A Reciprocal Model of Pain and Substance Use: Transdiagnostic Considerations, Clinical Implications, and Future Directions

Abstract

Pain and substance use are highly prevalent and co-occurring conditions that continue to garner increasing clinical and empirical interest. Although nicotine and tobacco, alcohol, and cannabis each confer acute analgesic effects, frequent or heavy use may contribute to the development and progression of chronic pain, and pain may be heightened during abstinence. Additionally, pain can be a potent motivator of substance self-administration, and it may contribute to escalating use and poorer substance-related treatment outcomes. We integrated converging lines of evidence to propose a reciprocal model in which pain and substance use are hypothesized to interact in the manner of a positive feedback loop, resulting in the exacerbation and maintenance of both conditions over time. Theoretical mechanisms in bidirectional pain–substance use relations are reviewed, including negative reinforcement, social cognitive processes, and allostatic load in overlapping neural circuitry. Finally, candidate transdiagnostic factors are identified, and we conclude with a discussion of clinical implications and future research directions.

Pain Severity and Alcohol Use Among Daily Tobacco Cigarette Smokers

“…For example, regular alcohol use has been implicated in the onset and progression of several painful conditions, 10,11 pain intensity has been positively associated with AUDIT total scores, 12 and laboratory pain induction has been shown to increase the urge to drink 13 . Alcohol has also been shown to confer acute analgesia, 14 and, consistent with negative reinforcement models of addiction, 15 amelioration of negative affect has been identified as a key mechanism in the effects of experimental pain induction on motivation to drink alcohol 7,13 …”

“…There is growing empirical and clinical interest in the role of pain in hazardous drinking 6,7 . Pain is more common among problem drinkers than nonproblem drinkers, 8 and individuals with chronic pain (vs no pain) are twice as likely to meet the diagnostic criteria for alcohol dependence 9 .…”

“…Pain is more common among problem drinkers than nonproblem drinkers, 8 and individuals with chronic pain (vs no pain) are twice as likely to meet the diagnostic criteria for alcohol dependence 9 . An established reciprocal model posits that pain and alcohol use interact in the manner of a positive feedback loop, resulting in the exacerbation of both conditions over time 7 . For example, regular alcohol use has been implicated in the onset and progression of several painful conditions, 10,11 pain intensity has been positively associated with AUDIT total scores, 12 and laboratory pain induction has been shown to increase the urge to drink 13 .…”

“…In addition, no previous work has tested indirect associations between spontaneous pain intensity (ie, pain in the absence of an experimental stimulus) and the urge to drink alcohol via negative affect. Indeed, negative affect has been hypothesized to be a key mechanism in pain‐substance interrelations 6,7,17 . Pain has consistently been associated with increased negative affect among tobacco cigarette smokers, 18–20 and preliminary experimental work has provided causal evidence that negative affect mediates the effects of pain induction on the motivation to drink alcohol 13 .…”

“…Moreover, nicotine and alcohol co‐use has been associated with poorer health outcomes, 26,27 and it is important to identify factors that contribute to concurrent use, in order to inform the development of tailored interventions. Given established bidirectional associations between pain and substance use, 7 as well as converging evidence that pain is a potent motivator of nicotine and alcohol use, 19,28,29 it is possible that smokers with pain (vs no pain) are more likely to consume alcohol and engage in problematic patterns of drinking in an effort to extend/supplement the analgesic effects of nicotine 30 …”