Pain and Psychiatric Comorbidity in Patients With Opioid Use Disorder

My colleagues and I set up a research-based clinic at the APT Foundation in New Haven, Connecticut, in 2006 to examine and address the clinical needs of patients with co-occurring chronic pain and opioid use disorder, and to assist their providers. Although many researchers and clinicians at the time were advocating for the use of prescription opioids for treating chronic non-cancer pain, we were noticing an uptick in the number of patients with chronic pain presenting for treatment for opioid use disorder and attributing their addiction to being prescribed opioids for pain relief.

We conducted a couple of studies (Barry et al 2008 and Barry et al 2010) of providers, which found that they experienced multiple clinical management problems working with these patients and were frustrated with the practice of continued opioid prescribing for relief of chronic pain in this patient group. We then conducted a series of studies (Barry et al 2009, Barry et al 2009, Barry et al 2011, Barry et al 2012, and Barry et al 2013) of patients with opioid use disorder seeking or enrolled in methadone maintenance treatment or buprenorphine-naloxone treatment. These studies documented a high prevalence of comorbid chronic pain, a high rate of reported licit and illicit substance use to cope with pain, a wide range of conventional and alternative medicine interventions used to address pain, and elevated levels of self-reported psychiatric symptoms and trauma among this population.

In a 2016 study, we examined more systematically the DSM-IV-TR Axis I and II psychiatric burden among patients seeking treatment at our research program for co-occurring chronic pain and opioid use disorder. In addition to the high prevalence of psychiatric disorders (typically higher than one sees in patients with either chronic pain or opioid use disorder), what struck me about the findings of the study was the similarity between lifetime and current rates of mood and anxiety disorders among these patients. The persistence of these psychiatric disorders may explain in part the difficulty that providers experience in treating these patients. Researchers may need to target the high levels of psychopathology when developing and testing treatments for these patients.

Financial disclosure:Dr Barry has received honoraria from the Connecticut Psychological Association and the Westport Day School.​