Alcohol and Opioid Use, Co‐Use, and Chronic Pain in the Context of the Opioid Epidemic: A Critical Review

Abstract

The dramatic increase in opioid misuse, opioid use disorder (OUD), and opioid-related overdose deaths in the United States has led to public outcry, policy statements, and funding initiatives. Meanwhile, alcohol misuse and alcohol use disorder (AUD) are a highly prevalent public health problem associated with considerable individual and societal costs. This study provides a critical review of alcohol and opioid misuse, including issues of prevalence, morbidity, and societal costs. We also review research on interactions between alcohol and opioid use, the influence of opioids and alcohol on AUD and OUD treatment outcomes, respectively, the role of pain in the co-use of alcohol and opioids, and treatment of comorbid OUD and AUD. Heavy drinking, opioid misuse, and chronic pain individually represent significant public health problems. Few studies have examined co-use of alcohol and opioids, but available data suggest that co-use is common and likely contributes to opioid overdose-related morbidity and mortality. Co-use of opioids and alcohol is related to worse outcomes in treatment for either substance. Finally, chronic pain frequently co-occurs with use (and co-use) of alcohol and opioids. Opioid use and alcohol use are also likely to complicate the treatment of chronic pain. Research on the interactions between alcohol and opioids, as well as treatment of the comorbid disorders is lacking. Currently, most alcohol research excludes patients with OUD and there is lack of measurement in both AUD and OUD research in relation to pain-related functioning. Research in those with chronic pain often assesses opioid use, but rarely assesses alcohol use or AUD. New research to examine the nexus of alcohol, opioids, and pain, as well as their treatment, is critically needed.

The Association Between Alcohol Consumption and Pain Interference in a Nationally Representative Sample: The Moderating Roles of Gender and Alcohol Use Disorder Symptomatology

“…In contrast, there is evidence for a positive association between excessive alcohol consumption and increased pain, although evidence for this relation has been more mixed. A prospective study of older adults has found that problem drinkers experienced higher levels of pain and pain interference (Brennan et al, ), and Witkiewitz and Vowles’s () review documented that 16 to 25% of chronic pain patients in treatment reported a history of heavy alcohol use or AUD. In contrast, population‐based and clinical studies have linked heavy drinking to reduced pain and pain‐related functioning among patients with chronic pain disorders (e.g., Kim et al, ; MacFarlane et al, ).…”

Initiation and engagement as mechanisms for change caused by collaborative care in opioid and alcohol use disorders

“…Alcohol use disorders affect an estimated 15.8 million people, an estimated 1.9 million people abuse or are dependent on prescription opioids and 323,000 are dependent on heroin (Center for Behavioral Health Statistics and Quality, 2015; Substance Abuse and Mental Health Services Administration, 2014). OAUDs also frequently co-occur with each other and with other substance use disorders (SUDs) (Grant et al, 2015), making them more challenging to treat and more likely to be persistent and severe (McCabe and West, 2017; Moss et al, 2015; Upah et al, 2015; Witkiewitz and Vowles, 2018). …”

Global use and misuse of opioids

“…The synergism of negative health outcomes occurring with the consumption of opioids with other agents has become commonplace as well. Witkiewitz and Vowles have pointed to heavy consumption of alcohol accompanying opioid misuse had led to a public health crisis with deleterious impacts upon patient morbidity and mortality. They also suggest that concurrent abuse of alcohol coupled with opioid abuse co‐occurs along with chronic pain and, in fact, is under‐researched .…”

“…Witkiewitz and Vowles have pointed to heavy consumption of alcohol accompanying opioid misuse had led to a public health crisis with deleterious impacts upon patient morbidity and mortality. They also suggest that concurrent abuse of alcohol coupled with opioid abuse co‐occurs along with chronic pain and, in fact, is under‐researched . Australian researchers, Degenhardt and Hall, suggest that level of illicit drug use, including opioids, occurs more frequently in high‐income countries or in countries geographically close to drug‐producing countries.…”

“…They also suggest that concurrent abuse of alcohol coupled with opioid abuse co-occurs along with chronic pain and, in fact, is under-researched. [2] Australian researchers, Degenhardt and Hall, [3] suggest that level of illicit drug use, including opioids, occurs more frequently in highincome countries or in countries geographically close to drug-producing countries. The resultant difference in illicit drug use in lower income countries, however, may be due to under-reporting or lack of ability to collect and subsequently analyse drug-misuse data.…”