Chronic Pain and Alcohol Abuse

Perry argued that patients who are abusing alcohol and other drugs should be getting more pain medication, not less, in order to compensate for their developed tolerance [10]. He also noted that it has been very difficult to know how adequate analgesia might affect addiction patterns, because most of these patients simply do not receive sufficient doses of narcotics. Unfortunately, very few studies have investigated crosstolerance between alcohol and opioids at a practical level or in humans. The only class of drugs known to have a direct crosstolerance with alcohol are the benzodiazepines.

Chronic Pain and Alcohol Abuse

This will allow the patient to feel more in control of their environment and they will probably use less medication as a result. Finally, a comprehensive, multimodal approach that includes various classes of medications and nonpharmacological interventions is particularly important when working with patients with substance abuse issues. The second concern regards the presumption that patients with a substance abuse history are more likely to abuse opioid medications [30].

“This study has uniquely shown that alcohol dependence is not required to worsen pain outcomes and that even moderate drinking can lead to pain pathology, and thus consumption of ethanol is a poor strategy for dealing with pain,” Dr. Nothem told MNT. To date, the lack of preclinical, or animal, 2022 national drug and alcohol facts week ndafw models of alcoholic neuropathic pain limited the investigation of pathological mechanisms underlying the onset of neuropathic pain in people with alcohol use disorder. This phenomenon is more common in women, affecting around 60% of cases, than in men, in whom it affects around 50% of cases.

Alcohol & trauma

A comprehensive approach to the treatment of alcohol addiction, which considers chronic conditions like chronic pain, is necessary for effective treatment of both. The input of medical professionals and behavioral experts in a therapeutic, compassionate environment is essential to developing a personalized, long-term plan for recovery from alcohol addiction and effective strategies to address pain. Alcohol use, which is not that good at addressing chronic pain anyway, ultimately makes the pain worse. Additionally, prolonged, excess consumption of alcohol can actually cause small fiber peripheral neuropathy. This type of neuropathy causes symptoms like pain, tingling, “pins and needles” sensations in the extremities, or altered sensations, especially in the feet. Whatever short-term relief from pain alcohol may provide (at least at first), it is far outweighed by more pain over the long term.

Importantly, almost 38% of current problem drinkers reported using alcohol to manage pain, whereas in contrast, only 15% of nonproblem-drinking men and 13% of nonproblem-drinking women did so. Among the problem drinkers who experienced moderate to severe pain, almost 57% of men and 59% of women reported using alcohol for pain management, compared to 21% of nonproblem-drinking men and women with the same level of pain. This is the first study to generate a preclinical model of alcohol withdrawal-related allodynia and alcohol-induced neuropathic pain in vivo.

Acute pain management

Consequently, decisions regarding prescribing pain medications in this population should be made on an individual basis. The onset of chronic pain may precede memory problems, and chronic pain has been shown to increase the risk of dementia in older adults (Whitlock et al., 2017). Unfortunately, the assessment of pain in patients who already have been diagnosed with varying types or combinations of types of dementia and amnesia, is especially challenging, and therefore, research and clinical treatment with these populations has been limited and inadequate (Buffum, Hutt, Chang, Craine, & Snow, 2007). Compared to healthy controls, individuals suffering from chronic back pain or complex regional pain syndrome have a smaller hippocampus, a brain structure that is involved in memory formation and consolidation (Mutso et al., 2012).

  1. Despite this challenge, there are a number of validated for assessments of pain intensity and for evaluating multiple dimensions of the pain experience, as well as overall functioning, that rely on subjective perceptions of pain apart from physiologic or neurologic measurements (Younger et al., 2009).
  2. AUD may share common neural pathways with chronic pain, which may facilitate pain affecting alcohol use patterns, or facilitate modulatory effects of alcohol on pain processing, thereby precipitating the risk of chronic pain development.
  3. The administration of pain medication is largely controlled by the nursing staff, who rely on patients’ reports of pain.
  4. In the Boston Collaborative Drug Surveillance Program, only one out of 11,882 hospitalized patients who had no prior history of substance abuse and who received narcotics while in the hospital developed a drug dependency [17].

They found that the most important factor in patient satisfaction regarding their pain was whether or not the medical staff had communicated to their patient that pain control was a high priority, even if they did nothing to actually control pain. These results support previous studies that showed that patients have low expectations regarding pain relief [20,21]. Ward and Gordon concluded, “until patients expect that pain can be relieved, they will be satisfied with pain management even though they are in pain” [19]. The patients’ low expectations directly impact the issue of inadequate pain management because they may not be asking for pain medications when they need them. Staff and patient stoicism toward pain, as well as the staff’s difficulty in assessing patients’ pain, are all contributing to the problem of undermedication.

Impulsivity is multidimensional construct referring to a predisposition for individuals to react quickly in response to an internal or external stimulus, without consideration of the possible negative consequences (Lejuez et al., 2010). While not a prominent trait in chronic pain patients, impulsivity may be especially relevant to individuals with AUD who suffer from chronic pain. These individuals would be in a situation that is analogous to what has been described for opioid analgesic misuse risk in chronic, low-back pain patients who had been prescribed opioid analgesics (Marino et al., 2013). The experience of physical pain also has been reported to be elevated in alcohol dependent patients having high levels of impulsivity, with physical pain being an independent correlate of both subjectively reported and objectively measured levels of impulsivity (Jakubczyk, Brower, et al., 2016). In particular, there seems to be a role for an attention dimension of impulsivity that represents heightened distractibility and compromised cognitive control, both in AUD (Jakubczyk, Brower, et al., 2016) and in opioid analgesic misuse in chronic pain patients (Marino et al., 2013). There are two major concerns when treating patients for pain who have chronic histories of alcohol and drug abuse.

