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Benzodiazepine Use and Dependence in Relation to Chronic Pain Intensity and Pain Catastrophizing

Published:October 11, 2022DOI:https://doi.org/10.1016/j.jpain.2022.09.019

      Highlights

      • Findings extend limited prior work examining pain in relation to addiction-relevant BZD use patterns.
      • Pain intensity was positively associated with BZD dependence severity and likelihood of BZD misuse.
      • Pain catastrophizing accounted for variance in BZD use beyond that accounted for by pain intensity.
      • Fifty-six percentage of participants endorsed pain as a symptom for which they seek relief by taking BZDs.
      • Future research should elucidate mechanisms and temporal ordering in pain-BZD use relations.

      Abstract

      Benzodiazepines (BZDs), a class of sedative-hypnotic medications, generated concern as their popularity grew, with particular alarm regarding elevated rates of BZD use among chronic pain populations. Consistent with negative reinforcement/motivational models of substance use, desire for pain alleviation may motivate BZD use. Yet, little is known about relations between pain and addiction-relevant BZD use processes. This cross-sectional survey study aimed to: a) test associations between pain intensity and clinically relevant BZD use patterns, and b) examine the role of pain catastrophizing in hypothesized pain-BZD relations. Participants included 306 adults with chronic musculoskeletal pain and a current BZD prescription who completed an online survey study (Mage = 38.7, 38.9% female). Results indicated that pain intensity was positively associated with past-month BZD use frequency, BZD dependence severity, and likelihood of endorsing BZD misuse behaviors (ps < .05). Pain catastrophizing was positively associated with BZD dependence/likelihood of BZD misuse, covarying for pain intensity (P < .05). These findings build upon an emerging literature by highlighting positive covariation of pain intensity and pain catastrophizing with addiction-relevant BZD use behaviors. Results underscore the need to further investigate high-risk BZD use among individuals with chronic pain, with and without concurrent opioid use, to inform prevention/intervention efforts.

      Perspective

      This article presents findings on cross-sectional associations of pain intensity and pain catastrophizing with clinically relevant benzodiazepine (BZD) use outcomes, including dependence and misuse, among individuals with chronic pain. Findings help elucidate the higher burden of BZD misuse/dependence in chronic pain populations and suggest that pain relief may be a common, yet under recognized, self-reported motivation for taking BZDs.

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      References

        • Agarwal SD
        • Landon BE
        Patterns in outpatient benzodiazepine prescribing in the United States.
        JAMA Network Open. 2019; 2e187399
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
        5th ed. Author, Arlington, VA2013
        • Bachhuber MA
        • Hennessy S
        • Cunningham CO
        • Starrels JL.
        Increasing benzodiazepine prescriptions and overdose mortality in the United States, 1996–2013.
        Am J Public Health. 2016; 106: 686-688
        • Bandelow B
        • Michaelis S
        • Wedekind D.
        Treatment of anxiety disorders.
        Dialogues Clin Neurosci. 2017; 19: 93-107
        • Bastien CH
        • Vallieres A
        • Morin CM.
        Validation of the Insomnia Severity Index as an outcome measure for insomnia research.
        Sleep Med. 2001; 2: 297-307
        • Bergtold JS
        • Yeager EA
        • Featherstone AM
        Sample size and robustness of inferences from logistic regression in the presence of nonlinearity and multicollinearity.
        in: Agricultural and Applied Economics Association 2011 Annual Meeting, Pittsburgh, PA2011
        • Beymer MR
        • Holloway IW
        • Grov C.
        Comparing self-reported demographic and sexual behavioral factors among men who have sex with men recruited through Mechanical Turk, Qualtrics, and a HIV/STI clinic-based sample: Implications for researchers and providers.
        Arch Sex Behav. 2018; 47: 133-142
        • Black JC
        • Rockhill K
        • Forber A
        • Amioka E
        • May KP
        • Haynes CM
        • Dasgupta N
        • Dart RC.
        An online survey for pharmacoepidemiological investigation (survey of non-medical use of prescription drugs program): validation study.
