Accepted Manuscript

Alcohol and Opioid Use in Chronic Pain: A Cross-Sectional

Examination of Differences in Functioning Based on Misuse Status

Kevin E Vowles PhD , Katie Witkiewitz PhD , Melissa Pielech MA ,

Karlyn A. Edwards BA , Mindy L. McEntee MS ,
Robert W. Bailey MS , Lena Bolling BS ,
Mark D. Sullivan MD, PhD

PII: S1526-5900(18)30164-0
DOI: 10.1016/j.jpain.2018.04.013
Reference: YJPAI 3580

To appear in: Journal of Pain

Received date: 13 November 2017

Revised date: 16 March 2018
Accepted date: 29 April 2018

Please cite this article as: Kevin E Vowles PhD , Katie Witkiewitz PhD , Melissa Pielech MA ,
Karlyn A. Edwards BA , Mindy L. McEntee MS , Robert W. Bailey MS , Lena Bolling BS ,
Mark D. Sullivan MD, PhD , Alcohol and Opioid Use in Chronic Pain: A Cross-Sectional Ex-
amination of Differences in Functioning Based on Misuse Status, Journal of Pain (2018), doi:
10.1016/j.jpain.2018.04.013

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service
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 ACCEPTED MANUSCRIPT

Alcohol and Opioid Use in Chronic Pain 1

RUNNING HEAD: ALCOHOL AND OPIOID USE IN CHRONIC PAIN

Alcohol and Opioid Use in Chronic Pain:

A Cross-Sectional Examination of Differences in Functioning Based on Misuse Status

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Kevin E Vowles, PhD1

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Katie Witkiewitz, PhD1

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Melissa Pielech, MA1

Karlyn A. Edwards, BA1

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Mindy L. McEntee, MS1

Robert W. Bailey, MS1

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Lena Bolling, BS1

Mark D. Sullivan, MD, PhD2

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1
Department of Psychology, University of New Mexico, Albuquerque, New Mexico
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2
University of Washington, Departments of Psychiatry and Behavioral Sciences, University of

Washington
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16 March 2018
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Keywords: Chronic Pain, Opioids, Alcohol, Substance Misuse

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Correspondence to: Kevin E Vowles, PhD, Department of Psychology, University of New

Mexico, MSC03-2220 Logan Hall, Albuquerque, NM, 87131-0001, kvowles@unm.edu (email),
505-277-4121 (phone)

Disclosures: This research was supported by grants funded by the National Center for
Complementary and Integrative Health for KEV (R34 AT08398, Vowles, PI). The authors have
no additional disclosures to declare.
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Alcohol and Opioid Use in Chronic Pain 2

Highlights:

- Opioid and alcohol misuse was examined in opioid-using people with chronic pain.

- 35.9% were not misusing either

- 22.9% were misusing both

- 38.2% were misusing opioids

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- 3.0% were misusing alcohol.

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- No misuse was related to better functioning compared to misuse of opioids/both.

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Abstract

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Opioid misuse is regularly associated with disrupted functioning in those with chronic pain. Less

work has examined whether alcohol misuse may also interfere with functioning. This study
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examined frequency of opioid and alcohol misuse in 131 individuals (61.1% female) prescribed

opioids for the treatment of chronic pain. Participants completed an anonymous survey online,

consisting of measures of pain, functioning, and opioid and alcohol misuse. Cut-scores were
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used to categorize individuals according to substance misuse status; individuals were

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categorized as follows: 35.9% (n = 47) were not misusing either opioids or alcohol, 22.9% (n =

30) were misusing both opioids and alcohol, 38.2% (n = 50) were misusing opioids alone, and
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only 3.0% (n = 4) were misusing alcohol alone. A multivariate analysis of variance was

performed to examine differences in pain and functioning between groups (after excluding
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individuals in the alcohol misuse group due to the small sample size). Group comparisons

indicated that individuals who were not misusing either substance were less disabled and
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distressed in comparison to those who were misusing opioids alone or both opioids and alcohol.

No differences were indicated between the latter two groups. Overall, the observed frequency of

opioid misuse was somewhat higher in comparison to previous work (approximately 1 out of

every 3 participants), and misuse of both alcohol and opioids was common (approximately 1 out
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Alcohol and Opioid Use in Chronic Pain 3

of every 5 participants). While these data are preliminary, they do suggest that issues of

substance misuse in those with chronic pain extends beyond opioids alone.

