Highlights
- •A high proportion of patients on methadone maintenance had moderate to extreme pain.
- •Those with higher pain severity were more likely to self-manage their pain.
- •Those with higher pain severity were more likely to perceive that their methadone dose was too low.
- •Patients receiving methadone may be prone to undertreated pain or opioid-induced hyperalgesia.
- •Patient education and assessment may prevent high-risk self-management behaviors.
Abstract
The complexity of treating concurrent pain and opioid dependence among many methadone-maintained
individuals presents a major challenge in many clinical settings. Furthermore, recent
expert guidelines have called for increased research on the safety of methadone in
the context of chronic pain. This study explores the prevalence and correlates of
pain among a prospective cohort of people who use illicit drugs in Vancouver, British
Columbia, Canada, who reported enrollment in methadone maintenance treatment (MMT)
between 2011 and 2014. Among the 823 participants eligible for this analysis, 338
(40.9%) reported moderate pain and 91 (11.1%) reported extreme pain at the first study
visit. In multivariable, generalized, linear mixed model analyses, higher pain severity
was positively and independently associated with self-managing pain (adjusted odds
ratio [AOR] 2.15, 95% confidence interval [CI] 1.77–2.60), patient perception of methadone
dose being too low (AOR 1.82, 95% CI 1.41–2.34), older age (AOR 1.31, 95% CI 1.13–1.51),
having a physical disability (AOR 4.59, 95% CI 3.73–5.64), having ever been diagnosed
with a mental illness (AOR 1.44, 95% CI 1.13–1.84), white ethnicity (AOR 1.42, 95%
CI 1.10–1.83), and marijuana use (AOR 1.25, 95% CI 1.02–1.52). These findings suggest
several areas for clinical intervention, particularly related to patient education
and alternative analgesic approaches for MMT patients experiencing pain.
Perspective
To better understand the complexity of concurrent pain and opioid dependency among
individuals on methadone maintenance treatment, this article describes the prevalence
and correlates of higher pain severity among methadone-maintained people who use illicit
drugs. Patients on methadone with comorbid pain may benefit from education and alternative
analgesic approaches.
Key words
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References
- Opioid-induced hyperalgesia: a qualitative systematic review.Anesthesiology. 2006; 104: 570-587
- Guilty until proven innocent: a qualitative study of the management of chronic non-cancer pain among patients with a history of substance abuse.Addict Behav. 2010; 35: 270-272
- Pain and substance-related pain-reduction behaviors among opioid dependent individuals seeking methadone maintenance treatment.Am J Addict. 2009; 18: 117-121
- Chronic pain in Canada: have we improved our management of chronic noncancer pain?.Pain Res Manag. 2007; 12: 39-47
- Assessing proportionality in the proportional odds model for ordinal logistic regression.Biometrics. 1990; 46: 1171-1178
- A comparison of pain report and adequacy of analgesic therapy in ambulatory AIDS patients with and without a history of substance abuse.Pain. 1997; 72: 235-243
- The accuracy of pain and fatigue items across different reporting periods.Pain. 2008; 139: 146-157
- Methadone safety: a clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society.J Pain. 2014; 15: 321-337
- Pain and ethnicity in the United States: a systematic review.J Palliat Med. 2006; 9: 1454-1473
- Physical disability and the experience of chronic pain.Arch Phys Med Rehabil. 2002; 83: 229-235
- Severity and interference of chronic pain in methadone-maintained outpatients.Pain Med. 2014; 15: 1540-1548
- Race, ethnicity and pain.Pain. 2001; 94: 133-137
- Chronic pain secondary to disability: a review.Clin J Pain. 2003; 19: 3-17
- Chronic and acute pain and pain management for patients in methadone maintenance treatment.Am J Addict. 2013; 22: 75-83
- Do opioids induce hyperalgesia in humans? An evidence-based structured review.Pain Med. 2009; 10: 829-839
- Applied Longitudinal Analysis.John Wiley, New Jersey2004
- Pain catastrophizing and pain coping among methadone-maintained patients.Pain Med. 2011; 12: 79-86
- Measuring health-related quality of life in rheumatoid arthritis: validity, responsiveness and reliability of EuroQol (EQ-5D).Br J Rheumatol. 1997; 36: 551-559