        J Med Internet Res. 2019; 21: e15830
        • Blanco C
        • Han B
        • Jones CM
        • Johnson K
        • Compton WM.
        Prevalence and correlates of benzodiazepine use, misuse, and use disorders among adults in the United States.
        J Clin Psychiatry. 2018; 7918m12174
        • Box GE
        • Tidwell PW.
        Transformation of the independent variables.
        Technometrics. 1962; 4: 531-550
        • Boyd CJ
        • Austic E
        • Epstein-Ngo Q
        • Veliz PT
        • McCabe SE.
        A prospective study of adolescents' nonmedical use of anxiolytic and sleep medication.
        Psychol Addict Behav. 2015; 29: 184-191
        • Brett J
        • Murnion B.
        Management of benzodiazepine misuse and dependence.
        Australian Prescriber. 2015; 38: 152-155
        • Campbell CM
        • Kronfli T
        • Buenaver LF
        • Smith MT
        • Berna C
        • Haythornthwaite JA
        • Edwards RR.
        Situational versus dispositional measurement of catastrophizing: associations with pain responses in multiple samples.
        J Pain. 2010; 11 (e442): 443-453
        • Chandler J
        • Shapiro D.
        Conducting clinical research using crowdsourced convenience samples.
        Annu Rev Clin Psychol. 2016; 12: 53-81
        • Chandler JJ
        • Paolacci G.
        Lie for a dime: When most prescreening responses are honest but most study participants are impostors.
        Soc Psychol Personal Sci. 2017; 8: 500-508
        • Cheng S
        • Siddiqui TG
        • Gossop M
        • Kristoffersen ES
        • Lundqvist C.
        The severity of dependence scale detects medication misuse and dependence among hospitalized older patients.
        BMC Geriatr. 2019; 19: 174
        • Cunningham JA
        • Godinho A
        • Kushnir V.
        Using mechanical turk to recruit participants for internet intervention research: experience from recruitment for four trials targeting hazardous alcohol consumption.
        BMC Med Res Methodol. 2017; 17: 156
        • Cunningham JL
        • Craner JR
        • Evans MM
        • Hooten WM.
        Benzodiazepine use in patients with chronic pain in an interdisciplinary pain rehabilitation program.
        J Pain Res. 2017; 10: 311-317
        • Dasgupta N
        • Funk MJ
        • Proescholdbell S
        • Hirsch A
        • Ribisl KM
        • Marshall S.
        Cohort study of the impact of high-dose opioid analgesics on overdose mortality.
        Pain Med. 2016; 17: 85-98
        • de las Cuevas C
        • Sanz EJ
        • de la Fuente JA
        • Padilla J
        • Berenguer JC.
        The Severity of Dependence Scale (SDS) as screening test for benzodiazepine dependence: SDS validation study.
        Addiction. 2000; 95: 245-250
        • Dellemijn PL
        • Fields HL.
        Do benzodiazepines have a role in chronic pain management?.
        Pain. 1994; 57: 137-152
        • Ditre JW
        • Brandon TH.
        Pain as a motivator of smoking: effects of pain induction on smoking urge and behavior.
        J Abnorm Psychol. 2008; 117: 467-472
        • Ditre JW
        • Zale EL
        • LaRowe LR.
        A reciprocal model of pain and substance use: Transdiagnostic considerations, clinical implications, and future directions.
        Annu Rev Clin Psychol. 2019; 15: 503-528
        • Dunn KE
        • Barrett FS
        • Yepez-Laubach C
        • Meyer AC
        • Hruska BJ
        • Sigmon SC
        • Fingerhood M
        • Bigelow GE.
        Brief Opioid Overdose Knowledge (BOOK): A questionnaire to assess overdose knowledge in individuals who use illicit or prescribed opioids.
        J Addict Med. 2016; 10: 314-323
        • Edwards RR
        • Cahalan C
        • Mensing G
        • Smith M
        • Haythornthwaite JA.
        Pain, catastrophizing, and depression in the rheumatic diseases.
        Nat Rev Rheumatol. 2011; 7: 216-224
        • Elman I
        • Borsook D.
        Common brain mechanisms of chronic pain and addiction.