Perspective: Opioid and alcohol misuse was examined in 131 individuals prescribed opioids for

chronic pain. In total, 35.9% were not misusing either, 22.9% were misusing both, 38.2% were

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misusing opioids, and 3.0% were misusing alcohol. Individuals not misusing either were

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generally less disabled and distressed compared to those misusing opioids or both.

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Alcohol and Opioid Use in Chronic Pain 4

Introduction

Opioids are commonly prescribed for the treatment of chronic pain. Rates of opioid

prescribing for pain vary across settings and chronic pain location, with estimates of

approximately 20% in a nationally representative survey in 2010 [13] to 58% in a community-

based health care system in 2012 [54]. While opioids have evidence for pain reduction, they

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also increase risk of morbidity and mortality [10,11,16,37,48]. Several observational surveys

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have indicated that rates of opioid-related problems have increased in a manner that parallels

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the increases in opioid prescription rates over the past few decades [9,61]. These risks are

significantly increased when opioids are misused [38,60,74]. A number of studies suggest that

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opioid misuse in those with chronic pain is associated with greater levels of distress and

disability, increased risk of overdose, greater healthcare costs, and decreased probability of
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success from rehabilitative treatments [21,43,45,64,68].

This adverse impact is unsurprising in many ways given that misuse of illicit and licit
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substances often imparts significant risks for individuals and society. Alcohol misuse is perhaps

the most well-researched example. Alcohol use disorder (AUD) is one of the most common
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psychiatric diagnoses with 29% of individuals in the United States meeting lifetime criteria [24]

and with rates of excessive alcohol use, such as binge drinking, exceeding 30% in some
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countries [73]. AUD is associated with disruptions across a host of body systems and both AUD

and alcohol misuse are associated with significant morbidity and mortality [5,36,50,56,58,62,63].
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Several studies have examined opioid misuse impact in chronic pain, but less work has

examined issues of alcohol misuse alone or in combination with opioid misuse. This area would
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seem important, given that alcohol co-use is relatively common in those who use prescribed

opioids, ranging from 12% to 36% across published work [20,35,49,57]. Furthermore, alcohol

and opioid co-use substantially increases risk of overdose [17,20,25,69]. To our knowledge,

only a single study has examined frequency and impact of alcohol misuse in a sample of

individuals on long-term opioid therapy [35]. This study found that “risky drinkers,” defined as
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Alcohol and Opioid Use in Chronic Pain 5

those who had consumed five or more drinks on at least a single occasion within the past year,

reported higher levels of pain interference in comparison to “non-risky” drinkers.

Given the frequency and risks associated with co-use, there is a need to examine

broader impacts of problematic, high-risk drinking in those who are using prescribed opioids for

the treatment of chronic pain. The purpose of this study was twofold. First, we screened for

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opioid and alcohol misuse in a sample of individuals who had been prescribed opioids for

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chronic pain. These results were used to classify individuals into one of four misuse groups: (1)

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no opioid or alcohol misuse, (2) both opioid and alcohol misuse, (3) only opioid misuse, and (4)

only alcohol misuse. Next, differences in pain-related physical and psychosocial functioning

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across these groups were examined to determine if misuse of either, or both, substances was

associated with differential disruptions in functioning. We included both measures of negative

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functioning (i.e., distress, depression, disability) and positive functioning (i.e., pain acceptance,

success in valued activity, adaptive pain behavior) to allow for a broad analysis of participant
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information across both maladaptive and adaptive impacts of pain. It was hypothesized that

individuals with evidence of misuse of both substances would have the greatest levels of
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disruption, followed by individuals misusing only one of the substances. Individuals with no

evidence of substance misuse were expected to have the lowest levels of disrupted functioning.
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Methods

Participants
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Participants were recruited using an on-line data collection system, the Amazon

Mechanical Turk (MTurk). This system allows researchers to collect secure and confidential
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data, as researchers only have access to a “worker ID” that is not linked to any protected health

information. Participants were compensated $3.00 for completing the survey. This study was

approved by the University of New Mexico’s Human Subjects Institutional Review Board.

