
more recent study employed a less conservative definition of
chronic pain (requiring 6 months but eliminating the intensity
and interference criteria) and reported even higher rates
(55%) of chronic pain.22 Although prevalence rates vary, the
low (about 30%) and high end (about 60%) of the range are
higher than most general population estimates.21–27
While the higher rate of chronic pain in drug-dependent
patients is not surprising, it is cause for substantial concern.
Chronic pain in other populations is routinely associated with
poor psychosocial functioning and quality of life, poor
workforce attendance and productivity, increased rates of
psychiatric disorders, reduced financial well-being, poor
self-rated health, and increased health care use.3,9,14,28,29
Available studies suggest that all of these debilitating features
associated with chronic pain are similarly present and probably
more severe in opioid-dependent patients with chronic
pain. Efforts to determine what aspects of chronic pain are
most predictive of continued drug abuse as well as psychiatric
and physical impairments in drug-dependent populations
were hindered by the use of pain measures lacking a comprehensive
and multidimensional framework.30–32
Relation Between Substance Use Disorders and
Chronic Pain Conditions
Beginning in the late 1990s, a more than 2-fold increase in
lifetime abuse and a nearly 3-fold increase in past-month
abuse of prescription opioids occurred in the United States.33
The Researched Abuse, Diversion and Addiction-Related
Surveillance System reported that prescription opioid abuse
has become widely prevalent.34,35 Increases associated with
the abuse of oxycodone and hydrocodone products are particularly
alarming. Results from a study of poison control centres
found that hydrocodone was the most widely prescribed
opioid with the highest rate of intentional exposure
(nonmedical use) in the general population.36 In contrast, rates
of intentional exposure for methadone were highest in clinical
samples. Increases in methadone diversion and abuse, primarily
in tablet form (that is, likely to be prescriptions for pain
management rather than take-home dosages from opioid
treatment programs) were also reported.37 This inflection
point appeared to coincide with efforts to encourage pain
identification and treatment by physicians in conjunction with
the marketing of opioid analgesics for the treatment of chronic
nonmalignant pain conditions. From 1997 to 2002, the medical
use of commonly prescribed opioids markedly increased:
morphine 73%, hydromorphone 96%, fentayl 226%, and
oxycodone 403%.38
McCracken et al39 studied the concerns of patients with
chronic pain about medications and their use. Several patterns
of nonadherence to or misuse of prescribed medications
were characterized. Taking more medication than prescribed
was associated with patients’ concerns about addiction, tolerance,
withdrawal, excessive scrutiny of medication use by
others, and a greater perceived need for medication. In a similar
study, chronic pain patients with a history of substance
abuse were more likely to believe that: narcotic medications
are more effective for pain, narcotic use will improve their
mood, they would be able to function better with free access
to these medications, and they need higher amounts of narcotics
to experience pain relief, compared with other
patients.40 Although patients achieved about 50% pain relief
and were prescribed similar narcotic dosages, compared with
patients without a history of substance abuse, they were significantly
more likely to misuse their prescribed medications
if they believed they required higher dosages of pain medications
than others and their pain control would improve if they
had control of the medication. These findings highlight the
complexity of managing a patient with both chronic pain and
a substance use disorder. Although patients with a history of
substance abuse experienced a significant reduction in pain
with treatment, there misuse of medications could still be a
manifestation of their chronic pain disorder and not simply a
reactivation of their addiction.
During the first 5 years after the onset of a chronic pain problem,
patients are at increased risk for developing new drug
use problems and disorders.41,42 The risk was highest among
those with a history of drug use disorder or psychiatric
comorbidity.43–47 Studies also show that opioid-dependent
patients with chronic pain have higher rates of drug use than
those without chronic pain.21,22,25,48 For example, chronic
pain patients receiving methadone for opioid dependence
have higher rates of illicit drug use (such as opioids,
benzodiazepines, and cannabis) than patients without
chronic pain. A more recent study49 examined the hypothesis
that persistent pain increases the risk of relapse into substance
use after detoxification. In a 24-month follow-up
study of 397 adults with heroin, alcohol, or cocaine abuse,
54% reported intermittent pain and 16% had persistent pain,
both associated with increased use of any substance (OR 4.2),
and specifically, opioids (OR 5.4).
