Treating co-occurring pain and 

substance use disorders

Mark Ilgen, PhD 

Ann Arbor VA, HSR&D Center of Excellence; 

Serious Mental Illness Treatment and Resource Center (SMITREC); 

Department of Psychiatry, University of Michigan
Disclosure Statement

• No conflicts of interest to disclose

• Research funding from:

– VA Health Services Research & Development

– National Institute on Drug Abuse

1 
Overview

• Review the literature on:

– The overlap between pain and Substance Use Disorders (SUDs)

– The challenges in treating pain in those with SUDs

– The use of prescription opioids in those with and without SUDs

• Describe new initiatives in the VHA to address concerns about 

the increasing use of prescription opioids:

– Opioid Safety Initiative

• Present early results of a randomized trial of Cognitive 

Behavioral Therapy (CBT) to address chronic pain in Veterans 

with SUDs

2 
Attendee Poll Question

3 
What’s meant by ‘pain and addiction’?

4 

Pain

Substance 

Use Disorders

(SUDs) 

Rx Opioid

Misuse
Chronic pain

5 

• “An unpleasant sensory and emotional experience associated 

with actual or potential tissue damage, or described in terms 

of such damage.” [International Association for the Study of Pain (IASP)].

• In national surveys, 25% of adults in the US report some form 

of persistent and/or significant pain (Ilgen et al., 2008; Krueger and Stone 

2008; National Center for Health Statistics 2006).

• Chronic pain is associated with poorer quality of life and 

decreased productivity (Becker et al., 1997; Stewart, 2003).

• Chronic pain is associated with increased risk of suicide (Ilgen et 

al., 2010; Ilgen et al., 2008; Ilgen et al., 2013).

• Chronic pain is linked to a higher prevalence of numerous 

psychiatric conditions (Currie & Wang, 2004; Dersh et al., 2002; MeansChristensen et al., 2008; Von Korff et al., 2005). 
Overlap between chronic pain and SUDs

• In community samples pain is associated with increased risk of SUDs – mainly 

alcohol use disorders (Von Korff et al., 2005). 

• SUDs in those with pain (Morasco et al., 2011): 

– In primary care, 10% of those with chronic non-cancer pain have a current 

SUD

– In specialty pain care, 10-30% of patients have a current SUD

• Pain in those with SUDs in VHA patients (N = 5,195,551):

– Among those with an SUD:

• 44.5% with arthritis (OR = 1.55; 1.54 -1.56) 

• 32.0% with back pain (OR = 2.00; 1.99 - 2.02) 

• 5.6% with neuropathic pain (OR = 1.39; 1.37 - 1.41) 

• 2.1% with migraine (OR = 1.43; 1.40 - 1.47) 

• Rates of pain in SUD treatment settings: 

– ~50% or more of patients in addictions treatment report pain:

• Rates are somewhat higher in programs that treat opioid dependence 

(Trafton et al., 2004; Potter et al., 2008).

• Those with pain typically report more severe patterns of substance 

misuse, psychopathology and functional limitations.

6 
Clinical implications of co-occurring pain 

and SUDs

• The presence of an SUD is associated with poorer functional 

outcomes following pain treatment

– Those with an SUD were 70% less likely to report functional 

improvements during standard pain treatment than those without an 

SUD (Morasco et al., 2011). 

• Chronic pain is associated with a poorer course of posttreatment outcomes following SUD treatment (Larson et al. 2007).

– In a large addictions treatment program, patients with persistent pain 

were more likely to drop out of treatment and were less likely to be 

abstinent at 1-year (Caldeiro et al. 2008).

• Need to improve methods for identifying and treating cooccurring pain and SUDs.

7 
Why do pain and SUDs co-occur?

• Individuals with pain are ‘self-medicating’ 

– Appealing to many patients

– Some support from self-report data (Riley & King, 2009).

– Poorer outcomes in those who use alcohol to manage pain 

(Brennan, Schutte & Moos, 2005).

• Third variables explain this association

• Substance use → injury → pain (Ilgen et al., 2010).