Prior to completing the survey, all potential participants completed an unpaid screening

survey, which was used to evaluate study inclusion criteria. To be eligible, participants had to
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Alcohol and Opioid Use in Chronic Pain 6

report that they experienced pain: (1) on most days of the week (i.e., 4 or more days per week),

(2) at an average weekly intensity of 3 or greater on an 11-point numerical rating scale (NRS),

(3) for at least three months in duration, and (4) that was not restricted to headache pain alone.

In total, 420 individuals met these initial inclusion criteria and began the survey. Seventeen

individuals (4.4%) provided data that was not useable; of these individuals, responses were

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either missing entirely (n = 10) or included demographic information only (n = 7). These

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individuals were excluded from further analyses.

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For the present analyses, data from 131 individuals who provided data and who reported

taking prescribed opioids for the treatment of chronic pain were used (32.5% of the total

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recruited sample). The majority of these individuals were female (61.1%), of White, Non-

Hispanic ethnicity (80.0%; Asian: 7.7%, Hispanic: 6.2%, Black: 5.4%, Other: 0.8%); and Married
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or Co-habitating (55.8%; Single: 33.3%, Divorced: 9.3%, Widowed 1.6%). Average age was

36.6 years (SD: 11.8). Mean years of education was 15.5 (SD: 2.3), which corresponded to the
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greatest proportion of individuals reporting that they had completed “some college” as their

highest level of education (38.2%; Bachelor’s degree: 33.6%, Postgraduate degree: 13.7%,
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Technical/trade school degree: 8.4%, High school degree: 6.1%).

As noted, all participants reported the presence of chronic pain. The most frequently
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reported pain location was low back (53.2%, Neck: 12.9%, Full body: 10.5%, Lower extremity:

9.7%, Upper extremity: 8.1%, Hips/Pelvis: 4.0%, Mid-back: 1.6%). Secondary pain sites were
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reported by 23.0% of individuals. Pain duration averaged 6.7 years (SD: 6.1). Just over half of

participants were employed (33.6% full-time; 23.6% part-time) and 34.4% were unemployed. An
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additional 6.1% reported working as a homemaker and 2.3% were retired.

Measures

Participants completed a battery of questionnaires, which included an assessment of

demographic variables, including gender, age, education duration, and employment status, as

well as pain-related details, including pain duration and location. Usual pain intensity and pain-
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Alcohol and Opioid Use in Chronic Pain 7

related distress over the past week on a 0 (no pain/pain-related distress) to 10 (maximum

possible pain/pain-related distress) Numerical Rating Scale (NRS). Participants also completed

a battery of self-report measures of psychosocial and physical functioning, which included

measures of depression, physical and psychosocial disability, pain acceptance, and adaptive

pain responding. Details for these measures are provided in the following paragraphs.

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Depression was evaluated using the British Columbia Major Depression Inventory

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(BCMDI; [29]), a 16-item measure based on the diagnostic criteria for Major Depressive

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Disorder from the 4th edition of the Diagnostic and Statistical Manual for Mental Disorders [1].

Possible scores for the BCMDI range from 0 to 80. Previous work has supported the

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psychometric properties of the measure [29]. In the present sample, internal consistency was

acceptable, Cronbach’s α = .90.

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Physical and Psychosocial Disability was assessed using the Sickness Impact Profile –

Chronic Pain (SIP-CP; [42]). The Physical Disability domain score of the SIP-CP includes items
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that evaluate functioning across body care, movement, mobility, and ambulation. The

Psychosocial Disability domain score includes 26 items evaluating functioning across

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communication, alertness, emotional functioning, and social interaction. Both Physical and

Psychosocial Disability scores range from 0 to 1 with higher scores indicating greater disability.
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The SIP-CP development study used an Item Response Theory approach to identify items of

the longer SIP [4] that were specifically appropriate for use in a chronic pain sample [42]. This
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same development study provided evidence for the convergent validity of the SIP-CP’s two

domain scores, as there were reliable correlations with relevant measures of chronic pain-
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related functioning. In the present sample, the Kuder-Richardson coefficient (for dichotomous

items) was used to evaluate internal consistency of the SIP-CP, which was acceptable for both

the Physical and Psychosocial Disability subscales, .70 and .85, respectively.

