This study is among the first to examine the utilization of allopathic and complementary and alternative medicine (CAM) treatments for pain relief among MMTP patients with either “some pain” (SP) or “chronic severe pain” (CSP). Overall, similar patterns of past-week allopathic and CAM utilization patterns were reported by both pain groups (i.e., SP and CSP); while there appeared to be more variability in lifetime as opposed to past-week allopathic and CAM utilization among SP and CSP groups (medical use of prescribed non-opiate medication, prayer, counseling, yoga, and physical therapy), these differences —with the exception of medical use of prescribed non-opiate medication—did not remain statistically significant after the application of a Bonferroni correction for multiple comparisons.
The most frequently endorsed past-week and lifetime allopathic pain intervention for SP and CSP groups was OTC pain medication. Whereas a previous study on opioid dependent patients found that among those with a lifetime history of chronic pain, past-week medical use of prescribed opioid and benzodiazepine medications was endorsed by 28% and 20%, respectively (24
), numerically smaller proportions of SP and CSP patients in the current study endorsed past-week medical use of prescription opioids (9% and 20%, respectively) and benzodiazepines (7% and 5%, respectively). While the previous study recruited opioid dependent patients seeking MMTP entry, the current study recruited opioid dependent patients who had been enrolled in their MMTP for at least 6 months. The relatively small proportions of SP and CSP groups endorsing past-week medical use of prescription opiates contrasts with some providers’ characterizations of these patients as “medication seeking” (14
) and may be consistent with prior reports that some methadone-maintained patients with pain receive inadequate opioid treatment for pain (27
). Given the concerns associated with drug-drug interactions among MMTP patients (29
), further investigation of the pattern in medical use of prescribed opioids and benzodiazepines at different phases of MMTP participation is warranted (e.g., pre-MMTP and quarterly follow-ups).
In contrast to the relatively small proportion of American adults endorsing lifetime use of acupuncture (4.1%) in the 2002 National Health Interview Survey (30
), 20% of study participants with some pain and 34% of those with chronic severe pain endorsed lifetime utilization of acupuncture, a branch of traditional Chinese medicine. Given the mixed findings concerning acupuncture’s efficacy in managing chronic pain (32
) and substance-related disorders (9
) and its potential efficacy in alleviating symptoms during detoxification treatment (37
), an examination of its potential role in managing pain in MMTPs is warranted.
The most frequently endorsed lifetime mind-body interventions were prayer (51%) and meditation (31%) among the SP group and prayer (71%) and counseling (43%) among the CSP group. While certain types of counseling such as cognitive-behavioral therapy have demonstrated efficacy in treating substance use disorders (39
) and chronic pain (41
), the role of prayer/spiritual healing and meditation in managing pain and promoting abstinence from illicit drugs has received less rigorous research attention and is thus unclear (11
). One notable exception has been the examination of mindfulness-based meditation; research to date indicates that it is a promising approach for pain relief and for promoting reductions in alcohol and illicit drug use (44
). In the present study, the content, duration, and frequency of participants’ use of prayer is unclear and merits further research investigation. The least frequently endorsed lifetime mind-body intervention utilization among SP and CSP groups was hypnosis (3% and 5%, respectively). Numerically larger proportions of SP and CSP groups reported lifetime utilization of yoga (7% and 21%, respectively). Hypnosis is more generally accepted than yoga in behavioral medicine since the former—unlike the latter — has been well-studied and has shown efficacy in clinical practice (50
). While yoga does not appear to enhance the efficacy of standard methadone treatment (12
), one study involving a randomized controlled trial of chronic low-back pain patients found that yoga was more effective than a self-care book for increasing pain functioning and reducing pain and that these benefits continued for several months (51
). Consequently, further research on prayer, hypnosis, meditation (especially mindfulness meditation) and yoga as pain management strategies in MMTPs is warranted.
Lifetime utilization of herbs/herbal medicine among SP and CSP groups (>15%) was numerically higher than that reported in a previous study on CAM use among individuals with intravenous drug use (5.3%) (52
). Past-week utilization of herbs/herbal medicine among SP and CSP groups were 5% and 9%, respectively. While several authors have queried the efficacy of CAM treatments, concerns about CAM safety have centered on herbal agents and dietary supplements, including the lack of regulation or quality control surrounding their use (53
), possible interactions with prescribed medications (55
), and side effects (56
). Our finding concerning the relatively high past-week and lifetime utilization of herbs/herbal medicine among both pain groups suggests that MMTP providers should assess their use among patients with pain and should provide psychoeducation about potential safety risks.
