Clinical Characteristics of Patients With and Without Chronic Pain Seeking Behavioral Health Treatment for Co-Occurring Opioid Use and Mental Health Disorders

Abstract

Background:

Among patients with chronic pain (CP; pain persisting for 3+ months) and opioid use disorder (OUD), ~3 in 4 report co-occurring mental health conditions, which may exacerbate difficulties accessing and engaging in behavioral health treatment. Beyond rates of co-occurring diagnoses, little is known about the differences in specific behavioral health needs of individuals with CP versus those without CP when they seek behavioral health treatment for OUD and co-occurring mental health disorders.

Methods:

These secondary analyses utilized data from a randomized controlled trial. Patients (n = 396) were individuals with (n = 281) and without CP (n = 115) seeking behavioral health treatment for OUD and co-occurring mental health disorders. Analyses focused on intake assessment data from validated patient-reported outcome measures for CP, OUD, and mental health: (1) pain intensity and interference (ie, impact on daily activities), (2) mental health symptoms and functioning, (3) current substance use, (4) quality of life, (5) sleep disturbance, (6) physical function, and (7) cognitive function.

Results:

Seventy-one percent of patients reported current CP at intake, and these patients reported high pain intensity and interference. Compared to those without CP, patients with CP reported significantly more depression, anxiety, and trauma symptoms; more difficulty with mental health functioning; lower quality of life; more sleep disturbance; and worse physical function. There were no significant differences in self-reported substance use or cognitive function.

Conclusions:

This study suggests that individuals with CP as well as OUD and co-occurring mental health disorders may have worse mental health, quality of life, sleep, and physical functioning upon entering treatment compared to those without CP. Thus, behavioral health treatment providers should assess broad mental and physical health needs in addition to screening for CP to address any issues, which may interfere with successful behavioral health treatment.

Keywords

chronic pain opioid use disorder mental health co-occurring disorders substance use

Highlights

Among patients with co-occurring opioid use and mental health disorders seeking behavioral health treatment, 71% reported current chronic pain (CP) at intake.

Those with CP reported significantly worse mental health, quality of life, and physical function as well as more sleep disturbances than those without CP.

Opioid and other substance use in the 90 days prior to intake was not significantly different between those with and those without CP.

Mental health, physical function, and sleep might represent targets for improving pain outcomes among people with CP and co-occurring opioid use and mental health disorders.

Introduction

Chronic pain (CP) is a major public health problem impacting 1 in 4 Americans.¹ Patients with CP are at high risk of using opioids in ways other than prescribed,² and 35% of patients with CP have opioid use disorder (OUD).³ With interactions among biological, psychological, and social aspects of CP,⁴ individuals with CP and OUD are likely to encounter barriers to OUD treatment, difficulties with treatment completion, and relapse risks.^5,6 Treatment is further complicated as 78% of patients with CP and OUD report additional lifetime substance use disorders, resulting in many targets for treatment as well as greater potential for relapse.⁷

Among patients with CP and OUD, 70% to 82% also report co-occurring mental health conditions, specifically depression and anxiety disorders.^7,8 Co-occurring conditions may exacerbate difficulties for individuals with CP and OUD as they engage with substance use treatment. Specifically, patients with OUD and co-occurring mental health disorders (without CP) have more treatment complications than those with OUD only. For example, they tend to have more substance use relapses⁹ and mental health symptom exacerbations¹⁰ as well as higher risk of overdose and misuse.^11,12

However, less is known about differences in behavioral health needs among individuals with CP versus those without CP who have OUD and co-occurring mental health disorders. Prior research indicates that nearly half of patients with OUD report lifetime depression, and those with OUD who have depression are more likely to report CP than those without depression.¹² Thus, the complex physical, mental, and behavioral health needs of those with CP, OUD, and co-occurring mental health conditions may have an impact on successful OUD and mental health treatment.⁴ This article presents secondary analyses utilizing data collected during a randomized controlled trial (RCT) for patients with and without CP who are currently prescribed medication for OUD (MOUD) and are seeking behavioral treatment for OUD and co-occurring mental health disorders.¹³ These analyses aimed to explore how behavioral health needs differ between those with and without CP upon starting treatment.

