Psychoactive substance use

There is a higher rate of alcohol and analgesic misuse in patients with chronic pain. Between 12 and 28 percent of patients attending specialized pain clinic facilities reach the criterion for diagnosis under this category.12 High average alcohol consumption before developing a chronic painful state was found to be a poor prognostic sign in a large follow-up study of patients with lower limb pain.72 Despite these findings of an increased prevalence of substance misuse generally, there has been a change in attitude about the use of opioid medication for patients with chronic nonmalignant pain. Although it has been argued that long-term opioid use leads to increased drug dependency and further functional impairment in patients who have disproportionate pain and disability,73 recent work has not found clear evidence that this is the case. In a large study of patients with chronic pain comparing opioid users with nonusers, there was no increase in illness behavior exhibited by the opioid users after controlling for other variables.74 Benzodiazepine use, on the other hand, was associated with reduced activity and disability.

It seems that prior alcohol and substance abuse are likely risk factors in leading to what is described as a "downhill spiral'' in patients with chronic pain involving escalating doses and abuse of opioid therapy. Notwithstanding this, opioid use is not contraindicated in this population, except for those who have evidence of previous drug dependency or who are found to regularly ask for additional medication ahead of schedule. If there is definite evidence of opioid misuse, it is normally advisable to refer the patient to a specialized substance misuse center. Brief psychosocial interventions and contingency management (which consists of payment of money or tokens to patients if they succeed in reducing opiate use) have been found to improve compliance with therapy.75 Drug detoxification may be needed before these strategies are employed; the decision rests with the substance misuse team, to whom the patient should be referred if such treatments are being considered.

A specialized tool, the current opioid misuse measure (COMM),76 has very recently been developed to identify people who are prone to abuse opioids. The use of this instrument needs further assessment in more pain clinic settings.

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