Pain Acceptance was evaluated using the Chronic Pain Acceptance Questionnaire

(CPAQ; [40]). The CPAQ has 20 items, which evaluate engagement in important activities even
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Alcohol and Opioid Use in Chronic Pain 8

with the continued experience of pain and the degree to which respondents are willing to

experience pain in the service of activity. The CPAQ has been widely used in chronic pain

settings and typically is viewed as a measure of adaptive responding to chronic pain, in that

higher scores are negatively correlated with distress and disability and positively correlated with

measures of healthy functioning [18,39,53,67]. Possible scores range from 0 to 120. Its factor

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structure has been supported [55,65,71]. Internal consistency in the present sample was

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acceptable, Cronbach’s α = .90.

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Adaptive pain behavior was evaluated using scores from two measures, the Values

Success subscale of the Valued Living Scale (VLS; [30]) and the total score of the Brief Pain

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Response Inventory (BPRI; [41]). The VLS evaluates success in valued domains across eight

areas, including health, emotional well-being, friendships, productivity, community, caregiving/

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parenting, spirituality, and marital/romantic partnerships. Possible scores range from 0 to 80

with higher scores indicating more success in these valued domains. The BPRI includes 15
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items, which evaluate aspects of healthy responding to chronic pain. For example, items

evaluate frequency of non-avoidant pain responding and the frequency with which activity is
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moderated to allow for consistent pursuit of meaningful activity. The possible total score ranges

from 0 to 105 with higher scores indicating greater frequency of healthy responding. As is the
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case with CPAQ scores, greater scores for both the VLS and BPRI are generally negatively

correlated with measures of distress and disability and positively correlated with measures of
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adaptive functioning [30,41]. The internal consistency for both the VLS and BPRI was

acceptable in the present sample, Cronbach’s α = .81 and .88, respectively.

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Opioid misuse was assessed using the Current Opioid Misuse Measure (COMM [8]).

The COMM consists of 17 items, which assess patterns and frequency of opioid use, as well

cognitive difficulties, suicidal ideation and anger/irritability. Scores on the COMM range from 0-

68. Both the original evaluation study and subsequent work have indicated that a cut score of 9
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Alcohol and Opioid Use in Chronic Pain 9

or above, out of a possible range of 0-68, has reasonable sensitivity and specificity [7,8] for the

opioid misuse. Internal consistency in the present sample was acceptable, Cronbach’s α = .86.

Alcohol misuse was assessed using the 10-item Alcohol Use Disorders Identification

Test (AUDIT; [6]). The AUDIT is a well-established screening measure of problematic drinking

and has strong evidence of validity and reliability across a variety of clinical and non-clinical

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samples [51,52]. Scores can range from 0-40 with higher scores indicating greater probability of

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risky alcohol use. The recommended cut-score for risk of alcohol misuse is 7 for women and 8

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for men. Internal consistency in the present sample was acceptable, Cronbach’s α =.90.

Analytic Approach

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Initially, scores on both the COMM and the AUDIT for each individual were interpreted

relative to recommended cut-scores. As noted, participants were then placed into one of four
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groups based on misuse status: (1) no opioid or alcohol misuse, (2) both opioid and alcohol

misuse, (3) only opioid misuse, and (4) only alcohol misuse.
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Following categorization according to substance misuse status, a Multivariate Analysis

of Variance (MANOVA) was performed to investigate differences on measures of functioning

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across these four groups. Dependent measures included usual pain intensity, weekly pain-

related distress, depression, physical disability, psychosocial disability, pain acceptance,

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success in valued activities, frequency of healthy pain responding, as well as scores on the

opioid and alcohol misuse measures. It was planned that a significant overall omnibus test
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would be followed by a test of between-subject effects for each dependent measure, which if

significant, would then be followed by pairwise comparisons using a Bonferroni-corrected alpha

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to control for the probability of Type 1 error. Estimates of effect size for between group

differences, partial eta2, were calculated. Partial eta2 measures the proportion of the total

variance in dependent measures accounted for by between group differences. A maximum

likelihood procedure was used to make use of all available data.