Methods

These secondary cross-sectional analyses utilized intake assessment data from patients enrolling in a RCT designed to treat OUD and co-occurring mental health disorders simultaneously via an integrated psychotherapy intervention delivered by a case manager and peer with lived experience in recovery.¹³ Patients were recruited at MOUD clinics and recovery support settings in Massachusetts. Inclusion criteria were as follows: (a) 18+ years old; (b) receiving MOUD; and (c) experiencing a co-occurring depressive disorder, anxiety disorder, trauma related disorder, bipolar, and/or schizophrenia. Exclusion criteria were as follows: (a) acutely psychotic, suicidal with a plan, or homicidal; and/or (b) severe alcohol use disorder or high doses of benzodiazepine requiring detoxification. Research was conducted with approval of the institution’s institutional review board.

Measures

Analyses focused on key health domains for those with CP and OUD: (1) pain intensity and interference, (2) mental health symptoms and functioning, (3) current substance use, (4) quality of life, (5) sleep disturbance, (6) physical function, and (7) cognitive function. If patients reported pain for 3+ months or at least half the days in the past 6 months, they met criteria for CP.

Patients who met criteria for CP responded to Pain, Enjoyment of Life, and General Activity (PEG)¹⁴ and Patient-Reported Outcomes Measurement Information System^® (PROMIS^®) Pain Interference 4a scale.¹⁵ These measures were included in the RCT due to funding mechanism requirements. PEG rates intensity and interference of pain (ie, impact on daily functioning) from 0 to 10 across 3 items, which represent separate subscales that are averaged for the total score. Scores ≥5 indicate moderate to severe pain.¹⁶ PROMIS^® Pain Interference scale assesses pain interference on a scale from 1 to 5 for 4 items, and raw scores were transformed into T scores. Higher scores indicate more pain interference.

Mental health symptoms and functioning were based on several measures. Depression severity was measured via Patient Health Questionnaire-9 (PHQ-9).¹⁷ Scores range from 0 to 27 (5-9: mild, 10-14 moderate, 15-19 moderately severe, ≥20 severe). Anxiety severity was measured via Generalized Anxiety Disorder-7 (GAD-7).¹⁸ Scores range from 0 to 21 (0-4: minimal, 5-9: mild, 10-14: moderate, 15-21: severe). Trauma symptoms were measured using Post-Traumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5).¹⁹ Scores range from 0 to 80, and higher scores indicate greater symptom severity. These analyses used the common threshold score of 31 for determining a probable PTSD diagnosis.²⁰ Behavior and Symptom Identification Scale-24 (BASIS-24)²¹ generates an overall mean score and 6 subscale scores: depression/functioning, relationships, psychosis, emotional lability, self-harm, and substance use.

Substance and alcohol use were based on Timeline Follow-Back.²² Patients indicate use or no use for the 90 days leading up to the assessment.

Quality of life was assessed using World Health Organization Quality of Life (WHOQOL-BREF)²³ and PROMIS^® Preference (PROPr) score.²⁴ Higher scores on WHOQOL-BREF and lower scores on PROPr indicate better quality of life.

PROMIS^® Sleep Disturbance 4a,²⁵ Physical Function 4a,²⁶ and Cognitive Function 4a²⁷ scales assess each domain on a scale from 1 to 5 for 4 items, and raw scores were transformed into T scores. Higher sleep disturbance scores indicate more sleep disturbance/poorer sleep quality. For physical function and cognitive function, lower scores indicate worse physical and cognitive function respectively.

Analyses

Descriptive statistics were computed to characterize the study sample at intake. Chi-squared tests of independence were conducted for categorical variables (ie, sex, ethnicity, race) to examine differences between CP groups. General linear models (GLMs) were conducted to examine differences between CP groups for continuous variables. Statistical tests were based on a 2-sided alpha of .01 and conducted using IBM SPSS 23.²⁸

Results

Data from 396 assessments were analyzed, and 71% of patients (n = 281) reported CP. GLM analyses controlled for age as patients with CP were significantly older than those without CP (t (394) = −3.89, P < .001). Groups did not differ significantly in sex representation (χ² (1) = 1.49, P = .223). Overall and group means are presented in Table 1, and GLM results are discussed briefly below and presented in Table 2.

