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

Key PointsQuestionDoes an integrated behavioral pain management treatment (Improving Pain During Addiction Treatment [ImPAT]) added to standard residential addiction treatment improve pain-related and substance use-related outcomes compared with an attention-matched control condition in men and women? FindingsIn this randomized clinical trial including 510 participants, men randomized to the ImPAT condition displayed greater pain tolerance compared with men randomized to the control condition and women randomized to the ImPAT condition experienced significant improvements in pain intensity compared with women randomized to the control group over 12 months of follow-up. No differences were detected between the ImPAT and control conditions on substance use-related outcomes. MeaningWhen added to usual substance use treatment, ImPAT led to meaningful improvements in pain management for men and women, although additional services may be needed to enhance treatment outcomes in this relatively severe group of patients. This randomized clinical trial examines the efficacy of a behavioral pain management intervention for men and women with substance use disorders to treat pain, functioning, and substance use. ImportanceChronic 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. ObjectiveTo 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 ParticipantsIn 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. InterventionsImPAT 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 MeasurementsThe 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. ResultsOf 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 RelevanceBehavioral 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 RegistrationClinicalTrials.gov Identifier: NCT01372267