Opioid dependence disorder and comorbid chronic pain: comparison of groups based on patient-attributed direction of the causal relationship between the two conditions

Background: Chronic pain is highly prevalent in treatment-seeking opioid-dependent patients; therefore, this comorbid presentation is an important clinical consideration for both addiction and pain specialists. The objectives of the present study were to examine if the direction of causal attribution of opioid dependence disorder and chronic pain resulted in two distinct clinical populations, and, if so, to compare treatment received during the 5-year follow-up period.

Methods: Participants comprised opioid-dependent patients with chronic pain who reported a perceived causal relationship, in either direction, between the development of these two conditions (n=252). A range of health- and addiction-related instruments were used at study inception. Treatment characteristics were obtained for the follow-up period from national health registers.

Results: Those reporting that pain caused opioid dependence disorder (n=174; 69%) were characterised by poorer pain-related health, more illicit cannabinoid use (p=0.031), more frequent illicit use of opioid analgesics (p=0.025), and they were in receipt of higher doses of prescribed opioid analgesics. Those reporting that opioid dependence disorder caused pain (n=78; 31%) were characterised by poorer overall physical health (p=0.002), more severe psychiatric symptoms and more overall drug use (p=0.001).

Conclusions: Two distinct clinical populations were identified, determined by how participants perceive the causal relationship between opioid dependence disorder and chronic pain. These two populations have differing clinical profiles and treatment requirements: those reporting that pain caused opioid dependence disorder were characterised by poorer pain-related health and more illicit use of drugs with analgesic properties; and those reporting that opioid dependence disorder caused pain were characterised by more overall use of substances, multiple substance use and more intravenous substance use and poorer general health. Identifying the causal direction, where such a relationship exists, could help addiction and pain services to develop more effective, individualised treatment strategies.