Table 1.

Clinical Characteristics of Patients With Co-Occurring OUD and Mental Health Disorders, Stratified by Chronic Pain Group.

Characteristic	Overall (N = 396)	Chronic pain (n = 281)	No chronic pain (n = 115)
Age, years (SD)	39.62 (9.48)	40.79* (9.58)	36.77* (8.61)
Sex
Female	50.0%	52.0%	45.2%
Ethnicity
Hispanic/Latinx	24.7%	23.8%	27.0%
Non-Hispanic/Latinx	74.2%	75.8%	70.4%
Race
White	74.7%	76.9%	69.6%
Black/African American	9.6%	7.1%	15.7%
American Indian/Alaska Native	2.5%	3.6%	0.0%
Asian	1.3%	0.7%	2.6%
Mental health symptoms/functioning (SD)
PHQ-9	10.69 (6.30)	11.49* (6.14)	8.74* (6.26)
GAD-7	8.73 (5.54)	9.29** (5.53)	7.33** (5.32)
PCL-5	32.14 (21.28)	34.30** (22.24)	26.86** (17.37)
BASIS-24 total	1.24 (0.53)	1.31* (0.53)	1.08* (0.50)
Depression/functioning	1.71 (0.85)	1.83* (0.86)	1.44* (0.77)
Relationships	1.42 (0.87)	1.45 (0.89)	1.35 (0.82)
Psychosis	0.49 (0.66)	0.55 (0.70)	0.37 (0.56)
Emotional lability	1.94 (0.91)	2.04* (0.89)	1.68* (0.93)
Self-harm	0.15 (0.47)	0.17 (0.51)	0.10 (0.33)
Substance use	1.08 (0.92)	1.12 (0.93)	0.97 (0.88)
Days of use in past 90 days (SD)
Alcohol	3.92 (14.11)	3.91 (14.32)	3.96 (13.63)
Marijuana	13.51 (29.43)	11.51*** (27.13)	18.38*** (34.05)
Opioids	11.54 (25.80)	10.90 (26.47)	13.11 (24.12)
Cocaine	4.51 (14.42)	4.67 (15.77)	4.12 (10.47)
Crack	5.36 (15.79)	4.63 (15.34)	7.14 (16.78)
Hallucinogens	0.28 (2.32)	0.27 (2.62)	0.29 (1.33)
Stimulants	10.45 (25.82)	9.73 (26.35)	12.20 (24.50)
Sedatives	0.20 (2.25)	0.07 (0.75)	0.51 (4.00)
Benzodiazepines	1.27 (5.86)	1.17 (5.82)	1.50 (5.98)
Inhalants	0.06 (1.11)	0.00 (0.00)	0.19 (2.05)
Quality of life (SD)
WHOQOL-BREF	52.61 (9.86)	51.01* (9.93)	56.51* (8.55)
PROPr	84.44 (13.33)	86.90* (13.31)	78.42* (11.34)
Sleep disturbance (SD)	55.33 (10.11)	56.78* (9.74)	51.75* (10.15)
Physical function (SD)	46.73 (9.05)	44.38* (8.86)	52.50* (6.62)
Cognitive function (SD)	31.95 (3.60)	31.77 (3.69)	32.40 (3.36)

Abbreviations: BASIS-24, Behavior and Symptom Identification Scale-24; GAD-7, Generalized Anxiety Disorder-7; OUD, opioid use disorder; PCL-5, Post-Traumatic Stress Disorder Checklist for DSM-5; PHQ-9, Patient Health Questionnaire-9; PROPr, PROMIS^® Preference; WHOQOL, World Health Organization Quality of Life.

P < .001. **P < .01. ***P < .05.

Table 2.

GLM Results From Chronic Pain Group Versus No Chronic Pain Group.