8 
Why do pain and SUDs co-occur? 

– Special considerations for Rx Opioids

• Physical dependence on prescription opioids ≠ SUD

• SUD diagnostic criteria still apply but with 

reconsideration of tolerance and withdrawal

9 
Physiologic Criteria: 

Tolerance, as defined by either of the following:

a) a need for markedly increased amounts of the substance to 

achieve intoxication or the desired effect, or

b) markedly diminished effect with continued use of the same 

amount of the substance

Withdrawal, as defined by either of the following: 

a) the characteristic withdrawal syndrome for the substance, or 

b) the same (or closely related) substance is taken to relieve or avoid 

withdrawal symptoms

DSM-5 Criteria for Substance Use Disorder
Physiologic Criteria: 

Note:

Tolerance and Withdrawal are not counted for 

those taking medications under medical supervision 

such as analgesics, antidepressants, anti-anxiety 

medications or beta-blockers.

DSM-5 Criteria for Substance Use Disorder
DSM-IV: Criteria for SUDs

• Substance abuse: significant impairment or distress as manifested by 1 or more of the 

following, occurring within a 12-month period: 

– Failure to fulfill major role obligations at work, school, or home 

– Use in situations in which it is physically hazardous 

– Recurrent substance-related legal problems 

– Continued use despite social or interpersonal problems

• Substance dependence: significant impairment or distress, as manifested by 3 or more of 

the following, occurring any time in the same 12-month period: 

– Tolerance: (a) need for increased amounts to achieve intoxication or the desired effect or (b) 

diminished effect with continued use of the same amount of the substance

– Withdrawal: (a) The characteristic withdrawal syndrome for the substance or (b) substance is taken 

to relieve or avoid withdrawal symptoms

– The substance is often taken in larger amounts or over a longer period than intended

– There is a persistent desire or unsuccessful efforts to cut down use

– Excess time is spent obtaining, using or recovering from use

– Decrease of important social, occupational, or recreational activities 

– Continued use despite knowledge of problems due to use

• DSM-V adds craving and combines the categories

12
Why do pain and SUDs 

co-occur? – Rx opioids

• Physical dependence on prescription opioids ≠ SUD

• SUD diagnostic criteria still apply but with 

reconsideration of tolerance and withdrawal

• Pseudoaddiction (Weissman & Haddox 1989).

• Opioid induced hyperalgesia (Angst & Clark 2006).

• The terminology surrounding opioid misuse is confusing

13
Opioids for the treatment of chronic pain

– Opioids are now the most common form of 

treatment for chronic non-cancer pain (Turk & 

Okifuji, 2002). 

– In all patients, there are concerns about:

• Lack of data on the efficacy of long-term opioid 

therapy for non-cancer pain

• Overdose

• Misuse and diversion

14
Rates of prescription painkiller sales, deaths and 

SUD treatment admissions (1999-2010)

15
Is overdose risk related to dose of 

medication?

16

Bohnert et al., 2011 
Risk of Unintentional Overdose for SUDs

Bohnert et al., 2012 
Defining “opioid misuse”

• Sometimes called “opioid abuse”, “extra-medical use” or 

“non-medical use” of opioids

• Other aberrant drug-related behaviors – 

– lost meds, early refill requests, borrowing/sharing meds, 

getting meds from other providers (Dr. shopping?)

• NSDUH - “Have you ever, even once, used NAME OF 

DRUG that was not prescribed for you or that you took 

only for the experience or feeling it caused?”

18
Pain medication misuse

19

Is the medication being used for 

pain relief? 

(vs. other effects) 

No Yes

Is the medication taken as 

prescribed?

(to you!)

No

Yes
Past Year Substance Use Among U.S. Residents (Age 12 or 

older); 

2010 NSDUH 

20
Ways to assess for pain medication misuse

• Past 30 day pain medication misuse

– Current Opioid Medication Misuse (COMM; Butler et al., 2007)

• “How often have you needed to take pain medications belonging to 

someone else?”