- Response to methadone maintenance treatment of opiate dependent patients with and without significant pain.Drug Alcohol Depend. 2006; 82: 187-193
- Characteristics of methadone maintenance patients with chronic pain.J Pain Symptom Manage. 2000; 19: 53-62
- The prevalence of chronic pain in United States adults: results of an Internet-based survey.J Pain. 2010; 11: 1230-1239
- Categorising methadone: addiction and analgesia.Int J Drug Policy. 2013; 24: e18-e24
- Prescription opioid abuse, pain and addiction: clinical issues and implications.Drug Alcohol Rev. 2011; 30: 300-305
- Risk factors for developing a cutaneous injection-related infection among injection drug users: a cohort study.BMC Public Health. 2008; 8: 405
- Evaluation of abuse of prescription and illicit drugs in chronic pain patients receiving short-acting (hydrocodone) or long-acting (methadone) opioids.Pain Physician. 2005; 8: 257-261
- Homelessness as a structural barrier to effective antiretroviral therapy among HIV-seropositive illicit drug users in a Canadian setting.AIDS Patient Care STDS. 2012; 26: 60-67
- Chronic pain in Canada–prevalence, treatment, impact and the role of opioid analgesia.Pain Res Manag. 2002; 7: 179-184
NIAAA: Moderate & Binge Drinking. Available at: http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking Accessed November 1, 2013
- Correlates of pain in an in-treatment sample of opioid-dependent people.Drug Alcohol Rev. 2013; 32: 489-494
- Validity and responsiveness of EuroQol-5 dimension (EQ-5D) versus Short Form-6 dimension (SF-6D) questionnaire in chronic pain.Health Qual Life Outcomes. 2013; 11: 110
- Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse.Clin J Pain. 2006; 22: 173-181
- Significantly higher methadone dose for methadone maintenance treatment (MMT) patients with chronic pain.Pain. 2005; 113: 340-346
- Physical pain and associated clinical characteristics in treatment-seeking patients in 4 substance use disorder treatment modalities.Am J Addict. 2008; 17: 121-125
- Stigma, social inequality and alcohol and drug use.Drug Alcohol Rev. 2005; 24: 143-155
- Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities.JAMA. 2003; 289: 2370-2378
- Modern Epidemiology: Third Edition.Lippincott Williams & Wilkins, Philadelphia, PA2008
SAMHSA. Substance Abuse and Mental Health Services Administration (SAMHSA). (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4586Findings). Rockville, MD., 2010
- Treatment of pain in methadone-maintained patients.Mt Sinai J Med. 2000; 67: 412-422
- Barriers to use of free antiretroviral therapy in injection drug users.JAMA. 1998; 280: 547-549
- Needle exchange is not enough: lessons from the Vancouver injecting drug use study.AIDS. 1997; 11: F59-F65
- Treatment needs associated with pain in substance use disorder patients: implications for concurrent treatment.Drug Alcohol Depend. 2004; 73: 23-31
- The impact of sampling and measurement on the prevalence of self-reported pain in Canada.Pain Res Manag. 2003; 8: 157-163
- Validity of the EQ-5D as a generic health outcome instrument in a heroin-dependent population.Drug Alcohol Depend. 2006; 82: 111-118
- Self-management of pain among people who inject drugs in Vancouver.Pain Manag. 2014; 4: 27-35
- Research gaps on methadone harms and comparative harms: findings from a review of the evidence for an American Pain Society and College on Problems of Drug Dependence clinical practice guideline.J Pain. 2014; 15: 366-376
Article info
Publication history
Published online: June 20, 2015
Accepted:
June 6,
2015
Received in revised form:
May 28,
2015
Received:
April 24,
2015
Footnotes
Disclosures: This study was supported by the U.S. National Institutes of Health (R01DA011591 and R01DA021525). This research was undertaken, in part, thanks to funding from the Canada Research Chairs program through a Tier 1 Canada Research Chair in Inner City Medicine, which supports E.W. J.M. is supported with grants paid to his institution by the British Columbia Ministry of Health and by the U.S. National Institutes of Health (R01DA036307). He has also received limited unrestricted funding, paid to his institution, from Abbvie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck, and ViiV Healthcare. P.V. and K.H. are supported by the Canadian Institutes of Health Research. The authors have no other potential competing interests to declare.
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© 2015 American Pain Society. Published by Elsevier Inc. All rights reserved.