        Neuron. 2016; 89: 11-36
        • Faul F
        • Erdfelder E
        • Buchner A
        • Lang A-G.
        Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses.
        Behav Res Methods. 2009; 41: 1149-1160
        • Fillingim RB
        • King CD
        • Ribeiro-Dasilva MC
        • Rahim-Williams B
        • Riley 3rd, JL
        Sex, gender, and pain: a review of recent clinical and experimental findings.
        J Pain. 2009; 10: 447-485
        • George D
        • Mallery P
        SPSS for Windows Step by Step: A Simple Study Guide and Reference, 17.0 update, 10/e.
        Allyn & Bacon, Boston, MA2011
        • Granot M
        • Ferber SG.
        The roles of pain catastrophizing and anxiety in the prediction of postoperative pain intensity: A prospective study.
        Clin J Pain. 2005; 21: 439-445
        • Griffin 3rd, CE
        • Kaye AM
        • Bueno FR
        • Kaye AD
        Benzodiazepine pharmacology and central nervous system-mediated effects.
        Ochsner J. 2013; 13: 214-223
        • Guarino H
        • Fong C
        • Marsch LA
        • Acosta MC
        • Syckes C
        • Moore SK
        • Cruciani RA
        • Portenoy RK
        • Turk DC
        • Rosenblum A.
        Web-Based cognitive behavior therapy for chronic pain patients with aberrant drug-related behavior: outcomes from a randomized controlled trial.
        Pain Med. 2018; 19: 2423-2437
        • Gudin JA
        • Mogali S
        • Jones JD
        • Comer SD.
        Risks, management, and monitoring of combination opioid, benzodiazepines, and/or alcohol use.
        Postgrad Med J. 2013; 125: 115-130
        • Guina J
        • Merrill B.
        Benzodiazepines I: upping the care on downers: the evidence of risks, benefits and alternatives.
        Clin Med (Northfield Il). 2018; 7
        • Hayashi K
        • Suwannawong P
        • Ti L
        • Kaplan K
        • Wood E
        • Kerr T
        High rates of midazolam injection and associated harms in Bangkok, Thailand.
        Addiction. 2013; 108: 944-952
        • Hayes AF
        Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach.
        Guilford Publications, New York, NY2017
        • Herrero Babiloni A
        • De Koninck BP
        • Beetz G
        • De Beaumont L
        • Martel MO
        • Lavigne GJ.
        Sleep and pain: recent insights, mechanisms, and future directions in the investigation of this relationship.
        J Neural Transmiss (Vienna). 2020; 127: 647-660
        • Hydock C
        Assessing and overcoming participant dishonesty in online data collection.
        Behav Res Methods. 2018; 50: 1563-1567
        • IBM Corp
        IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY.
        IBM Corp, Armonk, NY2020
      1. Institute of Medicine: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.
        National Institutes of Health, Washington (DC)2011
        • Jones JD
        • Mogali S
        • Comer SD.
        Polydrug abuse: A review of opioid and benzodiazepine combination use.
        Drug Alcohol Depend. 2012; 125: 8-18
        • Kaufmann CN
        • Spira AP
        • Depp CA
        • Mojtabai R.
        Long-term use of benzodiazepines and nonbenzodiazepine hypnotics, 1999-2014.
        Psychiatr Serv. 2018; 69: 235-238
        • Kim HS
        • McCarthy DM
        • Hoppe JA
        • Mark Courtney D
        • Lambert BL
        Emergency department provider perspectives on benzodiazepine-opioid coprescribing: A qualitative study.
        Acad Emerg Med. 2018; 25: 15-24
        • Kneeland ET
        • Griffin ML
        • Taghian N
        • Weiss RD
        • McHugh RK.
        Associations between pain catastrophizing and clinical characteristics in adults with substance use disorders and co-occurring chronic pain.
        Am J Drug Alcohol Abuse. 2019; 45: 488-494
        • Kosiba JD
        • Zale EL
        • Ditre JW.
        Associations between pain intensity and urge to smoke: Testing the role of negative affect and pain catastrophizing.
        Drug Alcohol Depend. 2018; 187: 100-108
        • Krueger RF
        • Eaton NR.