• “How often have you had to go to someone other than your prescribing 

physician to get sufficient pain relief from your medications?”

• How often have you taken your medications differently from how they 

are prescribed?

• “How often have you had to take more of your medication than 

prescribed?”

• “How often have you borrowed pain medication from someone else?”

• “How often have you used your pain medication for symptoms other than 

for pain?” 

21
ADD QUIZ!– Heidi, please format for 

me. 

• How often do you ask the patients that you see 

who are currently receiving opioids from the VHA 

about the misuse opioids?

– Never

– Rarely

– Sometimes 

– Often 

– Almost always

– Always

– Not Applicable, I do not see any patients in my 

current role

22
Results of screening surveys of patients in 

different settings

• Adults treated in a low-income dental clinic at 

the University of Michigan (N = 384)

– 38.6% reported pain medication misuse

• Adults treated (n = 477) in an Urban 

Emergency Department

– 39.8% reported pain medication misuse

• Adults in residential SUD treatment (N = 351)

– 68% endorsed pain medication misuse

23
Opioid prescribing guidelines for those 

with SUDs

• VA opioid prescribing guidelines

http://www.healthquality.va.gov/COT_312_Fuller.pdf

– Those with a current SUD should

• Receive concurrent SUD treatment

• Frequent monitoring 

24
Opioid treatment in the VHA

• Poor overall adherence to clinical guidelines

– VHA primary care (Krebs et al., 2010):

• 14% assessed for drug/alcohol use

• 11% used an opioid agreement

• 15% used urine drug screens

– SUD vs. non-SUD patients (Morasco, Duckart & Dobscha, 2011):

• 30% had a mental health appointment (versus 17% of those without an SUD)

• 35% had a SUD treatment appointment

• 47% received a urine drug screen (versus 18% of those without an SUD) 

• High dose prescribing (> 180 mg/day morphine equivalent 

dose; Morasco et al., 2010):

– 2.4% of all chronic pain patients; 8.2% of those w/ an opioid

– More likely to have 4+ pain conditions, MH and SUDs and prescription of 

a benzodiazapine

25
Improving care for VHA patients with 

chronic pain and SUDs

• Increase the awareness of and adherence to clinical 

practice guidelines:

– Use of urine drug screens

– Referrals to specialty SUD treatment

• Identification and re-evaluation of high risk patients 

based on:

– Current opioid dose

– Adverse event

– Problematic pattern of service utilization

26
Improving care for VHA patients with 

chronic pain and SUDs

• In all settings, improve measurement of:

– Pain 

– functioning

– opioid misuse

– substance use disorders

• Increase awareness of effectiveness of behavioral 

treatments for pain and availability of these treatments 

• Increase use of evidence-based SUD treatment

– Pharmacotherapy for those with opioid dependence

• Weiss et al., 2011 – maintenance (47%) far better than taper (8%)

27
Uniform Mental Health Services in VA 

Medical Centers and Clinics

(i) Pharmacotherapy with approved, appropriately- regulated 

opioid agonists (e.g., buprenorphine or methadone) must be 

available to all patients diagnosed with opioid dependence for 

whom it is indicated and for whom there are no medical 

contraindications... in addition to, and directly linked with, 

psychosocial treatment and support.

– If agonist treatment is contraindicated or not acceptable, antagonist 

medication (e.g., naltrexone) needs to be available and considered for 

use when needed. 
Uniform Mental Health Services in VA 

Medical Centers and Clinics

Opioid agonist treatment can be delivered in either or both of the 

following settings:

• Opioid Treatment Program (OTP). 

– formally-approved and regulated opioid substitution clinic using 

methadone or buprenorphine 

– 32 OTPs in house plus 22 by off-site contract. 

• Office-based Buprenorphine Treatment. 

