Evidence on the Treatment of Co-occurring Chronic Pain and Opioid Use Disorder
Write-up by IRIS team member: Yali Deng
Chronic pain and opioid use disorder (OUD) frequently are experienced as co-occurring. Rates of chronic pain among OUD patients in the United States were 64.4% according to electronic health record data examined from 2006 to 2015, and 44% according to a meta-analysis of studies conducted globally (Hser et al., 2017; Yang et al., 2024). OUD patients with chronic pain were also more likely to have more severe mental health symptoms, including for depression and anxiety (Yang et al., 2024). To address the intertwined challenges of OUD, chronic pain, and mental illness, the National Institutes of Health created the Helping to End Addiction Long-term Initiative (HEAL) to address the opioid epidemic by improving both treatment for opioid misuse and pain care. In a previous research corner, we discussed the comorbidity between OUD and mental health disorders. The current research corner will examine the impact of chronic pain and OUD and will identify coordinated or comprehensive treatment strategies for pain and OUD.
The findings of an IRIS-funded research project led by Dr. Melanie Bennett indicated how chronic pain interferes with OUD treatment. First, chronic pain often precedes the onset of opioid use and thus may lead to daily use of opioids to reduce pain and support routine functioning. Withdrawal can induce pain and create barriers to treatment. Importantly, people reported feeling relieved when addiction treatment providers took their pain seriously and appreciated pain management, such as non-opioid pain medication and exercise. These results indicate the importance of a comprehensive treatment approach to address physical pain and opioid use together.
We will now examine the current evidence on the comprehensive treatment of co-occurring chronic pain and OUD by summarizing two articles. The first one presents a systematic review of collaborative care models and their effectiveness on pain-related and opioid use-related outcomes. The second article describes an integrated cognitive-behavioral group therapy model called STOP (Self-regulation Therapy for Opioid Addiction and Pain) and its impact on pain and substance use disorder (SUD) treatment outcomes. In both summaries, we include a description of the program itself and its evidence of efficacy. Our community partners may find the resources helpful in improving care for people with co-occurring OUD and chronic pain by incorporating collaborative care model components and training counselors in pain management.
Article 1
"Collaborative Care Models to Improve Pain and Reduce Opioid Use in Primary Care: A Systematic Review"
Heavey, S. C., Bleasdale, J., Rosenfeld, E. A., & Beehler, G. P. (2023). Collaborative Care Models to Improve Pain and Reduce Opioid Use in Primary Care: A Systematic Review. Journal of General Internal Medicine, 38(13), 3021–3040. https://doi.org/10.1007/s11606-023-08343-9
This study reviewed 18 randomized controlled trials that used Collaborative Care Management (CCM) in primary care clinics to manage chronic pain, reduce opioid use, or both. CCM is a team-based approach to overcome fractured medical care, especially for chronic medical conditions, and was applied to treat OUD and chronic pain. In this model, a care manager (usually nurse, social worker, or psychologist) regularly assesses patient needs and coordinates care with treatment specialists, primary care providers, and the patient. The care manager can also include additional components that meet patients’ needs, such as family engagement, social services, and/or community resources.
This review found that among the 12 studies focused on pain, 11 showed that CCM helped reduce pain severity or made daily functioning easier. Results for opioid use and treatment outcomes were less successful. Four out of nine such studies found an effect, including a reduction in opioid prescriptions or misuse, or an increase in treatment initiation, or improved buprenorphine treatment retention. The review also found that many people with chronic pain also experience depression and anxiety. Ten studies examined mental health outcomes, with seven showing improved depression symptoms, and three demonstrating reduced anxiety symptoms.