        Transdiagnostic factors of mental disorders.
        World Psychiat. 2015; 14: 27-29
        • LaRowe LR
        • Maisto SA
        • Ditre JW.
        A measure of expectancies for alcohol analgesia: Preliminary factor analysis, reliability, and validity.
        Addict Behav. 2021; 116106822
        • Lawton J
        • Simpson J.
        Predictors of alcohol use among people experiencing chronic pain.
        Psychol Health Med. 2009; 14: 487-501
        • Lembke A
        • Papac J
        • Humphreys K.
        Our other prescription drug problem.
        N Engl J Med. 2018; 378: 693-695
        • Liebschutz JM
        • Saitz R
        • Weiss RD
        • Averbuch T
        • Schwartz S
        • Meltzer EC
        • Claggett-Borne E
        • Cabral H
        • Samet JH.
        Clinical factors associated with prescription drug use disorder in urban primary care patients with chronic pain.
        J Pain. 2010; 11: 1047-1055
        • Limandri BJ
        Benzodiazepine use: The underbelly of the opioid epidemic.
        J Psychosoc Nurs Ment Health Serv. 2018; 56: 11-15
        • Löwe B
        • Decker O
        • Müller S
        • Brähler E
        • Schellberg D
        • Herzog W
        • Herzberg PY.
        Validation and standardization of the generalized anxiety disorder screener (GAD-7) in the general population.
        Med Care. 2008; 46: 266-274
        • Martel MO
        • Edwards RR
        • Jamison RN
        The relative contribution of pain and psychological factors to opioid misuse: A 6-month observational study.
        Am Psychol. 2020; 75: 772-783
        • Martel MO
        • Wasan AD
        • Jamison RN
        • Edwards RR
        Catastrophic thinking and increased risk for prescription opioid misuse in patients with chronic pain.
        Drug Alcohol Depend. 2013; 132: 335-341
        • Martin CS
        Timing of alcohol and other drug use.
        Alcohol Res Health. 2008; 31: 96-99
        • Maust DT
        • Lin LA
        • Blow FC.
        Benzodiazepine use and misuse among adults in the United States.
        Psychiatr Serv. 2019; 70: 97-106
        • McCabe SE.
        Correlates of nonmedical use of prescription benzodiazepine anxiolytics: results from a national survey of U.S. college students.
        Drug Alcohol Depend. 2005; 79: 53-62
        • McCabe SE
        • Cranford JA.
        Motivational subtypes of nonmedical use of prescription medications: Results from a national study.
        J Adolesc Health. 2012; 51: 445-452
        • McCabe SE
        • West BT
        • Cranford JA
        • Ross-Durow P
        • Young A
        • Teter CJ
        • Boyd CJ.
        Medical misuse of controlled medications among adolescents.
        Arch Pediatr Adolesc Med. 2011; 165: 729-735
        • McEwen BS
        Allostasis and allostatic load: implications for neuropsychopharmacology.
        Neuropsychopharmacology. 2000; 22: 108-124
        • McHugh RK
        • Votaw VR
        • Bogunovic O
        • Karakula SL
        • Griffin ML
        • Weiss RD.
        Anxiety sensitivity and nonmedical benzodiazepine use among adults with opioid use disorder.
        Addict Behav. 2017; 65: 283-288
        • Mogil JS
        Sex differences in pain and pain inhibition: multiple explanations of a controversial phenomenon.
        Nat Rev Neurosci. 2012; 13: 859-866
        • Morin CM
        • Belleville G
        • Bélanger L
        • Ivers H.
        The Insomnia Severity Index: Psychometric indicators to detect insomnia cases and evaluate treatment response.
        Sleep. 2011; 34: 601-608
        • Moskal D
        • Maisto SA
        • De Vita M
        • Ditre JW.
        Effects of experimental pain induction on alcohol urge, intention to consume alcohol, and alcohol demand.
        Exp Clin Psychopharmacol. 2018; 26: 65-76
        • Myers RH
        Classical and Modern Regression with Applications.
        Duxbury Press, Belmont, CA1990
        • Nicholson HL
        • Ford JA.
