Drug and Alcohol Dependence 73 (2004) 23–31 Treatment needs associated with pain in substance use disorder patients: implications for concurrent treatment Jodie A. Trafton * , Elizabeth M. Oliva, Doyanne A. Horst, Jared D. Minkel, Keith Humphreys Center for Health Care Evaluation, VA Palo Alto Health Care System and Stanford University School of Medicine, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA Received 14 May 2003; received in revised form 29 August 2003; accepted 29 August 2003 Abstract Although pain problems are prevalent in substance use disorder (SUD) patients, the special treatment needs of SUD patients with pain have not been investigated. This study examines the problems and behaviors associated with reported pain among veterans treated at eight opioid substitution treatment clinics. Patients reporting pain had more severe medical and psychiatric problems and greater health care utilization. Pain was associated with an increased propensity for misuse of substances with analgesic effects, suggesting that ongoing pain contributes to an altered and more severe pattern of drug-seeking behavior. Patients without pain rarely abused sedatives or opioid medication, indicating that misuse of these substances is unique to co-morbid pain and SUD patients. Patients reporting pain did not differ from patients without pain in use of heroin, alcohol, cocaine or in injection practices, demonstrating that they are truly SUD patients in need of SUD treatment. Pain complicates the treatment of SUD and should be addressed as an important co-morbidity during treatment. Published by Elsevier Ireland Ltd. Keywords: Pain; Methadone maintenance; LAAM; Health care utilization; Co-morbidity 1. Introduction Many clinicians have observed a high prevalence of pain in substance use disorder (SUD) patients but there has been little research into the reasons for this high co-morbidity. Recent studies by Jamison et al. (2000) and Rosenblum et al. (2003) demonstrated that 37–60% of patients in methadone maintenance treatment for opioid dependence have chronic pain conditions, and a large per- centage (34%) of these patients report using illicit drugs to treat their pain. But as these studies examined long-term maintenance and thus likely SUD symptom-free patients, they are unable to determine whether the patients with chronic pain only used substances in response to their pain (i.e. opioid pseudoaddiction (Weissman and Haddox, 1989)) or whether they suffered from severe SUDs and a co-morbid pain disorder. There are major clinical implica- tions of this distinction. Patients with opioid pseudoaddic- tion should be directed to appropriate pain management and * Corresponding author. Tel.: +1-650-493-5000x22474; fax: +1-650-617-2736. E-mail address: jodie.trafton@med.va.gov (J.A. Trafton). may not require SUD treatment. Patients with co-morbid pain and SUD may require combined treatment for both conditions. Co-occurring pain and substance use disorders could com- plicate treatment for SUD in several ways. First, pain drives drug-seeking for opioids both in animals (Colpaert et al., 2001; Kupers and Gybels, 1995) and humans (Weissman and Haddox, 1989), so SUD patients with ongoing pain may have increased drug-seeking behaviors and cravings. Im- provement of the condition producing the pain or success- ful pain management eliminates opioid-seeking behavior in laboratory studies (Weissman and Haddox, 1989; Colpaert et al., 2001); pain treatment might therefore be expected to improve SUD outcomes in patients with pain. Similarly, as pain reduces subjective well-being and quality of life, pain may increase the drive to use any drug that produces eu- phoria. Second, pain is often associated with mental health problems that worsen SUD outcomes. For example, trauma related to pain problems may produce post-traumatic stress disorder (PTSD) (Beckham et al., 1997), a disorder associ- ated with greater drug abuse severity (Clark et al., 2001) and worse treatment outcomes (Ouimette et al., 1998). Lastly, functional and social disability associated with pain might 0376-8716/$ – see front matter. Published by Elsevier Ireland Ltd. doi:10.1016/j.drugalcdep.2003.08.007