Commentary on Yang et al.: The need for a renewed focus on identifying and responding to chronic pain among people with substance use disorders

Chronic non-cancer pain (hereafter referred to as chronic pain) is defined as non-malignant pain persisting for 3 months or longer. It is a common problem world-wide, affecting approximately one in five people globally [1]. Yang et al.’s [2] review is the first to provide pooled estimates of the prevalence of current pain and chronic pain among the specific group of people seeking or receiving opioid agonist treatment (OAT), finding a prevalence twice that of the general population (44%). Importantly, although chronic pain is more prevalent in people seeking or receiving OAT, emerging research suggests that it is also common among people with other substance use disorders [3]. We recently estimated the prevalence of chronic pain to be 37.5% among 9413 clients enrolled in a large not-for-profit alcohol and other drug (AOD) service in Australia [4]. However, evidence on the causes, consequences and appropriate treatment responses remain relatively underdeveloped.

We know that in the general population, chronic pain is associated with being older, higher levels of socio-economic disadvantage via reduced working ability [5], poorer physical and mental health [5], functional decline and loss of independent living [6] and increased risk of suicide [7]. Many of these characteristics are more pronounced among AOD treatment populations, particularly those with opioid use disorder. Yang et al. [2] report that among people seeking treatment or receiving OAT, chronic pain was associated with a greater risk of unemployment and more severe mental health symptoms compared to people without chronic pain. We found similar associations among people with chronic pain entering general AOD treatment [4]. Additionally, we found that chronic pain was associated with a two times increased risk for suicide-related behaviours, homelessness and eviction [4]. Chronic pain is also associated with poorer AOD treatment outcomes, including poorer rates of abstinence [8].

Access and affordability of appropriate pain management services remain an issue in the general population [9, 10]. These barriers are probably greater among people entering treatment for substance use disorders due to financial disadvantage and poorer private health insurance coverage [11]. Integrated behavioural pain management treatments incorporated into AOD treatments show promise [12]; however, there is a need to invest in further research to improve outcomes for people with chronic pain and substance use disorders.

Chronic pain should be incorporated into AOD work-force education and development and more effectively integrated into our treatment responses. Furthermore, to date, only a small percentage of substance use treatment facilities report having programmes to treat patients with co-occurring chronic pain and substance use disorder [13], with 2.6% of residential facilities reporting having a chronic pain programme [14]. There is a need for improved screening and assessment of chronic pain and enhanced treatment responses, particularly in terms of suicide prevention. Research needs to examine new approaches, including person-centred and accessible interventions for people with substance use disorders and chronic pain.

G.C. is supported by the Australian Government Department of Health awarded to the National Centre for Youth Substance Use Research (NCYSUR) and the National Health and Medical Research Council (NHMRC) Meaningful Outcomes in Substance Use Treatment Centre of Research Excellence. B.L. has no competing interests to declare.