        Correlates of prescription opioid misuse among black adults: findings from the 2015 national survey on drug use and health.
        Drug Alcohol Depend. 2018; 186: 264-267
        • Nielsen S
        • Lintzeris N
        • Bruno R
        • Campbell G
        • Larance B
        • Hall W
        • Hoban B
        • Cohen ML
        • Degenhardt L.
        Benzodiazepine use among chronic pain patients prescribed opioids: associations with pain, physical and mental health, and health service utilization.
        Pain Med. 2015; 16: 356-366
        • Nieto SJ
        • Green R
        • Grodin EN
        • Cahill CM
        • Ray LA.
        Pain catastrophizing predicts alcohol craving in heavy drinkers independent of pain intensity.
        Drug Alcohol Depend. 2021; 218108368
        • Olfson M
        • King M
        • Schoenbaum M.
        Benzodiazepine use in the United States.
        JAMA Psychiatr. 2015; 72: 136-142
        • Osman A
        • Barrios FX
        • Gutierrez PM
        • Kopper BA
        • Merrifield T
        • Grittmann L.
        The pain catastrophizing scale: Further psychometric evaluation with adult samples.
        J Behav Med. 2000; 23: 351-365
        • Pandraud-Riguet I
        • Bonnet-Zamponi D
        • Bourcier E
        • Buyse M
        • Laribe-Caget S
        • Frémont P
        • Pautas E
        • Verny C
        • Hindlet P
        • Fernandez C.
        Monitoring of potentially inappropriate prescriptions in older inpatients: A French multicenter study.
        J Am Geriatr Soc. 2017; 65: 2713-2719
        • Paolacci G
        • Chandler J.
        Inside the Turk: Understanding mechanical Turk as a participant pool.
        Curr Dir Psychol Sci. 2014; 23: 184-188
        • Pergolizzi JV
        • LeQuang JA.
        Reappraising the use of benzodiazepines in chronic pain patients.
        Postgrad Med J. 2020; 132: 10-12
        • Quartana PJ
        • Campbell CM
        • Edwards RR.
        Pain catastrophizing: a critical review.
        Expert Rev Neurother. 2009; 9: 745-758
        • SAMHSA
        2018 National Survey on Drug Use and Health: Methodological Summary and Definitions.
        Center for Behavioral Health Statistics and Quality, Rockville, MD2018
        • Schmitz A
        Benzodiazepines: The time for systematic change is now.
        Addiction. 2021; 116: 219-221
        • Schutte-Rodin S
        • Broch L
        • Buysse D
        • Dorsey C
        • Sateia M.
        Clinical guideline for the evaluation and management of chronic insomnia in adults.
        J Clin Sleep Med. 2008; 4: 487-504
        • Sharpe Wessling K
        • Huber J
        • Netzer O.
        MTurk character misrepresentation: Assessment and solutions.
        J Consumer Res. 2017; 44: 211-230
        • Soyka M
        Treatment of benzodiazepine dependence.
        N Engl J Med. 2017; 376: 1147-1157
        • Spitzer RL
        • Kroenke K
        • Williams JBW
        • Löwe B.
        A brief measure for assessing generalized anxiety disorder: The GAD-7.
        Arch Intern Med. 2006; 166: 1092-1097
        • Stein MD
        • Kanabar M
        • Anderson BJ
        • Lembke A
        • Bailey GL.
        Reasons for benzodiazepine use among persons seeking opioid detoxification.
        J Subst Abuse Treat. 2016; 68: 57-61
        • Sterniczuk R
        • Whelan J.
        Cannabis use among Canadian armed forces veterans.
        J Military Veteran Family Health. 2016; 2: 43-52
        • Strickland JC
        • Lile JA
        • Stoops WW.
        Contribution of cannabis-related cues to concurrent reinforcer choice in humans.
        Drug Alcohol Depend. 2019; 199: 85-91
        • Strickland JC
        • Lile JA
        • Stoops WW.
        Evaluating non-medical prescription opioid demand using commodity purchase tasks: Test-retest reliability and incremental validity.
        Psychopharmacology (Berlin). 2019; 236: 2641-2652
        • Strickland JC
        • Stoops WW.
