Pain Management, Mental Health, and Substance Use

Globally, 1 in 5 adults suffers from pain, which is the most common reason people seek health care and the leading cause of disability in the world. Low back pain has the highest prevalence among musculoskeletal conditions and is the leading cause of disability worldwide, according to the World Health Organization. Chronic pain, defined as pain that persists or recurs for longer than three months, exerts an enormous personal and economic burden, affecting more than 30% of people worldwide. Indeed, even when higher rates of depression, suicide, and opioid use are controlled for, chronic pain is still associated with a lower life expectancy.

Women are a key group with less access to optimal pain management. Often the pain they report is taken less seriously, they have to wait longer on average for treatment, and they experience more intense pain. For example, as reported by The Washington Post, women with acute abdominal pain are 25% less likely than male counterparts to be treated with powerful opioids, while women with chest pain wait 29% longer in emergency departments.

Similarly, quality of pain management is influenced by race and ethnicity. A review of 2012-2014 National Emergency Medical Services Information System (NEMSIS) data suggested that pre-hospital providers are less likely to treat Black patients who experience burns, penetrating injuries, or fractures with pain medication than White patients, and that providers are less likely to use pain medication when treating Black and Hispanic patients experiencing blunt trauma. Additionally, analysis of Oregon NEMSIS data found that Black, Asian, other-race, and unknown-race patients treated for traumatic injury or complaining of pain are less likely to receive pain medication than White patients.

Furthermore, mental health has a significant impact on pain management, and vice versa. People living with chronic pain are at heightened risk for mental health problems, including depression, anxiety, and substance use disorders (SUD). An estimated 35% to 45% of people with chronic pain experience depression (Vadivelu, et al., 2017). Depression and pain frequently co-occur, although estimates of pain prevalence in people with depression vary widely.

Similarly, pain prevalence is high in individuals with bipolar disorder, with approximately 29% of individuals reporting pain—more than double the risk for healthy controls. Meta-analyses of experimental studies show that adults with schizophrenia have elevated pain thresholds and tolerance. However, 35% of them report clinical pain, similar to individuals without mental illness.

Chronic pain prevalence among individuals with an SUD is approximately 60% (Wyse, et al., 2021). Understanding which occurred first might be helpful for treatment of both. One possibility is that patients might be self-medicating chronic pain, ultimately resulting in an SUD. Another is that pain causes stress, and stress makes individuals vulnerable to SUDs.

There is a tendency for physicians to under-medicate individuals with substance use disorder, possibly out of an abundance of caution—because an estimated 10% of chronic pain patients misuse prescription opioids (Garland, et al., 2013). Chronic pain and associated emotional distress are believed to dysregulate the brain’s stress and reward system, thereby increasing the risk for opioid use disorder.

Clearly, pain management is a public health challenge—one that psychiatrists are uniquely trained to confront. We can, and we should. ■

Vadivelu N, Kai AM, Kodumudi G, et al.: Pain and psychology: a reciprocal relationship. Ochsner J 2017; 17(2):173-180

Wyse JJ, Lovejoy J, Holloway J, et al.: Patients’ perceptions of the pathways linking chronic pain with problematic substance use. Pain 2021; 162(3):787-793

Garland EL, Froeliger B, Zeidan F, et al.: The downward spiral of chronic pain, prescription opioid misuse, and addiction: cognitive, affective, and neuropsychopharmacologic pathways. Neurosci Biobehav Rev 2013; 37(10 Pt 2):2597-607