Lifetime utilization rates of manipulative and body-based methods were generally high among SP and CSP respondents. For example, more than half of each group reported lifetime utilization of passive (e.g., stretching) and active therapeutic exercise (e.g., physical exercise) and passive modalities (e.g., heat) employed by physical and occupational therapists in the promotion of tissue recovery and rehabilitation (57
). Comparably high proportions of SP and CSP groups endorsed past-week utilization of stretching (over one-third) and physical exercise (over one-quarter). Clinical trials that have examined the long-term efficacy of manipulative and body-based methods in pain management have demonstrated mixed treatment outcomes (e.g., (58
))—in part due to variability in diagnostic and treatment methods (62
). Thus, the examination of manipulative and body-based methods in pain management for MMT with pain merits further research investigation.
In comparison to the CSP group, those with SP rated their prior pain treatment as more helpful. While the former pain subgroup, on average, rated their prior pain treatment between “helped moderately” and “helped a lot,” the latter, on average, rated their prior pain treatment between “helped a little” and “helped moderately.” In contrast, a similarly high proportion of both pain subgroups endorsed interest in pain treatment. Thus, while on average the CSP group did not rate their prior treatment as particularly helpful, the majority of the CSP (and SP) group was still interested in pursuing pain treatment at the MMTP.
Although evidence-based pain management interventions for MMTP patients are lacking, research on non-addicted patients has found that multidisciplinary treatment is more effective than standard medical treatment or no treatment in treating chronic pain (63
). Multidisciplinary treatment incorporates at least three of the following categories: psychotherapy, physiotherapy, relaxation techniques, medical treatment or patient education, and vocational therapy (63
). While the CSP, SP, and NP groups did not differ statistically on full-time employment status, the proportion of the CSP group that was employed full-time (4%) was noticeably lower than both the SP and CSP groups (10% and 11%, respectively). These findings suggest the importance of vocational assessment and training for all MMTP patients, irrespective of their pain status. Respondents’ pattern of allopathic and CAM utilization for pain relief, accompanied by a reported strong interest in pursuing pain treatment, suggest that if multidisciplinary pain interventions in MMTP were to be offered, pain patients would avail of such services and that further examination of multidisciplinary MMTP pain treatments is warranted.
Several potential limitations are worth noting. Participants self-selected for study participation based on a flyer indicating that APT wanted to better understand patients’ experiences and treatment needs; thus, it is unclear if patients who enrolled in the study were different from those who did not. Participants were enrolled in treatment at three opioid agonist treatment clinics run by the same organization in a particular geographic location; thus, our findings may or may not generalize to other MMTPs in different geographic regions. Although the data were collected anonymously and participants were informed that their answers would not affect their treatment at APT, the questionnaire was completed at the treatment facility and this may have affected the responses of participants concerned about how staff might react to their responses. In the current study, we did not examine thoughts (e.g., attributed meaning of the pain), feelings (e.g., hopelessness), and desires (e.g., immediate relief from all pain), some of which may be specific to opioid addiction (1
) further research on pain experiences among opioid dependent patients in MMTPS might benefit from an examination of these factors.
The survey was cross-sectional and thus limits statements regarding causation between study variables. No independent assessments of participants’ self-reported responses—including pain status and use of allopathic and CAM interventions — were conducted. Given the absence of validated pain treatment utilization measures for MMTP patients, we used a recently developed instrument for assessing pain treatment utilization among patients seeking MMTP entry (24
), which although face-valid, has not been formally validated. In particular, the list of examples of prescription medication classes that was provided to participants was not exhaustive. In particular, the list of examples of prescription medication classes that was provided to participants was not exhaustive. For example, hydrocodone preparations, such as Vicodin and Lorcet, and tramadol preparations, such as Ultram and Ultricet, were not included. Future research on this topic might benefit from a more comprehensive listing of these types of medications. While this is one of the first studies, to our knowledge, to examine allopathic and CAM pain treatment utilization among SP and CSP groups, future research investigations might benefit from a more systematic examination of pain types (e.g., a larger variety of pain groups based on chronicity) and a more detailed assessment of pain-related allopathic (e.g., surgery) and CAM (e.g., aquatic therapy) interventions.
Despite these limitations, this exploratory study represents an important investigation of pain-related treatment utilization among MMTP patients. The findings highlight the importance of assessing some pain in conjunction with chronic severe pain among MMTP patients. Among both SP and CSP groups, lifetime allopathic and CAM utilization for pain management was common and (after controlling for multiple comparisons), generally, did not vary as a function of pain group status. Finally, these findings may have implications for resource and program planning in MMTPs. Specifically, MMTPs might consider assessing and addressing (1
) some pain in addition to chronic severe pain and (2
) allopathic and CAM pain treatment utilization, especially given the reluctance of some patients to spontaneously disclose CAM use to their providers (2