Chronic Pain and Substance Abuse

The management of chronic or even short-term pain is a difficult science to master because tolerance to discomfort is individualized and uniquely personal. But it is the individual nature of pain tolerance that actually decides the risk factors associated with substance misuse of opioid pain medications.

Scientists have been testing why it is that one person can be treated with an opioid for pain and have no issues stopping the medication and why others immediately struggle with substance misuse. There appears to be a link between the person’s ability to handle distress and their propensity for substance misuse.

What are the implications of this finding? How does knowing this impact prescribing practices for physicians dealing with patients in chronic pain?

Substance Misuse, Pain Management, and Individual Tolerance

A study in The Journal of Pain tracked 51 participants to determine the risk factors for substance misuse when using opioids for pain management. Their goal was to determine why some people can use opioids for pain management safely without becoming addicted and why some people fall into substance misuse and even an addiction. Once these factors are determined, suitable protocols can help further the ability to mitigate the risk of substance misuse. Simply put, if physicians understand who is most at risk for substance misuse, they can make better prescription decisions about treating chronic pain.

Previous studies had determined multiple factors put a person at risk of substance misuse when using opioids, including:

• A history of prior substance misuse
• Mood disorders
• A history of legal problems

Researchers determined that although much progress has been made in identifying risk factors, accurately predicting who will misuse their medication is still somewhat problematic and that the mechanisms underlying this risk still remain a mystery to some extent.

The scientists in this study developed a theory that “distress intolerance” is a factor that predisposed individuals to substance misuse. Their study was designed to prove this theory by tracking patients with chronic pain that had been prescribed opioid medication.

Researchers defined the concept of distress intolerance as “the perceived or actual inability to handle aversive somatic or emotional states.” The idea was that the subject attempted to block or avoid the distress with substance misuse or other harmful behaviors.

Researchers surmised that some people simply have a low tolerance for physical or even emotional pain or distress and are therefore more inclined toward substance misuse as a way to block or avoid the issue.

The Study and The Results

To prove their theory, scientists selected 51 patients from a pain management clinic at a large urban hospital. The patients were between the ages of 18 to 70 and had chronic back pain as well as a current prescription for an opioid pain reliever.

Researchers used the Distress Intolerance Index (DII) to measure how strongly the participants felt fear or anxiety at the possibility of having emotional or physical distress. This was a 10-question self-assessment to determine the individual’s concerns about feeling mental or physical pain. The questions were weighted on a five-point scale with the responses reflecting the severity of the person’s feelings toward distress. Participants were also measured for pain severity and tested on their ability to persevere by completing a challenging and frustrating task.

During the course of the study, 31 of the 51 study participants met the criteria for substance misuse. Scientists surmised it was no coincidence that they also scored higher on the DII. The higher DII scores seemed to correlate with more severe substance misuse. However, these patients did not rank higher than the remaining patients on the level of chronic pain they felt.

While this was a small study, the clinicians that conducted it suggest that an individual’s intolerance for distress does play a role in their propensity for substance misuse. They recommended that DII evaluations be conducted on anyone with chronic pain before an opioid is prescribed.

People that score high on the DII evaluation are more likely to fall into a substance use disorder. The researchers concluded that the relationship likely occurs “because patients who are intensely apprehensive of distressing experiences may seek quick stress relief through behaviors such as substance use, risk-taking, avoidance and escapism.”

What the Findings Suggest

While this study did seem to correlate distress intolerance as a risk factor for substance misuse, more research must be done. This study was both short in duration and the sample size was small. With that said, there are implications here that are of use to the behavioral health community. The findings could be used to improve their outcomes with people living with a substance use disorder.

The study participants that ranked higher on the DII had a more than 10 percent higher likelihood to fall into substance misuse than people that had more tolerance for distress. Ironically, these people did not have higher pain than the rest of the group, but they did rank higher on their fear of pain and distress. That fear of distress is what potentially led them to substance misuse, suggesting that addressing emotional pain may be one way to help mitigate the risk of substance misuse for some.

This study is potentially helpful for addiction treatment programs and their understanding of what makes some people gravitate toward substance misuse and others steer clear. The good news is that stress tolerance can be mitigated with cognitive-behavioral therapies, which seek to change the human response to distressing emotions like frustration or fear. Instead of seeking to escape the anxiety with an opioid, the person learns coping mechanisms and new ways of behaving to help stop substance misuse.

For the behavioral health community seeking new ways to treat patients, the concept that a person’s ability to handle stress and anxiety could be tied to their substance misuse is an important one. Pre-screening the person’s ability to handle distress could have merit for future treatment plans and positively affect the ability to fight the opioid epidemic with new tools to predict substance misuse.

If you deal with both chronic pain and a substance use disorder, there are treatments and therapies that can help you manage both more effectively. Contact The Recovery Village Ridgefield today to learn about your treatment options.