Individuals with addictive disorders or substance abuse problems are at increased risk of receiving inadequate pain management. Undertreatment has been most clearly demonstrated among populations, such as those with cancer or HIV/AIDS, for which opioid therapy would be the conventional first-line approach for moderate to severe chronic pain. Many factors may contribute to the undertreatment of pain overall, and to the particular reluctance to use opioids if otherwise indicated. Physicians generally have limited knowledge and inadequate training in both pain management and addiction medicine, a fear of contributing to addiction through the use of opioid medications, societal prejudices against persons with addictive disorders, and fear of regulatory sanctions.¹

Treatment of pain in the heterogeneous population with substance use disorders can be challenging. Paradoxically, patients must be considered high risk to abuse analgesics, but at the same time, pain should be presumed to be a contributor to addiction,² and effective pain management might actually reduce the risk of aberrant drug taking. Although pain control might be achievable for some patients without the use of potentially abusable drugs, some patients (such as those with acute pain or persistent pain associated with advanced medical illness) have a clear indication for opioid therapy others appear to gain a degree of benefit from these drugs that outweighs the risks. Finally, certain physiological and psychological aspects of addictive disease may make pain more difficult to treat.

Patients with pain and a history of addiction or substance abuse may be encountered in the office or hospital when they seek treatment for complications of their substance abuse or a comorbidity, or a history of substance abuse may itself be a comorbid condition when patients seek treatment for pain. Undertreatment of pain is possible in either situation. If the patient is labeled an addict, the pejorative connotations of this term may follow him or her throughout the health care system.³