Full length articleChronic pain, craving, and illicit opioid use among patients receiving opioid agonist therapy
Introduction
In 2014, an estimated 1.9 million people in the United States had an opioid use disorder related to prescription pain relievers, and an estimated 586,000 had an opioid use disorder related to heroin use (SAMHSA, 2015). Chronic pain is common in patients with opioid use disorders who are on opioid agonist therapy (OAT). Studies of patients maintained on methadone or buprenorphine suggest that a third to more than a half report pain that has been present 3 or more months (Barry et al., 2009a, Barry et al., 2013, Jamison et al., 2000, Rosenblum et al., 2003). Chronic pain is highly relevant to substance use outcomes, as it may serve as a barrier to treatment entry, retention or success, and a trigger for relapse. Among HIV-infected substance users, pain has been associated with persistent use of heroin (Tsui et al., 2013). In some studies, patients with chronic pain who received addiction treatment were more likely to relapse to drug use compared to patients without pain (Caldeiro et al., 2008, Larson et al., 2007). However, not all studies have demonstrated worse outcomes (Dhingra et al., 2015, Fox et al., 2012, Ilgen et al., 2006).
Drug craving is a subjective phenomenon conceptualized as an individual’s desire or urges to use a previously experienced substance (Sayette et al., 2000, Tiffany and Wray, 2012). Opioid craving predicts opioid use among persons with heroin and prescription opioid use disorders (McHugh et al., 2014, Tsui et al., 2014), and treatment with methadone and buprenorphine reduces craving (Fareed et al., 2010). Pain may be associated with increased craving for opioids. Among patients with chronic pain, craving has been associated with aberrant use of prescription opioids (Wasan et al., 2009), and among persons with prior heroin use, increased sensitivity to pain has been associated with opioid craving (Ren et al., 2009). Among patients with treated opioid use disorders, it is unknown whether chronic pain is associated with opioid craving and thereby an increased likelihood of relapse. In addition, the mechanisms whereby pain leads to craving or relapse are relatively unexplored. Prior research suggests that negative affect may be associated with heroin and other drug craving among persons in treatment for opioid use disorders (Epstein et al., 2009, Huhn et al., 2016), and in methadone maintenance treated samples, persons with chronic severe pain have been observed to have more symptoms of depression and anxiety (Barry et al., 2009a).
The study aim is to assess whether having chronic pain was associated with (a) opioid craving and (b) illicit opioid use in a sample of adults who were treated with buprenorphine or methadone for their opioid use disorders. In addition, we explored the roles of anxiety and depression in these relationships to assess whether they might be potential confounders or mediators.
Section snippets
Objective and study design
This is secondary analysis of a cross-sectional study of adults on methadone or buprenorphine for treatment of opioid use disorders in the VIP (Viral Infections and Pain) study. The parent study explored the contributions of hepatitis C virus (HCV) infection to pain and pain hypersensitivity among persons with treated opioid use disorders on buprenorphine or methadone with and without HCV (Tsui et al., 2015). The current study included all participants whose data on their chronic pain status
Results
The sample included 105 persons, of the 106 total participants in the VIP study, who reported information on chronic pain. Median age was 45 (IQR: 37–51) years; 48% were female and 32% non-white. Most participants (81%) were treated with buprenorphine. The majority of the sample (84%) reported pain in the past week, 68% reported chronic pain and 38% reported moderate to severe chronic pain. The most frequent location of the pain was the back; the second most reported was the knees. Overall,
Discussion
In this study of adults maintained on methadone or buprenorphine for treatment of opioid use disorder, we found that participants with chronic pain had significantly higher odds of reporting craving for opioids, and that the association was highest with those with moderate to severe chronic pain. We were unable to detect an association between chronic pain and having a UDT positive for opiates. Depression is a potential confounder of the relationship between chronic pain and opioid craving.
This
Author contributions
Each author has contributed to the submission in the following manner:
Study concept: Judith I. Tsui, Robert E. Edwards, Jeffrey H. Samet.
Study design: Judith I. Tsui, Debbie M. Cheng.
Data collection: Judith I. Tsui, Marlene C. Lira.
Data analysis: Judith I. Tsui, Michael R. Winter.
Interpretation of data: all authors (Judith I. Tsui, Marlene C. Lira, Debbie M. Cheng, Michael R. Winter, Daniel P. Alford, Jane M. Liebschutz, Robert R. Edwards, and Jeffrey H. Samet).
Drafting of manuscript: Judith
Role of funding
This study was supported by grant K23DA027367 from the National Institute on Drug Abuse, R25 DA013582 and through BU-CTSI Grant Number KL2 TR000158. The funding sources had no involvement in study activities.
Contributors
All authors have contributed significantly to claim authorship, and have seen and approved of the manuscript.
Conflict of interest
The authors declare that there are no conflicts of interest.
Acknowledgements
We wish to thank the participants of the study for their contributions.
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