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In Review
Relation Between Prescription Opioid Abuse
and Chronic Pain
Little information is known about the characteristics of individuals
abusing prescription opioids. Certainly, pain may
motivate people to use licit and illicit drugs.50,51 For example,
45% of patients in methadone maintenance treatment believed
that opioids prescribed for pain led to their addiction.25 In
another study, 31% of patients with controlled-release
oxycodone dependence admitted to an inpatient drug abuse
treatment facility reported controlled-release oxycodone was
initially obtained from a physician for a medical indication
such as pain.52
Another retrospective review assessed prescription opioid
abuse by patients entering methadone treatment.30 In general,
prescription opioid-dependent patients were significantly
more likely to have a history of or ongoing problems with pain
than heroin-dependent patients. Notably, 24% used only prescription
opioids (that is, not heroin) and most of them (86%)
reported that pain was the reason they began using opioids.
Another 24% of the overall sample had used prescription
opioids, but subsequently switched to heroin. Among those
patients, 62% reported pain as the primary reason for starting
to use opioids. Interestingly, data from this study also suggested
that the group with prescription opioid abuse had better
rates of treatment retention.
Unfortunately, the substance use disorders of chronic pain
patients also tend to be severe. Passik et al53 conducted a prospective
survey of chronic pain patients abusing prescription
opioid entering a drug abuse treatment facility. Surprisingly,
84% reported legitimately receiving a physician’s prescription
for pain treatment. However, 91% purchased prescription
opioids through illegitimate sources and 80% altered the
delivery system of the prescription drug. These studies suggest
different circumstances under which individuals arrive at
opioid dependence (such as, prior substance abuse, compared
with no prior substance abuse, and obtaining the opioid from a
physician for a legitimate medical indication, compared with
illicit acquisition). Unfortunately, other than a history of substance
abuse, the characteristics of patients prescribed opioids
initially to treat chronic pain that would reliably predict who
will progress to problematic use of the medication are still
largely unknown.
Comorbid Psychiatric Conditions in Patients
With Chronic Pain and Opioid Dependence
Chronic pain is associated with rates of psychiatric disorder
that routinely exceed general population estimates.54–65 The
increased use of prescribed opioids was shown more strongly
associated with anxiety and depressive disorders than drug
abuse disorders.66 The complexity of these relations is
enhanced by the generally high rates of psychiatric
comorbidity detected in opioid-dependent patients in methadone
treatment. For example, studies consistently report high
rates (50%) of psychiatric comorbidity in opioid-dependent
individuals seeking outpatient methadone treatment.67–72
Similar findings were reported in studies on chronic pain
conducted in methadone treatment programs.21,24,25 However,
these studies did not assess associations between psychiatric
comorbidity and chronic pain. The relation between
the increased rates of psychiatric problems reported in prior
studies of chronic pain in methadone treatment patients and
the high rates of psychiatric comorbidity often reported in
methadone treatment settings remains unclear.
Effect of Chronic Pain on Response to Drug
Abuse Treatment
Chronic pain was shown to negatively affect the course and
outcome for an array of medical and psychiatric
problems.73–75 Similar findings were reported in studies of
opioid-dependent patients receiving outpatient drug abuse
treatment with methadone and counselling. Conceptually,
there are at least several ways that chronic pain could alter
and interfere with the response to drug abuse treatment:
chronic pain could increase illicit drug-seeking motivation
and drug-taking behaviour to reduce pain symptoms; chronic
pain could increase the motivation to use illicit drugs that produce
euphoria to improve subjective well-being and quality
of life of these already demoralized patients; chronic pain
symptoms and impairment are associated with the presence
of other psychiatric disorders, many of which were shown to
decrease response to drug abuse treatment; and chronic pain
is often associated with disability that reduces psychosocial
activity and subsequently hinders seeking or sustaining
employment or attending drug abuse treatment sessions,
common problems independently associated with reduced
drug abuse treatment response (see Currie et al,76 Fuller
et al,77 Kidorf and Brooner,78 Kidorf et al,79–82 Trafton et al,48
Weaver and Schnoll51).