– only by a “waivered” physician 

– includes non-specialty settings (e.g., primary care) 

– 123 medical centers and 121 community clinics
Change in opioid agonist 

pharmacotherapy FY09-11 

Includes office based care (buprenorphine/naloxone) 

Opioid Treatment Program (methadone or buprenorphine/naloxone),

or fee basis care

 Year Opioid

Diagnosis

Treated*

(num)

Diagnosed 

(denom)

 National 

FY09 Dependence 10681 34736 30.1%

FY10 Dependence 12149 38484 31.6%

FY11 Dependence 12894 40753 31.6%

Change 

FY09-11 +20.7% +17.3%
New VHA initiatives to improve care for 

those with pain (and SUDs)

• CBT for the management of chronic pain (evidence-based 

psychotherapy role-out) 

• Shift from opioid pain care agreements (‘opioid contracts’) → 

– Signed Consent for Long-Term Opioid Therapy for Chronic Pain 

– Patient Information Guide called “Taking Opioids Responsibly”

• VHA providers can access state prescription drug monitoring 

programs

• Opioid Safety Initiative” (OSI) which will provide prescriber-level 

data to each VHA facility about: 

– the number of patients prescribed opioids

– the average dose per day per drug

– the number of patients prescribed both opioids and sedatives 

– The number of fentanyl patches dispensed

31
Resources

– National Pain Management Website (www.va.gov/painmanagement ) 

– VA/DoD Clinical Practice Guideline on Management of Opioid Therapy (OT) for 

Chronic Pain (2010)

• http://www.healthquality.va.gov/Chronic_Opioid_Therapy_COT.asp 

– Payne, et al. A Rose by Any Other Name: Pain contracts / Agreements. American 

Journal of Bioethics. 2010;10(11):5–12 

– Handbook 1004.01 Informed Consent for Clinical Treatments and Procedures 

• Monthly “Spotlight on Pain Management” webinar (collaboration with HSR&D 

Center for Information Dissemination and Educational Resources)

• 56 pain-related Office of Research and Development funded research projects in 

FY11

• SUD Quality Enhancement Research Initiative (QUERI) SUD-Pain Work Group; see 

pages 54-57 in Strategic Plan available at 

http://www.queri.research.va.gov/about/strategic_plans/sud.pdf 

• CDC. Vital Signs: Overdoses of prescription opioid pain relievers—United States, 

1999–2008. MMWR 2011;60:1487–92. 

32
Rationale for studying CBT for pain in those 

with both pain and SUDs

• Pain is common in SUD patients and treatment is complicated 

• Patients in SUD treatment with pain tend to have worse outcomes 

SUD-related than those without pain 

• Psychological interventions such as CBT have demonstrated 

efficacy for reducing pain and improving functioning in persons 

with a broad spectrum of pain-related conditions (McCracken and Turk 2002;Turk and Okifuji 2002). 

• Prior studies have typically excluded those with substance use 

disorders.

• Only one existing study has explicitly examined the effects of CBT 

for pain in those with substance use disorders (Currie et al. 2003) 

and found significant reductions in pain, pain-related interference, 

medication misuse and more general measures of maladaptive 

coping from baseline to 12-month follow-up. 

• If found to be effective in SUD treatment settings, this treatment 

could be easily modified for other settings

33
Methods

34

 130 patients recruited at the start of an episode 

of VA outpatient SUD treatment

 No inclusion/exclusion criteria related to SUDs

 Required pain of at least moderate or greater 

 All participants received treatment as usual in the 

outpatient SUD program (1-3 sessions per week, 

relapse-prevention and harm-reduction model; 

encouragement of self-help group attendance) as 

well as usual treatment from other treatment 

providers.
Methods

35

 Participants were randomized to one of two 12-

week groups:

 CBT for pain and SUDs

 Supportive Psychoeducation Control (SPC) – similar in 

structure to what has been used in other SUD studies 

(Fals-Stewart & Klostermann, 2004) w/ specific pain 

content

 Participants were followed at 3-, 6-, and 12-

months with goal of examining impact of random 

assignment (CBT vs. SPC) on pain, functioning and 

substance use 
Methods

36

 Follow rates:

 3-month (81.82%) 

 6-month (85.61%) 

 12-monts (84.09%) 

