Heightened pain perception in illicit substance–using patients in the ED: implications for management

BackgroundSubstance users are commonly perceived to overstate their pain. Few data exist comparing pain intensity, perception, and related psychiatric comorbidities in the emergency department (ED) population.ObjectiveTo compare pain severity, duration, interference with function, and psychiatric and mood disturbance in substance-using (SU) and non–substance-using (NSU) patients in the ED.MethodsThis is a cross-sectional study. The setting is in an urban ED. Participants are SU and NSU patients in moderate to severe pain (numerical rating scale, 5-10). Outcome measures are as follows: pain intensity and duration, other painful conditions, pain-related functional interference (0-10), psychiatric disorders, and mood distress (profile of mood scale, 0-44).ResultsOf the 148 patients who enrolled, 28 (19%) reported recent illicit substance use (SU) and 120 (81%) did not (NSU). The SU patients' mean pain intensity was 8.96 (confidence interval [CI], 7.47-8.14) vs 7.81 (CI, 8.48-9.45) for NSU (P = .003). The SU patients reported higher levels of pain interference. Fifty-four percent of SU patients vs 31% of NSU patients reported a psychiatric illness (P = .02). Mean Profile of Mood State score was higher in SU (32.3; CI, 27.4-37.1) than in NSU (22.5; CI, 20.2-24.8; P < .001). Chronic pain was reported by 29% of SU patients vs 16% of NSU patients, and 75% of SU patients vs 58% of NSU patients reported another concurrent painful condition (P = .10).ConclusionsThe SU patients report more severe pain and functional interference, more psychiatric illness and mood distress, and more chronically painful conditions. Given the complex interplay between pain, substance use, and mood disorders, increased attention should be paid to identifying patients with these associated conditions and to facilitating appropriate referrals. Effective treatment of this challenging patient population requires treating the entirety of their medical, psychiatric, and addictive diseases.