Psychiatric and medical disorders in patients with substance
abuse were shown to predict poorer outcomes to drug abuse
treatment. While studies generally report much higher rates
of drug use, psychiatric problems, and functional impairments
in patients with opioid dependence complicated by
chronic pain, associations between chronic pain and response
to outpatient methadone treatment were inconsistently
reported in a small group of studies.83,84 For example, Peles
et al22 showed that opioid-dependent patients in methadone
maintenance therapy, who reported chronic and severe pain,
submitted a greater proportion of sedative-positive urine
specimens than those without chronic pain. A similar study
found that opioid-dependent patients with chronic pain in
drug abuse treatment including methadone maintenance
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The Canadian Journal of Psychiatry, Vol 53, No 8, August 2008 499
therapy exhibited higher rates of misuse of drugs with analgesic
and sedating effects (opioids, sedatives).48
A more recent study reported a different pattern of results
showing all patients, regardless of chronic pain, experienced
comparable reductions in substance use with standard methadone
maintenance treatment.24 However, patients with pain
remained significantly more impaired in other domains of
physical and psychosocial functioning. A comparable study
examined the outcome of long-term methadone treatment for
chronic pain and problematic opioid use patients.85 Good pain
relief was achieved by 75% of patients on an average methadone
dosage of 82 mg/day. Quality of life and function significantly
improved; however, the study was limited by a small
sample size, high drop-out rates, and severe adverse events.
The authors concluded that long-term methadone for chronic
pain is a complex treatment process that should involve a
multidisciplinary team with “meticulous follow-up.”85, p 277
Unfortunately, most of these studies provide little information
on the scope of treatment services offered to patients (such as,
number of individual and group counselling sessions, and
urine testing schedules and procedures), and even less information
on the amount of treatment services they actually
received and how the treatment influenced the course of
chronic pain.
Ideally, substance abuse treatment should use a highly structured,
adaptive, stepped care approach with behavioural
incentives to motivate patient adherence.86–88 Many services
constituting routine substance abuse treatment in a program
with well-described outcomes, including the use of coping
skills training, significant other support, and incentives to
increase patient adherence, are recognized as important
aspects of good rehabilitative care for all people with chronic
health problems, including chronic pain syndromes.89–96
These features of effective substance abuse therapy could
indirectly benefit chronic pain because of an increase in general
function attributable to learning new skills coupled with
abstinence from drug use.
However, substance abuse treatment may directly decrease
chronic pain. For example, methadone may also provide
patients with analgesic benefits. In a study of opioiddependent
patients, those with severe chronic pain received
higher dosages of methadone, compared with those without
chronic pain.22 While higher dosages may reflect attempts to
treat pain, indicators of substance abuse treatment outcomes
were worse for this group, suggesting a more severe substance
abuse disorder. The relations between chronic pain and treatment
of substance use disorders still need clarification.
Assessment of Chronic Pain in
Opioid-Dependent Patients
The obvious risks of patients misusing or abusing analgesic
medications in the context of opioid and other drug dependence
disorders is clearly mitigated, to some extent, by the
substantial risks of undertreating pain. The undertreatment of
pain was reported as disproportionately more problematic in
patients with substance use disorders, including those receiving
long-term methadone maintenance therapy.27,97 Most
experts agree, the systematic undertreatment of chronic pain
can inadvertently increase drug use and the overall severity
of a drug dependence disorder.48,98–100 However, detecting
and evaluating the misuse of prescribed opioids in patients
with chronic pain and an opioid or other substance use disorder
remains a challenge.45,101–103
Practitioners struggle with the diagnosis of drug dependence
(that is, addiction) in patients receiving opioids for pain management.
Regardless of chronic pain presence or prescribed
opioid treatment, patients with substance use disorders still
manifest the same criteria of their disorder: loss of control
over drug use; compulsive drug use; and continued drug use
despite harm, including deteriorations in function.104,105
While aberrant medication-taking behaviours are not uncommon
in chronic pain patients, all patients need ongoing
assessment about how any aspect of their condition and its
treatment is affecting their functioning.106,107 If function is
stable and productive, then the problems are likely addressed
and treatment is probably safe and effective. If function is
deteriorating, then the cause (such as, addiction, cognitive
impairment, psychiatric disorder, diversion, worsening pain,
and medical problems) must be sought and defined so that
specific modifications to the treatment plan can be implemented.