Results
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Alcohol and Opioid Use in Chronic Pain 10

The proportion of individuals in each risk category was as follows: 35.9% (n = 47) were

not misusing either opioids or alcohol, 22.9% (n = 30) were misusing both opioids and alcohol,

38.2% (n=50) were misusing opioids alone, and only 3.0% (n = 4) were misusing alcohol alone.

Because of the small number of individuals in the alcohol misuse only category, this group was

eliminated from further analyses. Descriptive statistics for each of the measures used to create

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the categories are provided in Table 1. Overall, the means of the measures in this sample all fall

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within one SD of published normative data [6,8,31,41,42,67].

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As noted, differences among these groups across measures of pain-related functioning

were then evaluated using a MANOVA. The omnibus test was significant, Wilks Lambda = .13,

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p < .001, partial eta2 = .65. Follow-up ANOVA’s were significant for all measures of functioning,

all F (2, 126) > 8.0, all p < .001, range partial eta2 = .13 - .70, with only two exceptions, which
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were for pain intensity and physical disability, both F (2, 126) < 1.8, p > .17, partial eta2 = .03 in

each case.
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The results of the pairwise comparisons are displayed in Table 1. The pattern of group

differences across eight of nine analyses were identical such that individuals who were not
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misusing either substance were functioning better than either of the other two groups.

Specifically, the “no misuse” group reported lower levels of pain-related distress, depression,
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physical and psychosocial disability, and opioid or alcohol misuse, as well as greater pain

acceptance, success in valued areas, and frequency of adaptive pain behavior. No between
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group differences were indicated between the group misusing both alcohol and opioids and the

group misusing opioids alone. The sole exception to this finding was for alcohol misuse, for
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which individuals who were misusing both substances had higher AUDIT scores then either of

the other two groups (i.e., no misuse, opioid misuse alone). These latter two groups did not

differ on AUDIT scores.

Discussion
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Alcohol and Opioid Use in Chronic Pain 11

The current study examined frequency of opioid and alcohol misuse in adults with

chronic pain who were prescribed opioids for pain treatment, as well as the association between

alcohol and opioid misuse and functioning. Overall, results indicated that misuse of both opioids

and alcohol or misuse of opioids alone were frequent and reliably associated with more pain-

related distress, depression, and psychosocial disability, as well as lower acceptance,

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engagement in valued activity, and adaptive pain behavior, in comparison to no misuse of either

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substance. Misuse of alcohol alone was rare in this sample, suggesting that alcohol and opioid

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misuse are more likely to co-occur than for alcohol misuse to occur in the absence of opioid

misuse.

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The overall proportion of alcohol misuse, among individuals also misusing opioids, in this

sample of opioid-prescribed individuals with chronic pain is noteworthy. As previously cited,

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there is only one other study to our knowledge which has specifically examined risky alcohol

use in individuals who are taking opioids for the treatment of chronic pain. This study, by
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Larance and colleagues [35], found that 24% of an Australian sample engaged in “risky”

drinking, defined as the consumption of more than four standard drinks on at least one occasion
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in the past twelve months. The overall proportion of individuals misusing alcohol from our

sample was similar, as 26% of individuals were identified as “risky” drinkers overall, with the
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majority also identified as risky opioid users as well. If it is indeed accurate that approximately

one in four individuals prescribed opioids for the treatment of chronic pain are drinking in a
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problematic manner, then there is a clear need to address alcohol use in pain treatment

settings. Areas for focused effort include improved assessment of alcohol consumption,
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additional investigation into the potential adverse consequences associated with risky alcohol

consumption in this population, and the development of appropriate interventions to decrease

risky use and minimize the likelihood of adverse events. Concomitant use of opioids and alcohol

significantly increases risk of overdose, as both are central nervous system depressants [17,25],

and recent toxicology reports of opioid-related overdose deaths have indicated that alcohol, as
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Alcohol and Opioid Use in Chronic Pain 12

well as other sedatives, are regularly present in the blood of the decedents [9,22,23,25,32,33].

In combination, these issues would seem to suggest important areas for future clinical and

research work among opioid-prescribed patients with chronic pain.

With regard to treatment options, within the addictions field, there is reasonably good

evidence regarding the efficacy of brief interventions in reducing alcohol consumption [34,70].