Outcome	F	df	P	ηp²
Mental health symptoms/functioning
PHQ-9	13.91	1, 391	<.001	.03
GAD-7	9.88	1, 391	.002	.03
PCL-5	8.10	1, 389	.005	.02
BASIS-24 total	14.12	1, 393	<.001	.04
Depression/functioning	16.29	1, 393	<.001	.04
Relationships	1.41	1, 393	.235	.00
Psychosis	3.49	1, 393	.063	.01
Emotional lability	13.41	1, 393	<.001	.03
Self-harm	2.74	1, 393	.099	.01
Substance use	2.18	1, 393	.140	.01
Days of use in past 90 days
Alcohol	0.12	1, 393	.726	.00
Marijuana	4.03	1, 393	.045	.01
Opioids	0.38	1, 393	.540	.00
Cocaine	0.11	1, 393	.739	.00
Crack	2.15	1, 393	.143	.01
Hallucinogens	0.07	1, 393	.798	.00
Stimulants	0.74	1, 393	.389	.00
Sedatives	3.25	1, 393	.072	.01
Benzodiazepines	0.13	1, 393	.718	.00
Inhalants	2.12	1, 393	.146	.01
Quality of life
WHOQOL-BREF	24.70	1, 393	<.001	.06
PROPr	38.07	1, 389	<.001	.09
Sleep disturbance	18.89	1, 392	<.001	.05
Physical function	62.43	1, 393	<.001	.14
Cognitive function	2.52	1, 365	.114	.01

GLMs controlled for age as patients with CP were significantly older than those without CP (P < .001).

Abbreviations: BASIS-24, Behavior and Symptom Identification Scale-24; CP, chronic pain; GAD-7, Generalized Anxiety Disorder-7; GLMs, general linear models; PCL-5, Post-Traumatic Stress Disorder Checklist for DSM-5; PHQ-9, Patient Health Questionnaire-9; PROPr, PROMIS^® Preference; WHOQOL, World Health Organization Quality of Life.

Pain Intensity and Interference

On PEG, those experiencing CP reported an average score of 5.50 (SD = 2.17). For pain in past week, individuals with CP reported an average of 5.85 (SD = 2.12). Patients with CP also report average interference with enjoyment of life at 5.47 (SD = 2.52) and interference with general activity at 5.19 (SD = 2.62). For PROMIS^® Pain Interference 4a, patients with CP reported a score of 59.68 (SD = 8.48).

Mental Health Symptoms and Functioning

Patients with CP reported significantly more depression symptoms via PHQ-9, anxiety symptoms via GAD-7, and PTSD symptoms via PCL-5 than those without CP. Additionally, average scores for those with CP met thresholds for moderate depression and probable PTSD diagnosis (no formal clinical interviews to confirm), whereas those without CP only met criteria for mild depression. For BASIS-24, patients with CP reported significantly more difficulty or distress (as indicated by higher scores) than those without CP.

Substance Use

Groups did not indicate significant differences in substance use in the 90 days before intake.

Quality of Life

Patients with CP reported significantly worse quality of life than those without CP.

Additional PROMIS^® Measures

Patients with CP reported significantly more sleep disturbances and worse physical function than those without CP. There was not a significant difference in cognitive function.

Discussion

This study explored how behavioral health needs differed among individuals seeking behavioral treatment for OUD and co-occurring mental health disorders. A high rate of CP was observed in the study sample. Those with CP were significantly older, and they reported that pain was severe and caused significant interference. Patients with CP reported more depression, anxiety, and PTSD symptoms; more general mental health distress; and worse quality of life, sleep, and physical function than those without CP. Thus, behavioral health treatment intake screenings should explore patients’ current mental health, sleep, physical function, and quality of life issues. Given these high rates of CP, such screenings would enable providers to also understand how these issues may also be exacerbated by CP and exacerbate CP symptoms in turn. Providers can then target these issues to improve both pain and behavioral health outcomes in this population with OUD and co-occurring mental health disorders.

