Efficacy of a Psychosocial Pain Management Intervention for Men and Women With Substance Use Disorders and Chronic Pain: A Randomized Clinical Trial

Abstract

Importance: Chronic pain is common in those with substance use disorders (SUDs) and predicts poorer addiction treatment outcomes. A critical challenge for addiction treatment is to develop effective methods to improve pain-related and substance use-related outcomes for those in treatment for SUDs.

Objective: To examine the efficacy of an integrated behavioral pain management intervention (Improving Pain During Addiction Treatment [ImPAT]) for men and women with SUDs to treat pain, functioning, and substance use.

Design, setting, and participants: In this randomized clinical trial, 8 sessions of ImPAT were compared with 8 sessions of a supportive psychoeducational control (SPC) condition for adults with pain treated at a large residential SUD treatment program. Follow-up occurred at 3, 6, and 12 months postbaseline. A total of 1372 adults were screened, including 960 men and 412 women, and 510 adults were randomized, including 264 men and 246 women. The goal was to recruit approximately equal numbers of men and women to examine results separately in men and women. A total of 470 of 510 participants (92.2%) completed at least 1 follow-up assessment. Data were collected from October 3, 2011, to January 14, 2016. Data were analyzed from February 1, 2016, to May 1, 2020.

Interventions: ImPAT focused on how a psychosocial model of pain was associated with functioning and relapse prevention and provides skills to manage pain. SPC served as the active control condition and involved discussions of topics like nutrition and the course of addiction, which were intended to be relevant to the patient population and to have face validity but be distinct from the content of ImPAT.

Main outcomes and measurements: The primary outcomes were pain intensity, pain-related functioning, and behavioral pain tolerance at 12 months. Secondary outcomes were frequency of alcohol and drug use over 12 months.

Results: Of the 510 included participants, the mean (SD) age was 34.8 (10.3) years. A total of 133 men and 122 women were assigned to ImPAT, and a total of 131 men and 124 women were assigned to the SPC condition. Over 12 months of follow-up, randomization to the ImPAT intervention was associated with higher tolerance of pain among men, higher by a mean score of 0.11 (95% CI, 0.03 to 0.18; P = .004; Cohen d = 0.40) at 3 months and by 0.07 (95% CI, -0.01 to 0.19; P = .11; Cohen d = 0.25) at 12 months. Women receiving the ImPAT intervention experienced a reduction in pain intensity from 3 to 12 months, while women receiving the SPC condition experienced an increase in pain intensity, resulting in lower pain in the ImPAT condition by a mean score of 0.58 (95% CI, -0.07 to 1.22; P = .08; Cohen d = -0.22) at 12 months. No differences were found between the ImPAT and SPC conditions on alcohol or drug use.

Conclusions and relevance: Behavioral pain management is not typically included in addiction treatment, but the present results indicate that this type of intervention was associated with better pain-related outcomes, including pain tolerance in men and pain intensity in women. Improvements in substance use-related outcomes beyond that achieved by treatment as usual were not observed. Treatment programs should consider providing psychosocial pain management services to augment standard addiction treatment.

Trial registration: ClinicalTrials.gov Identifier: NCT01372267.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Ilgen is a part of ArborSense, which is developing a wearable alcohol sensor, and consults for Northrop Grumman on a project to prevent suicide in military personnel. Dr Blow has received personal fees from the Hazelden Betty Ford Foundation. No other disclosures were reported.

Figures

Figure 1.. CONSORT Diagram by Sex

Patients were randomized to the Improving Pain During Addiction Treatment (ImPAT) intervention or a supportive psychoeducational control (SPC) condition.

Figure 2.. Model-Estimated Pain Intensity, Functioning, and Tolerance Over Follow-up Assessments

Pain intensity was measured at baseline and each time point using the Numeric Rating Scale of Pain Intensity item 1; pain functioning, the West Haven-Yale Multidimensional Pain Inventory general activity subsection; and pain tolerance, the ischemic pain task. Baseline observed values are provided for reference. Error bars indicate SEs. ImPAT indicates Improving Pain During Addiction Treatment; SPC, supportive psychoeducational control.

Figure 3.. Model-Estimated Proportion Days Abstinent From Alcohol and Drugs Over Follow-up Assessments

Alcohol and drug use were measured at baseline and each time point using Timeline Followback. Baseline observed values are provided for reference. Error bars indicate SEs. ImPAT indicates Improving Pain During Addiction Treatment; SPC, supportive psychoeducational control.