This pragmatic approach to patient care in real time
helps resolve continuing philosophical debates over concepts
of beneficence, nonmalfeasance, therapeutic dependence,
pseudoaddiction, and subtle withdrawal phenomena.42,108,109
The question is not if patients with substance use disorder and
chronic pain should ever be treated with opioids but how the
medication should be used when the need arises.
Treatment of Chronic Pain With Opioids in
Opioid-Dependent Patients
Long-term opioid use for the treatment of chronic pain
remains controversial and may be complicated by numerous
adverse outcomes.110,111 Systematic reviews of chronic
opioid therapy for chronic pain have failed to solidify support
for this practice, citing lack of efficacy, limitations in design,
sample size, and inadequate follow-up.112,113 A qualitative
study of patients in methadone maintenance with chronic
pain characterized the themes of patients unable to obtain
adequate pain treatment, having difficulty fulfilling
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In Review
responsibilities owing to pain, and holding beliefs that methadone
was causing pain. Patients often feared that other opioids
taken for pain would worsen their addiction or even create a
new addiction.26
Numerous guidelines were established for the treatment of
chronic nonmalignant pain with opioids.111 All versions
attempt to codify the common sense principles embodied in
careful assessment and close follow-up: opioid therapy has
risks, some of these risks are greater in individuals with substance
use problems, nonopioid modalities of pain treatment
should be emphasized (such as, medications, cognitivebehavioural
psychotherapy, physical therapy, interventions
such as nerve blocks, epidural steroids, and complementary–
alternative medicine); second opinions and consults should be
regularly obtained; sustained-release opioid preparations are
preferred over short-acting ones; and the goals of treatment
should be closely monitored with a focus on pain relief and
improved function while minimizing drug-related adverse
events and aberrant drug-taking behaviours.51 Scimeca et al27
reviewed the principles of treating pain in patients receiving
methadone maintenance. Similarly, their approach emphasized
the need for a careful assessment with detailed evaluation
of pain and all comorbidities, appropriate analgesia with
other mu agonists added to methadone, and close monitoring
with a team of professionals.
An interesting study of opioid treatment investigated aberrant
drug-related behaviours in patients with HIV-related pain and
a history of substance abuse, compared with patients with cancer
pain and no history of substance abuse.114 The HIV
patients reported more than twice as many aberrant
drug-related behaviours. Inadequate pain relief from prescribed
analgesic therapy was associated with the following
actions: raising the dosage of opioids on one’s own, telling
family members that they would use street drugs to relieve
pain, using more opioids than the physician recommended,
and using opioids to treat other symptoms. Aberrant drugtaking
behaviours were predicted better by demographics,
drug abuse history, and psychological distress than by
pain-related variables. Therefore, the emphasis in treatment
should be on behaviour and function, past and present. While
pain relief is an important outcome, the deterioration in a
patient’s function and the emergence of aberrant drug-taking
behaviours are red flags for providing more intensive treatment.
Although it is likely the need is for more intensive substance
abuse treatment, reexamining the patient’s pain
treatment plan should also be performed.
As noted, one of the more important aspects of successful
management of patients with both chronic pain and substance
use disorder is avoiding the trap of deciding whether pain
complaints are real or a manifestation of drug-seeking. This
trap leads to a premature and uninformed guess about the need
to focus treatment on either pain or substance abuse. The initial
assumption is simple. Their pain complaints are real and
not a substance abuse manifestation but a request for treatment.
Until what treatment forms should be used are clear,
treatment should address both problems simultaneously (Figure
1). Patients should be initiated into therapy with a comprehensive
evaluation of the characteristics and severity of
their specific problems. If more than one problem exists, a
multidisciplinary treatment plan should be formulated. The
patient’s ongoing response to treatment for each problem
should be assessed frequently. The problem- specific outcome
measures should then guide the degree to which each
problem receives more intensive therapy. Despite best intentions,
this approach usually devolves to an excessive focus on
one problem coupled with an inadequate focus on the other
problem. First, it is crucial to remember that patients with
both disorders require ongoing careful evaluation for both.