Previous work presented rates of co-occurring mental health disorders among individuals with OUD and CP.^7,8 Current findings extend that work by highlighting broad mental health needs of patients who have CP during OUD treatment. For example, the average PHQ-9 score for those with CP indicates moderate depression, whereas the average score for those without CP indicates mild depression, which aligns with prior research.^8,12 As overdose risk is a concern among individuals with CP, OUD, and depression, providers should be mindful of high prescription doses, other simultaneous prescriptions (ie, benzodiazepines), and multiple prescribers to mitigate this risk.^29,30 Similarly, the average PCL-5 score for those with CP met a common threshold for a probable PTSD diagnosis, yet the average score for those without CP did not. However, formal clinical interviews were not carried out to confirm diagnoses in either group. Our findings also extend prior work, which suggests individuals with PTSD seeking OUD treatment report greater pain severity and interference, more complications related to behavioral health, and increased service utilization.³¹

Additionally, patients with CP reported significantly worse quality of life, sleep, and physical function than those without CP. These findings are consistent with prior research,³² as those with OUD also report worse quality of life than those without OUD, particularly when they have co-occurring mental health disorders.³³ The complex behavioral and physical health needs of individuals with CP and OUD are contributing factors to these lower scores. Behavioral health treatment providers should strive to track these health and quality of life domains to adjust care accordingly and/or recommend supports. Finally, considering those with CP were significantly older than those without CP, they may face unique challenges in both pain and behavioral health treatment. Therefore, providers should consider how older patients may encounter more issues than younger patients across the healthcare landscape.

Limitations

The main limitation of these secondary analyses is bias associated with temporality and the cross-sectional picture of patients’ needs. Also, additional measures of pain intensity and interference were only collected among individuals who met criteria for CP; thus, they were not available for those without CP. Additionally, there are limitations in causal inferences as analyses did not account for other potential confounders (eg, socioeconomic status, treatment background). For example, previous work suggests behavioral health treatment needs differ depending on whether patients with OUD had OUD prior to their CP diagnosis or CP prior to their OUD diagnosis.⁸ Thus, analyzing history of treatment and duration of diagnoses would provide important context for this sample. Moreover, we do not yet have treatment engagement or outcome data from the ongoing RCT, which are critical to understanding the impact of CP on behavioral health treatment. Finally, based on prior literature,³⁴ it was surprising there were not significant differences in self-reported substance use in this population. With fentanyl contamination as a key driver in overdoses among those with OUD,³⁵ it would be important to know more about the exposure to fentanyl and its impact on substance use in those with and without CP in future studies. Thus, objective measures of substance use (ie, urinalyses) may provide clarity on potential differences in use among those with OUD.

Conclusions

These analyses suggest that individuals seeking treatment for OUD and co-occurring mental health disorders are greatly impacted by CP. These patients have more mental health needs upon entering treatment, which make recovery more difficult. This work lends critical evidence for behavioral health providers to examine the effect of CP on mental health during OUD treatment. Further, providers should also seek out opportunities to address the impact of mental health, sleep, and physical function issues in those with CP, OUD, and co-occurring mental health disorders. Thus, future treatment studies with this population should closely screen patients at intake and monitor these symptoms to evaluate the impact on pain and behavioral health outcomes and to address patients’ complex needs.

Footnotes

Acknowledgements

The views and opinions of authors expressed herein do not necessarily state or reflect those of the United States Government and shall not be used for advertising or product endorsement purposes. We wish to thank NIH for their support of this work.

Author Contributions

AH conceptualized and designed the study, drafted the initial manuscript, and critically reviewed and revised the manuscript. EK collected data and critically reviewed and revised the manuscript. PMS, OTH, and DS critically reviewed and revised the manuscript for important intellectual content.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by grants from the National Institute of Mental Health, the National Institute on Drug Abuse, and the National Institute of Neurological Disorders and Stroke of the National Institutes of Health: R01MH128904 and K12NS130673. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance,Ethical Standards,and Ethical Approval

Institutional review board approval was not required.

ORCID iD

Abigail Helm

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Clinical Characteristics of Patients With and Without Chronic Pain Seeking Behavioral Health Treatment for Co-Occurring Opioid Use and Mental Health Disorders

Abstract

Background:

Methods:

Results:

Conclusions:

Keywords

Highlights

Introduction

Methods

Measures

Analyses

Results

Pain Intensity and Interference

Mental Health Symptoms and Functioning

Substance Use

Quality of Life

Additional PROMIS® Measures

Discussion

Limitations

Conclusions

Footnotes

Acknowledgements

Author Contributions

Declaration of Conflicting Interests

Funding

Compliance,Ethical Standards,and Ethical Approval

ORCID iD

References

Additional PROMIS^® Measures