Association Between Substance Use Disorder Status and Pain-Related Function Following 12 Months of Treatment in Primary Care Patients With Musculoskeletal Pain

  • Benjamin J. Morasco
    Address reprint requests to Benjamin J. Morasco, PhD, Portland VA Medical Center (R&D99), 3710 SW US Veterans Hospital Road, Portland, OR 97239.
    Mental Health and Clinical Neurosciences Division, Portland VA Medical Center, Portland, Oregon

    Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
    Search for articles by this author
  • Kathryn Corson
    Department of Psychiatry, Oregon Health & Science University, Portland, Oregon

    Portland Center for the Study of Chronic, Comorbid Medical and Psychiatric Disorders, Portland VA Medical Center, Portland, Oregon
    Search for articles by this author
  • Dennis C. Turk
    Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington
    Search for articles by this author
  • Steven K. Dobscha
    Mental Health and Clinical Neurosciences Division, Portland VA Medical Center, Portland, Oregon

    Department of Psychiatry, Oregon Health & Science University, Portland, Oregon

    Portland Center for the Study of Chronic, Comorbid Medical and Psychiatric Disorders, Portland VA Medical Center, Portland, Oregon
    Search for articles by this author
Published:September 20, 2010DOI:


      The goal of this study was to examine relationships between substance use disorder (SUD) history and 12-month outcomes among primary care patients with chronic noncancer pain (CNCP). Patients were enrolled in a randomized trial of collaborative care intervention (CCI) versus treatment as usual (TAU) to improve pain-related physical and emotional function. At baseline, 72 of 362 patients (20.0%) had a history of SUD. Compared to CNCP patients without SUD, those with comorbid SUD had poorer pain-related function and were more likely to meet criteria for current major depression and posttraumatic stress disorder (all P values <.05). Logistic regression analyses were conducted to examine whether SUD status was associated with clinically significant change over 12 months in pain-related function (30% reduction in Roland Morris Disability Questionnaire Score). The overall model was not significant in the CCI group. However, within the TAU group, participants with a SUD history were significantly less likely to show improvements in pain-related function (OR = .30, 95% CI = .11–.82). CNCP patients with comorbid SUD reported greater functional impairment at baseline. Patients with SUD who received usual care were 70% less likely to have clinically significant improvements in pain-related function 12 months postbaseline, and SUD status did not impede improvement for the CCI group.