Second, an ongoing discussion with patients and family
about their response to treatment should occur regularly.
Finally, how the continuing plan of care will be modified
should be clear to all parties. These basic principles of treatment
form the foundation of a program designed to motivate
patients in treatment and adapt to individual needs to insure
successful outcomes.
Enhancing Treatment: New
Recommendations for Integrated Approaches
The common interactions between chronic pain, opioids, and
other drug use problems, and other medical and psychiatric
problems, makes treatment-seeking, opioid-dependent
patients a critically important subgroup of patients with a
compelling need for enhanced evaluation and treatment
services.98–100 Regrettably, patients with chronic pain and
substance use disorder (especially opioid dependence)
remain a largely stigmatized, maligned, and often neglected
population.21,23 This clinical and public health mismatch
likely increases the risk for drug-seeking behaviour in these
patients, including self-medication with illicit drugs and the
serious associated hazards.
While substance abuse treatment is generically recommended,
there is little discussion about how routine substance
abuse treatment can accommodate the needs of a
patient with a comorbid chronic pain syndrome. The level of
difficulty associated with managing these patients is
increased by the infrequent assessment typical of routine
chronic pain and drug abuse treatment programs, in addition
to their often inaccurate and underreported prescription medication
and illicit drug use.115,116 Some of these problems
would be reduced if routine treatment was modified to: incorporate
ongoing detailed assessments that begin with an
extensive history of prior pain and drug use problems;
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The Canadian Journal of Psychiatry, Vol 53, No 8, August 2008 501
provide for testing of weekly urine specimens for opioids
(prescribed and illicit) and other drugs; and offer appropriate
positive reinforcements for reporting the use of opioids prescribed
by other practitioners to account for the detection of
these potentially illicit substances in their urine specimens.
Interestingly, most research and clinical recommendations
discuss how to use opioids for the treatment of pain in people
with substance use disorders. There is comparatively little discussion
about whether other modalities of therapy may be
more effective, safe, and appropriate. The assumption that
opioids are first-line therapy in this population further stigmatizes
these patients by implying that a comprehensive evaluation
and treatment plan usually provided to patients without
substance use disorders should only be implemented as a last
resort for patients with both drug abuse and chronic pain. This
recommendation simply accepts that patients with substance
use disorder do not have access to high-quality medical care
and reinforces the belief that they do not deserve it or that they
would reject any alternative to opioid-based treatments.
For example, only brief mention is made of nonopioid medications
for the treatment of neuropathic pain problems,
interventional approaches for reducing musculoskeletal pain,
and active physical therapies for enhancing efforts of rehabilitation.
Multidisciplinary pain treatment programs have not
been incorporated into substance abuse treatment programs,
which are not staffed to provide pain evaluation and management.
Multidisciplinary pain treatment programs usually
seek to avoid patients with clear opioid dependence. The
so-called hot potato patient with both problems receives
inadequate or no treatment thereby decreasing any chance for
improvement and success.
A recent report from an ongoing randomized trial is already
showing that integrating specialized psychiatric treatment
services (pharmacotherapies and psychotherapies) in a substance
abuse treatment setting is associated with significant
improvement in the number of people receiving care,
amounts of service received, psychiatric symptoms, weekly
urine test results, and self-report ratings of response to
treatment.117,118 This pattern of findings was also shown in
studies integrating a limited number of primary care or
obstetric services into drug abuse treatment settings.119,120
The rationale is strong for assuming that similar success
would be achieved from the integration of on-site evaluation
and treatment of chronic pain into large substance abuse
treatment settings managing people with opioid dependence.