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For example, the “SBIRT” framework (Screening, Brief Intervention, and Referral to Treatment)

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is an approach to decrease risk for development of a substance use disorder and identify

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patients in need of substance abuse treatment [2]. Adaptation of SBIRT for patients with chronic

pain is one potential clinical option to better assess and address the needs of these patients.

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Increased patient education regarding the complex interactions and risks associated with co-

occurring opioid and alcohol use is recommended for patients receiving opioids for chronic pain
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management, perhaps alongside opioid agonist treatment for those meeting criteria for an

opioid use disorder [47] both preventatively and upon identification of opioid and/or alcohol
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misuse. Further, formal examination into patient’s perceived reasons for substance use (e.g.

pain reduction, coping, relaxation, to alleviate emotional distress) could provide meaningful
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guidance regarding needed treatment targets in this population and components missing in

traditional approaches to pain treatment. Substance use may also be a potentially salient
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variable missing in current measures of chronic pain risk stratification (e.g., [26]), since

substance misuse was associated with poorer functioning across multiple domains in the
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present data.

It was hypothesized that misuse of both alcohol and opioids would represent a
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significantly greater risk to functioning in comparison to opioid misuse alone, but this hypothesis

was not supported. Rather, no significant differences in functioning were indicated between

these two misuse groups. This finding is surprising given the fact that polysubstance use

disorder is generally more disruptive and difficult to treat then a single substance use disorder

[12,15]. It is possible that the independent effects of chronic pain and opioid misuse on physical
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Alcohol and Opioid Use in Chronic Pain 13

and emotional functioning are significantly large enough to render any additional difficulties

caused by alcohol misuse non-significant. Some of the raw differences observed between

misuse groups could, however, be meaningful and it may be that these differences would be

significant in a larger sample. For example, opioid misuse and alcohol misuse is higher in the

combined group in comparison to the single substance groups, d=.34 for opioid misuse and

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d=.15 for alcohol misuse. Thus, these results are likely best viewed as preliminary and in need

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of further examination in larger samples, including those specifically presenting to treatment

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clinics.

Relatedly, it has been argued that a robust predictor of eventual opioid-related morbidity

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or mortality is a history of a substance use disorder [28,44,45]. From these data, it is unclear

how many individuals in the current sample had such a history or had a current substance use
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disorder (versus subclinical levels of risky use behavior). It is also unclear in the current data if

patients were using substances other than alcohol or opioids. Future studies should assess for
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history of a substance use disorder along with current levels of substance use, including

substances beyond alcohol and opioids.

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The use of self-report measures of pain symptoms and opioid prescription is a limitation,

however the number of individuals with self-reported chronic pain who received opioid
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prescriptions in the current sample (32.5%) is consistent within the wide range indicated by

other studies that report rates of opioid prescribing for chronic pain (i.e., 20% to 58%
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[13,46,54]). Similarly, the use of self-report screening measures to identify those at risk of

opioid or alcohol misuse is an additional limitation of the present work, however the confidential
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nature of the data collection and strong psychometric properties of the two measures used

offers some counterbalance to this issue and may have aided in more accurate reporting. If we

assume that the overall reporting of risk status is accurate, there are a few points that warrant

further discussion.
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Alcohol and Opioid Use in Chronic Pain 14

First, the overall frequency of opioid misuse (61.1%, the sum of both the opioids only risk

group and the opioids and alcohol risk group) was higher than what has typically been reported

in previous work [19,27,37,66]. Although it is not possible to precisely identify the reasons that

frequency was so high in this sample, it does suggest that continued attention to issues of

substance misuse in this population is important, particularly given the association between

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misuse and poorer functioning.

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Second, care must be taken when interpreting the results from screening measures, as

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the positive predictive value of screening measures for opioid use disorders is complicated by

the variance in (generally low) base rates for this condition in patients with chronic pain [3,59].

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When screening for conditions with low base rates such as this one, screeners are typically

most accurate for ruling out or predicting those who will not misuse opioids. Thus, findings in the
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current study indicating risk for opioid and alcohol misuse must be interpreted with caution.

Given the cross-sectional nature of this study, it is impossible to know how many cases are
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false positives for substance misuse. Ideally, for those flagging up as at risk for misuse,

additional data would be collected to corroborate the screener data (e.g. clinical interview, urine
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drug screen).

