Substance use disorders in patients with chronic pain: The role of temperament in successful treatment

Patients with chronic pain and comorbid substance use disorders are at significantly greater risk for failure to achieve a successful outcome of either improved pain or improved function. This effect may be seen indirectly as well by the exclusion of patients with substance use disorders from many treatment trials for chronic pain disorders. The implication that substance abusers are more likely to be nonadherent to the treatment protocol and thus fail the therapy is clear. In practice, the presence of a substance use disorder in a patient's medical record may influence the decisions of physicians regarding candidacy for particular therapies, such as corrective surgical procedures, medications with abuse potential, or relatively scarce high-cost technologies that require long-term commitments for follow-up. Pain management physicians may find patients with personality disorders difficult to treat. A model for the genesis and perpetuation of substance use disorders in patients with chronic pain that would refine treatment principles can be elucidated for this complicated population by including information about the patient's temperament. This paper will outline the utility of examining temperament and how this information serves to transform the expectation of chronic pain treatment to one with a more therapeutically optimistic outcome.