A study of patients with both chronic pain and substance use
disorder showed that a 10-week outpatient group therapy for
pain management integrated with a multidisciplinary
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Intake assessment
Complete history
Examination: physical, mental
Multidimensional evaluation
Structured interviews
Standardized questionnaires
Treatment initiation
Induction process: steps of care
Multidisciplinary therapy
Symptom reduction
Outside consultations and referrals
Longitudinal assessment
Status of active problems
Degree of treatment adherence
Response to treatment
Interdisciplinary evaluation
Team-based interviews
Targeted questionnaires
Dynamic reformulation
Contribution of pain diagnosis
Contribution of psychiatric diagnosis
Severity of SUD
Treatment plan revision
Motivate treatment adherence
Interdisciplinary therapy
Symptom remission
Relapse prevention
Provisional formulation
Presence of pain diagnosis
Presence of psychiatric diagnosis
Severity of SUD
Induction into treatment Maintenance with adaptive treatment
Figure 1 Dynamic assessment approach for patients with substance use disorders (SUD)
substance abuse treatment program was associated with a
reduction in pain and emotional distress, improvement in coping
skills, and a reduction in the use of pain medications
including opioids.76 The expertise of multidisciplinary pain
management has largely been denied to substance use disorder
patients. Offering these patients more opioids may provide
some benefits yet to be determined; however, improving
access to adjuvant analgesics, nonpharmacologic treatments,
and structured rehabilitative programs with well- documented
efficacy should be a priority. At least some of these patients
are not seeking opioids merely for their intoxicating effects.
An appropriate starting point assumes that patients are seeking
relief from chronic pain and have little to no access or
knowledge about nonopioid modalities that are clearly less
controversial, less potentially destabilizing of their addiction,
and likely to be more effective at decreasing pain.
One promising approach for an integrated treatment program
for chronic pain and substance use disorder involves an adaptive
stepped care strategy initially designed for routine substance
abuse treatment (Figure 2).86–88 The basic principle of
this model of care relies on providing more services for
patients not meeting the expectations of treatment. In other
words, patients enter treatment at a level of care that provides
standard individual and group counselling, daily supervised
methadone dosing, and urine screening for illicit drug use. As
the patient continues in treatment, additional expectations for
improved function, such as productive activities in the community
(such as, employment, training, and volunteering),
increased relationships with others not using drugs, and structured
diversional activities, are required to remain in this routine
or low-intensity level of care (Step 1). If the patient does
well, their progress is reinforced with a less intensive schedule
of counselling services, more flexibility in the time of methadone
dosing, and increased take-home dosages of methadone
to reduce clinic visits. Patients are motivated by the obvious
positive reinforcements of methadone itself and the freedoms
that result with adherence to the behavioural treatment plan.
In addition, patients are further motivated to improve their
compliance with treatment by their own desire to avoid being
placed in more intensive treatment with even higher
expectations and the loss of desired privileges.
The determination to advance a patient to more intensive
treatment or a higher step of care is based on established a priori
rules that use the results of attendance and urine testing.
As patients begin to demonstrate poor adherence to these
expectations, the program adapts to that patient’s individual
needs. The practitioner assumes that the patient’s disorder is
more complex and requires more intensive treatment. Instead
of being discharged from treatment because they are not
ready to get well or just trying to gain unlimited access to
opioids, the patient is advanced to a higher level of care with
access to more experienced senior staff, more frequent group
therapy sessions, more individual counselling sessions, more
closely monitored methadone administration, and more frequent
illicit drug use monitoring. If patients do not respond
within a predetermined time frame, they are advanced to
higher steps of care. When patients begin responding to therapy
(attend counselling sessions, decrease use of illicit
drugs), they return to less intensive treatment schedules. As
noted, increased adherence is motivated by their pursuit of
desired or previously obtained positive reinforcements such
as take-home dosages of methadone and the opportunity to
achieve or return to less restrictive schedules of care.
Assessment and Management of Chronic Pain in Individuals Seeking Treatment for Opioid Dependence Disorder
The Canadian Journal of Psychiatry, Vol 53, No 8, August 2008 503
Figure 2 Adaptive substance abuse treatment: motivated stepped care paradigm
Patients with both chronic pain and substance dependence
appear to be excellent candidates for an adaptive stepped care
approach with only minimal modifications from the approach
used to manage substance use disorder not complicated by
chronic pain (Figure 3); these modifications are outlined
below.