Finally, the problems related to the significant increases in opioid prescription rates in
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many countries have been well-documented and there is a significant amount of current

academic, governmental, and media attention on this issue [14]. Opioids are certainly a
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problem, but it is important to also consider problems in alcohol use as well. Both are legally

obtainable and potentially easy to use in a risky manner. The available evidence suggests their
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potential for negative impact is enhanced when they are co-used in those with chronic pain (see

[72] for a review). Furthermore, while current guidelines for individuals providing treatment to

patients on long-term opioid therapy for chronic pain emphasize the importance of frequent

screening for risky opioid use, there is much less attention given to the need to screen for

alcohol misuse.
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Alcohol and Opioid Use in Chronic Pain 15

In closing, results from this study qualify the need for increased research and clinical

investigation into assessing and treating opioid and alcohol misuse behaviors in patients with

chronic pain. Evidence in the current study indicate that patients at risk for misusing opioids and

alcohol are functioning at lower levels and experiencing lower quality of life, compared to those

not misusing substances. Chronic pain is a complex condition that can have a multifaceted

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impact on functioning without the presence of substance misuse – when it is accompanied by

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the latter, it is assumed that this complexity is increased significantly. At present, there are few

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treatment options available that combine appropriate chronic pain and substance misuse

interventions. Data like those presented here suggest that there is a significant need for the

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development of such options, both in relation to opioid misuse, but crucially also for alcohol

misuse and alcohol/opioid co-use.

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Table 1

Means (SD’s) for study measures

Risk Group Full sample

Classification (n = 131)

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Dependent No misuse Opioid & Opioid Alcohol

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measure risk (n = 47) alcohol misuse risk (n misuse risk (n

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misuse risk (n = 50) = 4)+

= 30)

Usual Pain

intensity (past
4.7 (1.4) a 4.6 (1.6) a
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5.4 (1.4) a 4.0 (0.8) 4.9 (1.5)
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wk)

Pain-related 3.9 (2.4) a 5.8 (2.1) b 5.6 (2.5) b 3.8 (2.6) 4.9 (2.5)
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distress (past

wk)
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Depression 14.2 (10.5) a 32.1 (12.6) b 31.5 (13.4) b 21.5 (1.7) 25.1 (14.6)

Physical .10 (.11) a .11 (.13) a .15 (.13) a .19 (.17) .12 (.12)
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Disability

Psychosocial .11 (.09) a .26 (.21) b .29 (.18) b .33 (.12) .22 (.18)
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Disability

Pain 69.0 (13.2) a 58.2 (16.0) b 53.0 (17.6) b 67.8 (14.3) 60.1 (17.1)
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Acceptance

Values 41.7 (13.8) a 30.4 (12.5) b 28.0 (12.5) b 26.8 (7.2) 33.4 (14.2)

Success

Adaptive Pain 74.7 (17.3) a 54.3 (16.7) b 56.5 (20.7) b 78.5 (17.9) 63.2 (20.7)
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Alcohol and Opioid Use in Chronic Pain 25

Behavior

Opioid 5.0 (2.0) a 19.7 (9.1) b 16.9 (7.0) b 6.3 (1.7) 12.9 (8.9)

misuse risk

Alcohol 2.5 (2.4) a 15.2 (7.0) b 2.4 (2.1) a 14.0 (8.5) 5.7 (6.9)

misuse risk

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Notes: + The risk of alcohol misuse group was not included in MANOVA comparisons, due to its

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small sample size.

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Different superscripts indicate significantly different pairwise comparisons at the between group

level using a Bonferroni-controlled alpha.

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Opioid misuse risk was measured using the Current Opioid Misuse Measure, Alcohol misuse
risk was measured using the Alcohol Use Disorders Screening Test, Usual pain intensity and
Pain-related distress were measured using a 0 (no pain/distress) to 10 (maximal pain/distress)
NRS, Depression was measured using the British Columbia Major Depression Inventory,
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Physical and Psychosocial Disability were measured using the Sickness Impact Profile –
Chronic Pain, Pain acceptance was measured using the Chronic Pain Acceptance Inventory,
Values Success was measured using the Valued Living Scale, and Adaptive Pain Behavior was
measured using the Brief Pain Response Inventory.
M
ED
PT
CE
AC