 Preliminary descriptive analyses are presented to 

convey changes in key domains

 Final analyses will use expanded measurement of 

key domains (substance use, prescription use) 

and more sophisticated models of individual 

change that also control for clustering within 

groups
Demographic characteristics

37

 Treatment Group

p-value1

 SPC CBT

N 66 64 

Age (Mean, SD) 51.3 (10.1) 51.7 (9.3) NS

Gender (n, %) 

Men 57 (89%) 58 (88%) NS

Race/ethnic group 

White 44 (67%) 36 (56%) NS

All others 22 (33%) 28 (44%) 

Partnered 

Yes 15 (23%) 11 (17%) NS

Employed 

Yes 2 (3%) 8 (13%) 0.05 

Education 

H.S. or less 32 (48%) 27 (42%) NS
Results related to pain

38

 Treatment Group p-value

 SPC CBT 

 Mean (SD) Mean (SD) 

NRS1: average pain in the last week 

 3 mo. - BL difference -0.48 (0.30) -1.32 (0.29) < 0.05

 6 mo. - BL difference -0.48 (0.30) -1.36 (0.29) < 0.05

WHYMPI: General Activity score 

 3 mo. - BL difference -0.288 (0.110) 0.196 (0.101) < 0.05

 6 mo. - BL difference 0.136 (0.156) 0.071 (0.137) NS

Pain Tolerance (seconds) 

 3 mo. - BL difference -6.2 (50.2) 0.2 (33.0) NS

 6 mo. - BL difference 6.4 (49.2) 3.5 (28.6) NS

CPSS: Total SE score 

 3 mo. - BL difference 2.4 (7.6) 29.1 (7.6) < 0.05

 6 mo. - BL difference 11.8 (8.5) 31.5 (7.4) < 0.10
Results related to substance use

39

 Treatment Group

 SPC CBT

p-value

N 66 64

 N (%) N (%)

Alcohol: 

Abstinent at 3mo. 20 (39%) 25 (46%) NS

Abstinent at 6mo. 24 (55%) 29 (58%) NS

Marijuana: 

Abstinent at 3mo. 40 (77%) 40 (74%) NS

Abstinent at 6mo. 38 (86%) 41 (82%) NS

Cocaine: 

Abstinent at 3mo. 45 (88%) 47 (87%) NS

Abstinent at 6mo. 44 (100%) 47 (94%) NS

Rx Opioids Misuse: 

Abstinent at 3mo. 30 (59%) 41 (76%) < 0.10

Abstinent at 6mo. 28 (64%) 38 (76%) NS
CPSS Q 5) How certain are you that you can make a larger reduction in 

your pain by using methods other than taking extra medications?

40

0 

2 

4 

6 

8 

10

12

14

16

18

20

3 mo 6 mo

SPC

CBT
Summary of early results of 

randomized trial of CBT for pain and 

SUDs

• Delivery of CBT for pain was feasible during an episode of 

SUD treatment:

– Patients were very positive about these groups

• Early evidence indicate that, compared to an 

attention control condition (SPC), the CBT 

condition may be associated with reductions in 

pain level, improved functioning, and increased 

self-efficacy to control pain at one or more 

follow-up time period

• The effects on basic measures of abstinence 

were not seen (with the possible exception of 

the measure of prescription opioid misuse at 3- months)

• Further analyses are needed to examine these 

41
Steps to Improve Pain Management 

in Any Treatment Setting

• Ask about pain in SUD settings and how this relates to the patient’s 

substance-related goals

• Ask about prescription pain medications.

– “How often have you taken your medications differently from how 

they are prescribed?

– “How often have you had to take more of your medication than 

prescribed?”

– “How often have you borrowed pain medication from someone else?”

• Try to understand patients’ motivation for using pain medication –

what are their beliefs about pain medications?

• Reinforce the message that managing pain does not always have to 

involve using a substance.

• Discuss ‘hurt’ versus ‘harm’

42
Thank You!

Please feel free to contact me:

mark.ilgen@va.gov

43