The Triple Threat of Substance Abuse, Chronic Pain, and Psychiatric Disorders

Substance Use Disorder and Chronic Pain Rates Elevated in Psychiatric Patients

The lifetime prevalence of a substance use disorder (SUD) hovers around 20% in the general population. The lifetime prevalence of chronic pain is about the same.

Rates of both are much higher, however, in the psychiatric patient population.

“The overlap of these two disorders with other major psychiatric disorders such as depression, psychosis (schizophrenia), and post-traumatic stress disorder is substantial,” said Thomas R. Kosten, MD, professor of psychiatry, pharmacology, and neuroscience at Baylor College of Medicine in Houston, Texas. “Eighty percent of patients with schizophrenia and 35% of patients with major depression smoke. For alcohol and marijuana, the rates are also high, with about 20% to 30% of patients with major psychiatric disorders also having these SUDs.”

“Thus, having either a SUD or chronic pain—and often, both—occurs in about half of patients with major psychiatric disorders.”

During an upcoming session at Psych Congress, Dr. Kosten will coach mental health professionals on the ins and outs of treating patients with psychiatric disorders and chronic pain in the presence of SUDs.

As the United States continues to reckon with the opioid epidemic, mental health providers seeing patients with chronic pain syndromes are left with a tricky task: managing psychiatric disorders, finding nonopioid ways to ease benign physical pain, and recognizing and addressing any opioid use disorders that may have developed through years of medically sanctioned opioid prescriptions.

“The issue is simply that chronic benign pain has been incorrectly treated with chronic high doses of opioids based on misinformation from the pharmaceutical industry,” Dr. Kosten said.

“Reversing that pain epidemic requires treating the opioid use disorders that have been produced, as well as understanding the substantial number of psychiatric disorders, such as depressive and anxiety disorders, that have amplified these chronic pain conditions, such as chronic fatigue syndrome, low back pain, frequent recurrent headaches, peripheral neuropathies, and various gastrointestinal syndromes.”

The first step? Recognition of patients dealing with SUDs.

“The SUD can be worsened by being ignored. The SUD related to stimulants can be facilitated by prescribing stimulants for attention-deficit/hyperactivity disorder (ADHD), particularly in adults. The SUD related to opioids is worsened by prescribing opioids to the patient when antidepressants or other medications are indicated,” explained Dr. Kosten.

“Overall, SUDs have symptoms quite similar to depression and anxiety disorders, and the appropriate treatment is to stop the abused drug, not add other medications that can worsen symptoms.”

In a patient with anxiety and depression caused by alcoholism, alcohol treatment and detoxification are indicated, he pointed out, not benzodiazepines. The wrong treatment can wreak havoc in the presence of a SUD and can cause worsening of depression and anxiety, drug side effects, medication nonadherence, SUD progression, or even overdose.

Dr. Kosten’s session, being presented on October 3, will cover the complications that opioids bring to various brain and body systems when they’re used to reduce chronic pain, as well as alternatives to using opioids for chronic pain—including the potential of cannabinoids and data supporting their limited, specific use. Treatments for opioid use disorder, including medical withdrawal and relapse-prevention therapies, will also be presented.

“The co-occurrence of SUDs with psych disorders is not primarily due to opioids, but opioids are strong contributors to the triple comorbidity of SUDs, chronic pain, and psychiatric disorders,” he said. “Different drugs have taken the lead at different times, such as opioids in the current epidemic, stimulants in the previous epidemic, and in a rapidly evolving, new epidemic with amphetamines.”

Dr. Kosten has logged more than 40 years focusing on the treatment of people with SUDs. While in medical school at CornellRockefeller University in New York City, he worked with the husband-wife team of Vincent Dole, MD (winner of the Lasker Award for Clinical Medical Research), and Marie Nyswander, MD, in developing methadone treatment for adolescents with heroin addiction. Dr. Kosten then moved on to study psychiatry at Yale University, New Haven, Connecticut, and continued working in SUD drug development throughout his career. He has developed naltrexone and buprenorphine treatment for opioid use disorders and is currently working on vaccines for SUDs involving opioids and stimulants.

Dr. Kosten welcomes questions about the lecture and patient cases from attendees during the question-and-answer session that will follow his presentation at Psych Congress.