Pain and Substance Use Disorders

Background: Chronic non-cancer pain and substance use disorders frequently co-occur in VA
primary care and addictions treatment settings. The treatment for pain is complicated in
veterans with a history of alcohol or drug misuse because of a potential for abuse and
diversion of many prescription pain medications. Thus, treatment providers are left without
successful and empirically-supported methods for treating the large number of patients with
chronic pain who also have past or current substance use disorders. One potential strategy
is to use cognitive-behavioral treatment (CBT) interventions to manage pain and decrease
substance use abuse/misuse. Psychosocial interventions such as CBT have demonstrated
efficacy for reducing pain and improving functioning in persons with a broad spectrum of
pain-related problems. However, this form of treatment has not been explicitly tested in
patients with co-occurring substance use disorders. Determining the effectiveness of a
psychosocial intervention targeting both pain and substance use disorders would greatly
increase the available treatment options for veterans with these conditions.

Project Objectives: This project is designed to test the effect of a CBT intervention for
patients with chronic pain who are already engaged in VA treatment for substance use
disorders compared to an educational supportive condition on measures of pain intensity,
pain-related disability and pain-tolerance. A set of secondary analyses will examine if
group CBT compared to the educational supportive condition is associated with greater
reductions in illicit substance use over the follow-up time period and whether
during-treatment reductions in pain mediate the effect of treatment assignment on later
substance use. Finally, a series of secondary analyses will explore whether the hypothesized
mechanisms of action for the CBT intervention mediate the effect of this intervention on
pain intensity and pain tolerance.

Methods: The proposed study is a randomized controlled trial of group-based CBT compared to
an educational supportive condition in patients currently receiving drug and alcohol
treatment. A total of 128 Veterans with alcohol or drug abuse or dependence and at least
moderate pain currently treated in the Ann Arbor VA Substance Use Disorder treatment clinic
will be assessed at baseline and then randomly assigned to one of these two conditions.
These patients will be re-assessed at 3-months (i.e. immediately post treatment), 6-months
and 12-months. The primary outcomes will be pain intensity, pain-related disability and pain
tolerance. Mixed model regression analyses will be used for all primary analyses to estimate
between-group differences in changes in individual slopes over time. Finally, a series of
secondary analyses will explore (a) whether the intervention influences post-treatment
substance use, (b) if change in pain during treatment mediates the effect of the
intervention on subsequent substance use and (c) whether the hypothesized mechanisms of
action for the CBT intervention mediate the effect of this intervention on pain intensity
and pain tolerance.