      Chronic noncancer pain patients with a history of a substance use disorder (SUD) report poorer pain-related functioning and are less likely to experience clinically significant improvements from usual pain treatment. Providers should assess for SUD status and provide more intensive interventions for these patients.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Brooks R.
        • Rabin R.
        • Charro F.
        The Measurement and Valuation Of Health Status Using EQ-5D: A European Perspective.
        Kluwer Academic Publishers, Boston, MA2003
        • Bodenheimer T.
        • Wagner E.H.
        • Grumbach K.
        Improving primary care for patients with chronic illness: The chronic care model, Part 2.
        JAMA. 2002; 288: 1909-1914
        • Breckenridge J.
        • Clark D.J.
        Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain.
        J Pain. 2003; 4: 344-350
        • Bush K.
        • Kivlahan D.R.
        • McDonnel M.B.
        • Fihn S.D.
        • Bradley K.A.
        The AUDIT alcohol consumption questions (AUDIT-C).
        Arch Intern Med. 1998; 158: 1789-1795
        • Caldeiro R.M.
        • Malte C.A.
        • Calsyn D.A.
        • Baer J.S.
        • Nichol P.
        • Kivlahan D.R.
        • Saxon A.J.
        The association of persistent pain with out-patient addiction treatment outcomes and service utilization.
        Addiction. 2008; 103: 1996-2005
        • Chelminski P.R.
        • Ives T.J.
        • Felix K.M.
        • Prakken S.D.
        • Miller T.M.
        • Perhac J.S.
        • Malone R.M.
        • Bryant M.E.
        • DeWalt D.A.
        • Pignone M.P.
        A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity.
        BMC Health Serv Res. 2005; 5: 3
        • Cocco K.M.
        • Carey K.B.
        Psychometric properties of the Drug Abuse Screening Test in psychiatric outpatients.
        Psychol Assess. 1998; 10: 408-414
        • Compton P.
        • Charuvastra V.C.
        • Kintaudi K.
        • Ling W.
        Pain responses in methadone-maintained opioid abusers.
        J Pain Symptom Manage. 2000; 20: 237-245
        • Currie S.R.
        • Hodgins D.C.
        • Crabtree A.
        • Jacobi J.
        • Armstrong S.
        Outcome from integrated pain management treatment for recovering substance abusers.
        J Pain. 2003; 4: 91-100
        • Demyttenaere K.
        • Bruffaerts R.
        • Lee S.
        • Posada-Villa J.
        • Kovess V.
        • Angermeyer M.C.
        • Levinson D.
        • de Girolamo G.
        • Nakane Mneimneh Z.
        • Lara C.
        • de Graaf R.
        • Scott K.M.
        • Gureje O.
        • Stein D.J.
        • Haro J.P.
        • Bromet E.J.
        • Kessler R.C.
        • Alonso J.
        • Von Korff M.
        Mental disorders among persons with chronic back or neck pain: Results from the world mental health surveys.
        Pain. 2007; 129: 332-342
        • Dobscha S.K.
        • Corson K.
        • Flores J.A.
        • Tansill E.C.
        • Gerrity M.S.
        Veterans affairs primary care clinicians’ attitudes toward chronic pain and correlates of opioid prescribing rates.
        Pain Med. 2008; 9: 564-571
        • Dobscha S.K.
        • Corson K.
        • Leibowitz R.Q.
        • Sullivan M.D.
        • Gerrity M.S.
        Rationale, design, and baseline findings from a randomized trial of collaborative care for chronic musculoskeletal pain in primary care.
        Pain Med. 2008; 9: 1050-1064
        • Dobscha S.K.
        • Corson K.
        • Perrin N.A.
        • Hanson G.C.
        • Leibowitz R.Q.
        • Doak M.N.
        • Dickinson K.C.
        • Sullivan M.D.
        • Gerrity M.S.
        Collaborative care for chronic pain in primary care: A cluster randomized trial.
        JAMA. 2009; 301: 1242-1252
        • Duong B.D.
        • Kerns R.D.
        • Towle V.
        • Reid M.C.
        Identifying the activities affected by chronic nonmalignant pain in older veterans receiving primary care.
        J Am Geriatr Soc. 2005; 53: 687-694
        • Elliott A.M.
        • Smith B.H.
        • Smith W.C.
        • Chambers W.A.
        Changes in chronic pain severity over time: The Chronic Pain Grade as a valid measure.
        Pain. 2000; 88: 303-308
        • Fishbain D.A.
        • Bruns D.
        • Disorbio J.M.
        • Lewis J.E.
        Risk for five forms of suicidality in acute pain patients and chronic pain patients vs pain-free community controls.
        Pain Med. 2009; 6: 1095-1105
        • Fleming M.F.
        • Balousek S.L.
        • Klessig C.L.
        • Mundt M.P.
        • Brown D.D.
        Substance use disorders in a primary care sample receiving daily opioid therapy.
        J Pain. 2007; 8: 573-582
        • Gureje O.
        • Von Korff M.
        • Simon G.E.
        • Gater R.
        Persistent pain and well-being: A World Health Organization Study in Primary Care.
        JAMA. 1998; 280: 147-151
        • Ilgen M.A.
        • Trafton J.A.
        • Humphreys K.
        Response to methadone maintenance treatment of opiate dependent patients with and without significant pain.
        Drug Alcohol Depend. 2006; 20: 187-193
        • Jamison R.N.
        • Kauffman J.
        • Katz N.P.
        Characteristics of methadone maintenance patients with chronic pain.
        J Pain Symptom Manage. 2000; 19: 53-62
        • Jordan K.
        • Dunn K.M.
        • Lewis M.
        • Croft P.
        A minimal clinically important difference was derived for the Roland-Morris Disability Questionnaire for low back pain.
        J Clin Epidemiol. 2006; 59: 45-52
        • Katzman R.
        • Brown T.
        • Fuld P.
        • Peck A.
        • Schechter R.
        • Schimmel H.
        Validation of a short Orientation-Memory-Concentration test of cognitive impairment.
        Am J Psychiatry. 1983; 140: 734-739
        • Lauridsen H.H.
        • Hartvigsen J.
        • Manniche C.
        • Korsholm L.
        • Grunnet-Nilsson N.
        Responsiveness and minimal clinically important difference for pain and disability instruments in low back pain patients.
        BMC Musculoskelet Disord. 2006; 7: 82
        • Martell B.A.
        • O’Connor P.G.
        • Kerns R.D.
        • Becker W.C.
        • Morales K.H.
        • Kosten T.R.
        • Fiellin D.A.
        Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy and association with addiction.
        Ann Intern Med. 2007; 146: 116-127
        • Morasco B.J.
        • Dobscha S.K.
        Prescription medication misuse and substance use disorder in VA primary care patients with chronic pain.
        Gen Hosp Psychiatry. 2008; 30: 93-99
        • Nedeljkovic S.S.
        • Wasan A.
        • Jamison R.N.
        Assessment of efficacy of long-term opioid therapy in pain patients with substance abuse potential.
        Clin J Pain. 2002; 18: S39-S51
        • Ostelo R.W.
        • Deyo R.A.
        • Stratford P.
        • Waddell G.
        • Croft P.
        • Von Korff M.
        • Bouter L.M.
        • de Vet H.C.
        Interpreting change scores for pain and functional status in low back pain: Towards international consensus regarding minimal important change.
        Spine. 2008; 33: 90-94
        • Pinto-Meza A.
        • Fernandez A.
        • Fullana M.A.
        • Haro J.M.
        • Palao D.
        • Luciano J.V.
        • Serrano-Blanco A.
        Impact of mental disorders and chronic physical conditions in health-related quality of life among primary care patients: Results from an epidemiological study.
        Qual Life Res. 2009; 18: 1011-1018
        • Potter J.S.
        • Prather K.
        • Weiss R.D.
        Physical pain and associated clinical characteristics in treatment-seeking patients in four substance use disorder treatment modalities.
        Am J Addict. 2008; 17: 121-125
        • Pud D.
        • Cohen D.
        • Lawental E.
        • Eisenberg E.
        Opioids and abnormal pain perception: New evidence from a study of chronic opioid addicts and healthy subjects.
        Drug Alc Depend. 2006; 82: 218-223
        • Reid M.C.
        • Engles-Horton L.L.
        • Weber M.B.
        • Kerns R.D.
        • Rogers E.L.
        • O’Connor P.G.
        Use of opioid medications for chronic noncancer pain syndromes in primary care.
        J Gen Intern Med. 2002; 17: 173-179
        • Rhodin A.
        • Gronbladh L.
        • Nilsson L.H.
        • Gordh T.
        Methadone treatment of chronic non-malignant pain and opioid dependence – a long-term follow-up.
        Eur J Pain. 2006; 10: 271-278
        • Roland M.
        • Fairbank J.
        The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire.
        Spine. 2000; 25: 3115-3124
        • Roland M.
        • Morris R.
        A study of the natural history of back pain: Part 1. Development of a reliable and sensitive measure of disability in low-back spine.
        Spine. 1983; 8: 141-150
        • Romano J.M.
        • Jensen M.P.
        • Schmaling K.B.
        • Hops H.
        • Buchwald D.S.
        Illness behaviors in patients with unexplained chronic fatigue are associated with significant other responses.
        J Behav Med. 2009; 32: 558-569
        • Rosenblum A.
        • Joseph J.
        • Fong C.
        • Kipnis S.
        • Cleland C.
        • Portenoy R.K.
        Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities.
        JAMA. 2003; 289: 2370-2378
        • Savage S.R.
        Assessment for addiction in pain-treatment settings.
        Clin J Pain. 2002; 18: S28-S38
        • Skinner H.A.
        The Drug Abuse Screening Test.
        Addict Behav. 1982; 7: 363-371
        • Smith B.H.
        • Penny K.I.
        • Purves A.M.
        • Munro C.
        • Wilson B.
        • Grimshaw J.
        • Chambers W.A.
        • Smith W.C.
        The Chronic Pain Grade questionnaire: Validation and reliability in postal research.
        Pain. 1997; 71: 141-147
        • Spitzer R.L.
        • Kroenke K.
        • Williams J.B.W.
        Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study.
        JAMA. 1999; 282: 1737-1744
        • Stratford P.W.
        • Binkley J.M.
        • Riddle D.L.
        • Guyatt G.H.
        Sensitivity to change of the Roland-Morris Back Pain Questionnaire: Part 1.
        Phys Ther. 1998; 78: 1186-1196
        • Trafton J.A.
        • Oliva E.M.
        • Horst D.A.
        • Minkel J.D.
        • Humphreys K.
        Treatment needs associated with pain in substance use disorder patients: Implications for concurrent treatment.
        Drug Alcohol Depend. 2004; 73: 23-31
        • Tsang A.
        • Von Korff M.
        • Lee S.
        • Alonso J.
        • Karam E.
        • Angermeyer M.C.
        • Borges G.L.
        • Bromet E.J.
        • Demytteneare K.
        • de Girolamo G.
        • de Graaf R.
        • Gureje O.
        • Lepine J.P.
        • Haro J.M.
        • Levinson D.
        • Oakley Browne M.A.
        • Posada-Villa J.
        • Seedat S.
        • Watanabe M.
        Common chronic pain conditions in developed and developing countries: Gender and age differences and comorbidity with depression-anxiety disorders.
        J Pain. 2008; 9: 883-891
        • Turk D.C.
        • Okifuji A.
        Psychological factors in chronic pain: Evolution and revolution.
        J Consult Clin Psychol. 2002; 70: 678-690
      1. Veterans Integrated Service Network-20 Data Warehouse. Accessed March 6, 2007

        • Von Korff M.
        • Balderson B.H.
        • Saunders K.
        • Miglioretti D.L.
        • Lin E.H.
        • Berry S.
        • Moore J.E.
        • Turner J.A.
        A trial of an activating intervention for chronic back pain in primary care and physical therapy settings.
        Pain. 2005; 113: 323-330
      2. Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM: The PTSD checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the meeting of International Society for Traumatic Stress Studies, San Antonio, TX, October, 1993

        • Weathers F.
        • Ford J.
        Psychometric review of PTSD Checklist (PCL-C, PCL-S, PCL-M, PCL-PR).
        in: Stamm B.H. Measurement of Stress, Trauma, and Adaptation. Sidran Press, Lutherville, MD1996
        • Weisner C.M.
        • Campbell C.I.
        • Ray G.T.
        • Saunders K.
        • Merrill J.O.
        • Banta-Green C.
        • Sullivan M.D.
        • Silverberg M.J.
        • Mertens J.R.
        • Boudreau D.
        • Von Korff M.
        Trends in prescribed opioid therapy for non-cancer pain for individuals with prior substance use disorders.
        Pain. 2009; 145: 287-293