Recognize the Associations Between Chronic Pain and Substance
Use Disorder. Inadequately treated pain is recognized
as a cause of poor adherence and response to substance abuse
treatment. Screening patients with standardized questionnaires
for the presence of pain and its associated characteristics
(such as, intensity, unpleasantness, location, and
duration) is the first step (Figure 1). In addition to the characteristics
of pain, patients should be evaluated for the impact
that pain has on daily functioning and quality of life. This
information should then be reevaluated during the course and
follow-up of the patient in substance abuse treatment.
Pain-specific treatments should be initiated as soon as a
chronic pain disorder is discovered instead of waiting until the
patient has a poor response to substance abuse treatment.
Expect Pain to Complicate Substance Abuse Treatment. Similar
to other untreated medical and psychiatric problems,
chronic pain is expected to interfere with the clinical course
and outcome of substance abuse treatment. Therefore, either
complaints of pain or signs of poor adherence should result in
more aggressive diagnostic evaluation and implementation of
pain management strategies (steps) that occur simultaneously
with increased levels of drug abuse treatment. However, if the
problems worsen or improve independently from one another,
the steps of care can be disconnected. In other words, a patient
might continue in high-intensity (Step 3) treatment for substance
abuse but drop back to low-intensity (Step 1) treatment
for pain management. The patient, not the practitioner, determines
the priority list of problems through their response to
treatment. The treatment adapts to the objectively demonstrated
needs of the patient and is independent from the
worries or prejudices of the practitioners.
Akey principle for designing a stepped care program rests on
the fact that a higher step with more intensive treatment must
still offer to the patient an achievable set of changes to the
treatment plan. If the increased expectations of the patient are
too demanding with no potential for success, the patient will
become demoralized and leave treatment. Also, the step’s
efficacy must be assessed for all patients to determine if its
content is adequate or whether additional steps of even more
intensive treatment are required. When in place, the adaptive
treatment program offers a plan for patients who are not
doing well. However, the adaptive treatment program should
also be refined over time. The number of steps and their treatment
content should be based on the program’s ability to successfully
address the most complex patients’ needs.
Maximize the Benefits of Methadone. In addition to the
behavioural reinforcements that motivate patients in treatment
previously discussed, methadone can be used effectively
for the treatment of both chronic pain and substance
use disorders. If the patient is not responding well to treatment,
not only can the methadone dose be increased but the
dosing schedule can be split. Because methadone’s analgesic
properties last only about 6 hours, a split dosage schedule
may extend the hours throughout the day that a patient experiences
increased analgesia. This may initially be difficult for
the patient because they would have to return to the clinic
twice a day to receive the additional methadone dose based
on the requirements of their substance abuse treatment. If the
504 La Revue canadienne de psychiatrie, vol 53, no 8, août 2008
In Review
Step 2
• Modify pain management
Step 1
• Add pain management
Step 3 (if necessary)
• Increase pain management
Poor clinical response
Good clinical response
Pain management uses similar rules for step movement
• Ratings of pain intensity and pain-related interference
Untreated pain will modify effectiveness of substance abuse treatment
• Each problem influences the other responses to treatment
Chronic pain
Problem present
Substance abuse steps are independent from pain steps
• Each problem receives individualized and adaptive steps of care
Figure 3 Adaptive integrated pain treatment: behaviourally motivated stepped care for pain
patient is able to abstain from illicit drug use, they can initially
earn this second (one-half) dose as a take-home. Eventually,
as patients stabilize in treatment and receive full take-home
doses of methadone, they can split their own dose with the
potential of following up to a Q6-hour schedule.
Introduce Nonopioid Therapies Early. The use of nonopioid
therapies for chronic pain is inexcusably rare. These highly
effective modalities should be introduced early in therapy and
not as a last resort when opioid medications have failed. The
patient with chronic pain should receive education and group
therapy about the efficacy of nonopioid medications and
nonpharmacological modalities of managing chronic pain.
Stress management, coping skills training, relaxation–
biofeedback techniques, and physical therapies directed at
reducing chronic pain and improving function should be used.
Higher steps of pain management should offer more individual
sessions to understand and address the problems likely to
be more specific to the refractory patient.