        Perceptions of research risk and undue influence: Implications for ethics of research conducted with cocaine users.
        Drug Alcohol Depend. 2015; 156: 304-310
        • Strickland JC
        • Stoops WW.
        The use of crowdsourcing in addiction science research: Amazon mechanical Turk.
        Exp Clin Psychopharmacol. 2019; 27: 1-18
        • Sullivan MJL
        • Bishop SR
        • Pivik J.
        The pain catastrophizing scale: Development and validation.
        Psychol Assess. 1995; 7: 524-532
        • Szmulewicz A
        • Bateman BT
        • Levin R
        • Huybrechts KF.
        The risk of overdose with concomitant use of z-drugs and prescription opioids: A population-based cohort study.
        Am J Psychiatry. 2021; 178: 643-650
        • Torrance N
        • Mansoor R
        • Wang H
        • Gilbert S
        • Macfarlane GJ
        • Serpell M
        • Baldacchino A
        • Hales TG
        • Donnan P
        • Wyper G
        • Smith BH
        • Colvin L.
        Association of opioid prescribing practices with chronic pain and benzodiazepine co-prescription: a primary care data linkage study.
        Br J Anaesth. 2018; 120: 1345-1355
        • Treede RD
        • Rief W
        • Barke A
        • Aziz Q
        • Bennett MI
        • Benoliel R
        • Cohen M
        • Evers S
        • Finnerup NB
        • First MB
        • Giamberardino MA
        • Kaasa S
        • Kosek E
        • Lavandʼhomme P
        • Nicholas M
        • Perrot S
        • Scholz J
        • Schug S
        • Smith BH
        • Svensson P
        • Vlaeyen JW
        • Wang SJ.
        A classification of chronic pain for ICD-11.
        Pain. 2015; 156: 1003-1007
        • Vogel M
        • Knöpfli B
        • Schmid O
        • Prica M
        • Strasser J
        • Prieto L
        • Wiesbeck GA
        • Dürsteler-MacFarland KM
        Treatment or “high”: Benzodiazepine use in patients on injectable heroin or oral opioids.
        Addict Behav. 2013; 38: 2477-2484
        • Von Korff M
        Assessment of chronic pain in epidemiological and health services research: Empirical bases and new directions.
        Handbook of Pain Assessment. 3rd ed. The Guilford Press, New York, NY, US2011: 455-473
        • Von Korff M
        • Ormel J
        • Keefe FJ
        • Dworkin SF.
        Grading the severity of chronic pain.
        Pain. 1992; 50: 133-149
        • Votaw VR
        • Geyer R
        • Rieselbach MM
        • McHugh RK.
        The epidemiology of benzodiazepine misuse: A systematic review.
        Drug Alcohol Depend. 2019; 200: 95-114
        • Votaw VR
        • McHugh RK
        • Vowles KE
        • Witkiewitz K.
        Patterns of polysubstance use among adults with tranquilizer misuse.
        Subst Use Misuse. 2020; 55: 861-870
        • Walters K
        • Christakis DA
        • Wright DR.
        Are mechanical Turk worker samples representative of health status and health behaviors in the U.S.?.
        PLoS One. 2018; 13e0198835
        • Wiens TK
        • Walker LJ.
        The chronic disease concept of addiction: Helpful or harmful?.
        Addict Res Theory. 2015; 23: 309-321
        • Wright SL.
        Limited utility for benzodiazepines in chronic pain management: A narrative review.
        Adv Ther. 2020; 37: 2604-2619
        • Xu K
        • Hartz S
        • Borodovsky J
        • Bierut L
        • Grucza R.
        Association between benzodiazepine use with or without opioid use and all-cause mortality in the United States, 1999-2015.
        JAMA Network Open. 2020; 3e2028557
        • Xu KY
        • Borodovsky JT
        • Presnall N
        • Mintz CM
        • Hartz SM
        • Bierut LJ
        • Grucza RA.
        Association between benzodiazepine or z-drug prescriptions and drug-related poisonings among patients receiving buprenorphine maintenance: A case-crossover analysis.
        Am J Psychiatry. 2021; 178: 651-659