Source/Disclosures
Disclosures: Ilgen reports being part of ArborSense, which is developing a wearable alcohol sensor, and consulting for Northrop Grumman on a project to prevent suicide among military personnel. One author reports receiving personal fees from the Hazelden Betty Ford Foundation. The other authors report no relevant financial disclosures.
July 31, 2020
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Behavioral pain management effective for substance use disorders, chronic pain

Source/Disclosures
Disclosures: Ilgen reports being part of ArborSense, which is developing a wearable alcohol sensor, and consulting for Northrop Grumman on a project to prevent suicide among military personnel. One author reports receiving personal fees from the Hazelden Betty Ford Foundation. The other authors report no relevant financial disclosures.
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A behavioral pain management intervention was associated with improved pain-related outcomes among individuals with substance use disorders and chronic pain, according to study results published in JAMA Psychiatry.

However, this intervention is rarely included in addiction treatment.

“Existing observational evidence indicates that individuals with persistent pain have worse drug and alcohol treatment outcomes compared with individuals without pain or with reduced pain,” Mark A. Ilgen, PhD, of the VA Center for Clinical Management Research in the Department of Veterans Affairs Healthcare System, and colleagues wrote. “These findings point to the need to improve treatments for pain among those with SUDs as a method to both improve general functioning and potentially improve posttreatment substance use outcomes.”

A prior full-scale randomized trial evaluated the effect of a combined cognitive behavioral therapy and acceptance-based approach using an integrated behavioral pain management intervention, Improving Pain During Addiction Treatment (ImPAT), among 128 veterans who were recruited during an episode of substance use disorder (SUD) treatment. Results showed ImPAT was associated with significantly less pain, less alcohol use and improved functioning over a 12-month follow-up period compared with active controls. However, weaknesses of that study included a lack of generalizability because of its inclusion of only veterans and few women.

In the current study, Ilgen and colleagues aimed to examine the efficacy of ImPAT for treating pain, functioning and substance use among individuals with SUDs. They conducted a randomized clinical trial, during which they compared eight ImPAT sessions with eight sessions of a supportive psychoeducational control (SPC) condition for adults with pain treated at a large residential SUD treatment program. Follow-up was 3, 6 and 12 months after baseline. The investigators randomly assigned to treatment 264 men, with 133 to ImPAT and 131 to SPC, and 246 women, with 122 to ImPAT and 124 to SPC, with the goal of recruiting approximately equal numbers of men and women to examine results by sex. Follow-up data were available for 470 (92.2%) participants. The ImPAT intervention involved evaluating how a psychosocial model of pain was linked to functioning and relapse prevention, as well as a focus on providing pain management skills. The SPC intervention, which was the active control condition, incorporated discussion of nutrition and the course of addiction. Pain intensity, pain-related functioning and behavioral pain tolerance at 12 months served as the primary outcomes, and secondary outcomes included alcohol and drug use frequency over 12 months.

Results showed the ImPAT intervention was linked to higher pain tolerance among men by a mean score of 0.11 (95% CI, 0.03-0.18) at 3 months and by 0.07 (95% CI, 0.01 to 0.19) at 12 months. Women who received the ImPAT intervention reported a reduction in pain intensity from 3 months to 12 months, and those who received the SPC condition reported an increase in pain intensity, with those in the ImPAT condition exhibiting lower pain by a mean score of 0.58 (95% CI, 0.07 to 1.22) at 12 months.

Ilgen and colleagues reported no differences between the ImPAT and SPC conditions on alcohol or drug use.

“These findings highlight the potential benefits of this approach on pain-related outcomes for SUD treatment settings and raise the possibility that integrating behavioral pain management and SUD services could be particularly beneficial for the large number of individuals with cooccurring pain and SUDs,” they wrote. “However, the effect sizes were small, and we did not detect an effect of the ImPAT condition on SUD outcomes, highlighting the need for future work to continue to look at ways to enhance integrated pain and SUD treatment effects to improve clinical outcomes in the high-risk group of patients with both pain and SUDs.”