The combination of alcohol and opioid painkillers can be deadly, with alcohol increasing the risk of serious respiratory depression with opioids. In other words, the warning labels on prescription painkiller bottles to avoid alcohol are far more than mere suggestions; they can be life-saving. Dysfunction in descending pain modulatory circuits is thought to play an important role in the chronification of pain (Ossipov difference between crack and coke et al., 2014). This circuit, which controls top-down modulation of pain, receives inputs arising from multiple regions in the brain, including the hypothalamus, amygdala, and the rostral anterior cingulate cortex (Figure 2). These regions feed into the rostral ventromedial medulla, which includes the midline nucleus raphe and periaqueductal gray matter that have neural pathways to the spinal dorsal horn.

How does alcohol cause pain?

Given the analgesic effects of alcohol on pain, pervasiveness of alcohol use as a pain management strategy has proven to be substantial among individuals exhibiting pain. For example, in a study of older adult (ages 55–65) problem drinkers and healthy controls, the drinkers were more likely to report more severe pain, greater pain interference, and more frequent use of alcohol to manage pain (Brennan et al., 2005). In a recent large study (Alford et al., 2016), the investigators identified 589 adult primary care patients who screened positive for illegal drug use and misuse of prescription medications.

The administration of pain medication is largely controlled by the nursing staff, who rely on patients’ reports of pain. The validity of patient reports may be questioned if a patient has a substance abuse problem. However, this relationship seems to be mediated by other factors, including alcohol and drug status (acute intoxication vs chronic abuse), genetic risk factors and environmental factors. Morphine is the safest and most effective painkiller for constant, severe pain and has been used for centuries. It is prescribed for relatively short periods for hospitalized patients who are recovering from surgery or other traumas, and is also given for relatively long periods to patients suffering chronic pain caused by burns or incurable cancer [5].

In cases of neuropathic pain, neuropathic agents, such as gabapentin, should also be considered. Finally, nonpharmacologic interventions, such as hypnosis, relaxation and distraction, should not be overlooked as adjuncts to opiates for acute pain management. Finally, in a review paper, Gentillello et al. also found that nearly half of all trauma patients were under the influence of alcohol when injured [3]. They summarized the effects of brief interventions in in-patient and out-patient settings.

Chronic alcohol & drug use

They concluded that these brief interventions resulted in a decrease in drinking, and that a trauma can be an effective time to intervene. In a randomized controlled study, the same group showed that trauma recidivism was halved by a brief motivational intervention [4]. These studies also emphasize that, in addition to a thorough history and self-reported questionnaires, biochemical markers amphetamine addiction are needed to detect substance abuse problems. Drinking is known to numb the excitatory response of the nervous system, causing a temporary soothing effect and feeling of pain relief. However, studies have shown that for alcohol to reach the medical levels of pain moderation, one would typically have to consume much more than what’s considered healthy alcohol consumption by the CDC².

The fact is that alcohol is readily available, and effective pain medication sometimes is not. When Roberto’s group then measured levels of inflammatory proteins in the animals, they discovered that while inflammation pathways were elevated in both dependent and non-dependent animals, specific molecules were only increased in dependent mice. It also suggests which inflammatory proteins may be useful as drug targets to combat alcohol-related pain. “There is an urgent need to better understand the two-way street between chronic pain and alcohol dependence,” says senior author Marisa Roberto, PhD, the Schimmel Family Chair of Molecular Medicine, and a professor of neuroscience at Scripps Research. “Pain is both a widespread symptom in patients suffering from alcohol dependence, as well as a reason why people are driven to drink again.” Pain management in the trauma population has been a major focus of attention for the last two decades following studies showing that patients are generally undermedicated for pain and that high rates of pain while hospitalized can lead to poorer outcomes [5,6].

If you are struggling with alcohol abuse or addiction, with or without chronic pain, we encourage you to contact us at any time. One reason people often self-medicate pain with alcohol, aside from the fact that it is so easy to obtain, is that they see alcohol as also a way to manage stress, and chronic pain and stress frequently go together. Though alcohol does not have any direct pain-relieving properties, it can affect the central nervous system in such a way that pain is not perceived to be as bad. Drinking enough alcohol to “relieve pain” can mean drinking to the point of blackout, and this is an exceptionally unhealthy way to deal with pain, whether acute or chronic. Watch a couple of old Westerns on television and you are bound to see a character cope with a snake bite or a bullet wound by taking a swig of whiskey.

As highlighted throughout this review, heavy drinking and AUD, opioid misuse and OUD, and chronic pain are each significant public health problems. Yet, heavy drinking and AUD far surpasses opioid misuse and OUD with respect to prevalence (see Figure 1) and societal costs (approximately $78.5 billion due to opioids versus $249 billion due to alcohol in the U.S.; CDC, 2016; Florence et al., 2016). An alternative method of prescribing pain medication is slowly gaining acceptance, and recent studies have shown it to be quite effective. This is called ‘scheduled’ or ‘fixed’ dosing and was developed by an English physician who cared for people dying of terminal cancer. In this method, doses are given regularly according to a schedule that has been tailored in order to account for an individual’s response to pain medications.

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