Medications such as antidepressants and anticonvulsants used
to treat neuropathic pain should be prescribed. If necessary,
the dosing of these medications can be monitored in conjunction
with their methadone. They can be administered by
observant program staff to ensure the medication is taken as
prescribed. Serum levels may be obtained to monitor compliance
as well as adjust dosing schedules. As previously noted,
treatment is not contingent solely on compliance to counselling
sessions and abstinence from illicit drug use but reinforced
through the delivery of methadone and other
medications to minimize noxious symptoms and prevent
illicit drug effects, the patient’s desire to avoid more intensive
levels of care that the patient may believe are more restrictive,
and the pursuit of the rewards associated with lower steps of
care that accompany adherence, which is defined as a
decrease in illicit drug use coupled with increases in
functioning (such as, attendance and employment).
Conclusions and Future Research
There is a growing consensus that the prevalence of
cooccurring chronic pain and substance use disorders is high
and presents a significant burden to the health care system and
society. Treatment approaches that target either one of these
problems run the risk of ignoring the other and compromising
the overall care and prognosis of these patients. Cartesian
dualism in any form is an inadequate model for the assessment,
formulation, and treatment of patients. These patients
cannot be clearly understood from an either–or perspective.
Attributions of all of the patients’ symptoms to either chronic
pain or substance use disorder often fail to appreciate the complex
relations between these problems. In combination with
limited access to integrated treatment programs and settings,
the outcome for many of these patients is grim. Future
research is necessary to help guide progress. Studies that provide
much more comprehensive evaluation of both problems
and prospective characterization of chronic pain problems in
opioid-dependent patients seeking outpatient methadone
treatment would be most helpful. Equally important, interventions
for chronic pain to improve response to drug abuse
treatment are needed.
These new efforts should expand existing expertise in the
assessment of psychiatric comorbidity and integrated treatment
delivery models into the domain of chronic pain, which
is clearly an underdiagnosed and poorly treated medical and
psychiatric problem in substance use disorder patients.
Increasing nonopioid medication use, typically used to treat
chronic neuropathic pain conditions such as antidepressants
and anticonvulsants that are underused in general medical
care and rarely prescribed to substance use disorder patients,
should become a priority.21 Improving access to comprehensive
pain treatment programs would offer more hope to
patients with chronic pain and substance abuse than continuing
to advocate for the use of unimodal therapies such as
long-term opioid agonists.27,121
Implementing and evaluating the principles of rehabilitation
used by multidisciplinary pain centres and selected substance
abuse treatment programs would deepen our understanding
of the associations between chronic pain and response to
highly structured adaptive drug abuse treatment settings.
These data would improve outcomes and provide a strengthened
empirical foundation for the design and implementation
of clinical trials to reduce the suffering and impairment associated
with chronic pain in people with chronic and severe
opioid dependence. The results would likely generalize to
other chronic pain patient populations to improve our understanding
of the risks of opioid treatments, and hopefully prevent
the development of opioid dependence in at least some
of these high-risk individuals.
Funding and Support
The Canadian Psychiatric Association proudly supports the In
Review series by providing an honorarium to the authors.
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Manuscript received and accepted January 2008.
1Associate Professor, Department of Psychiatry and Behavioral Sciences,
Johns Hopkins University School of Medicine; Director, Chronic Pain
Treatment Programs, Johns Hopkins Medical Institutions; Associate
Medical Director, Addiction Treatment Services, Johns Hopkins Bayview
Medical Center, Baltimore, Maryland.
2Assistant Professor, Department of Psychiatry and Behavioral Sciences;
Associate Medical Director, Addiction Treatment Services, Johns
Hopkins Bayview Medical Center, Baltimore, Maryland.
3Professor of Medical Psychology and Psychiatry, Department of
Psychiatry and Behavioral Science, Johns Hopkins University School of
Medicine, Baltimore, Maryland.
Address for correspondence: Dr MR Clark, Department of Psychiatry and
Behavioral Sciences, Johns Hopkins University School of Medicine,
Osler 320, 600 North Wolfe Street, Baltimore, MD 21287-5371;
mclark9@jhmi.edu
Assessment and Management of Chronic Pain in Individuals Seeking Treatment for Opioid Dependence Disorder
The Canadian Journal of Psychiatry, Vol 53, No 8, August 2008 507
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