Notably, this study used the Patient-Centered Integrated Behavioral Health Care Principles & Tasks Checklist (PCC) to assess CCM components. This PCC included seven components and tasks, including: 1. Patient identification and diagnosis, 2. Engage the patient in an integrated care program, 3. Provide evidence-based treatment and adjust treatment, 4. Conduct systematic follow-up, outcome monitoring, treatment adjustment, and relapse prevention, 5. Coordinate care and communication, including care providers, social services, and families, 6. Conduct systematic psychiatric case review and consultation, and 7. Conduct program oversight and quality improvement. This systematic review found that some studies with the highest PCC score (i.e., alignment with more components) did not find a significant effect. The author suggests that this indicates the importance of determining which components of CCM are most important, and which elements, while ideal in theory, may not be included due to efficiency considerations.
In conclusion, this review indicates that collaborative care is promising in improving chronic pain-related outcomes, opioid use disorder, and co-occurring mental health issues. The PCC checklist can be a useful tool for case managers to align their services with CCM components, such as family engagement and follow-up with patients or mental health professionals. More research is needed, however, to determine which aspects of CCM are most effective in improving clients’ outcomes.
Article 2
"Developing a Novel Treatment for Patients With Chronic Pain and Opioid User Disorder"
Wachholtz, A., Robinson, D., & Epstein, E. (2022). Developing a Novel Treatment for Patients With Chronic Pain and Opioid User Disorder. Substance Abuse Treatment, Prevention, and Policy, 17(1), 35.
https://substanceabusepolicy.biomedcentral.com/articles/10.1186/s13011-022-00464-4
This second article introduced and tested an innovative group therapy called STOP (Self-regulation Therapy for Opioid Use and Pain). The program was designed for people who are being treated for OUD with co-occurring chronic pain. STOP was developed with direct input from community recovery centers and was delivered by addiction therapists who received specialized training in pain management. This makes the intervention practical and community-friendly, which facilitates its delivery by addiction counselors in outpatient settings.
This 90-minute, 12-week, rolling entry group therapy program combines cognitive behavioral therapy (CBT) with tools to help participants manage their physical responses to pain and cravings. The sessions include pain education, relapse prevention, sleep hygiene, and relaxation exercises. Participants practice a single relaxation technique in every session and at home, using a simple tool called a “Biodot”— a small sticker that changes color with skin temperature to show physical relaxation in real time. Importantly, the program protocol provides a full-day behavioral pain management training to therapists who deliver STOP. The training content includes basic pain physiology, the influence of mood states on pain and cravings, self-regulation and CBT for pain and OUD, the influence of sleep on pain, and linkages between OUD and pain.
This pilot study aimed to test the feasibility and acceptability of STOP, and also to examine the outcomes at pre-test, post-intervention, and three-month follow-up. Fourteen people who were on medication for OUD (MOUD) and had chronic pain participated in the study. Results indicate that all participants completed the program, which also had a high average attendance rate (80%). None of the participants tested positive for illegal drug use after week eight. Participants reported they were more active and could do more household, social, and recreational activities after completing the program. Participants could tolerate pain for longer periods (as measured in a lab test using cold water) after completing STOP, and those gains were still there three months later. Participants said they appreciated the hands-on tools, worksheets, and in-session exercises.
In conclusion, STOP shows potential as a treatment for people with both chronic pain and MOUD. The program can be quickly integrated into community treatment programs through provision of pain management training for counselors. Community recovery centers may find STOP to be a valuable addition to their services for people with OUD and chronic pain.
References
Hser, Y. I., Mooney, L. J., Saxon, A. J., Miotto, K., Bell, D. S., & Huang, D. (2017). Chronic Pain Among Patients with Opioid Use Disorder: Results from Electronic Health Records Data. Journal of Substance Abuse Treatment, 77, 26-30. https://doi.org/10.1016/j.jsat.2017.03.006
Yang, J., Jung, M., Picco, L., Grist, E., Lloyd‐Jones, M., Giummarra, M., & Nielsen, S. (2024). Pain in People Seeking and Receiving Opioid Agonist Treatment: A Systematic Review and Meta‐Analysis of Prevalence and Correlates. Addiction, 119(11), 1879-1901.