Study Suggests Veterans that Use Cigarette Smoking to Cope with Chronic Pain Experience Worse Pain-Related Outcomes

BACKGROUND:
Individuals with chronic pain have high rates of cigarette smoking, with some studies estimating that the odds of smoking are more than double among chronic pain patients compared to the general public. Smoking cigarettes may serve as a coping strategy to reduce pain, as nicotine has analgesic properties, and it also may reduce the emotional distress associated with chronic pain by shifting attention away from pain sensations. On the other hand, smokers with chronic pain report higher pain intensity, have increased likelihood of pain-related disability, as well as poorer outcomes after a pain treatment program compared to non-smokers with chronic pain. This cross-sectional study examined the relationship between smoking cigarettes to help cope with pain and pain-related outcomes. Using VA data from a larger research study on the relationship between chronic pain, hepatitis C virus, and substance use disorders, investigators identified 151 Veterans with chronic pain from one large, urban VAMC. Veterans were then divided into three groups: 1) non-smokers (n=72), 2) smokers who denied using cigarettes to cope with pain (n=40), and 3) smokers who reported using cigarettes to cope with pain (n=39). Study measures included: pain severity, pain-related function, anxiety and fear associated with pain, chronic pain coping skills, depression, anxiety, and use of prescription opioids in the 30 days prior to the study assessment.

FINDINGS:

• Veterans who reported smoking as a coping strategy for chronic pain scored significantly worse compared to Veterans who did not smoke and those who denied using cigarettes to cope with pain on the majority of measures of pain-related outcomes.
• After controlling for demographics and clinical factors, smoking as a coping strategy for pain was significantly and positively associated with pain intesity, pain interference, and fear of pain.
• There were no significant differences between the three groups on current symptoms of depression or anxiety, indicating that comorbid psychopathology likely did not contribute to poorer pain-related outcomes in the group who used cigarettes to cope with pain.
• The two smoking groups did not differ with respect to the frequency or severity of nicotine dependence, use of opioid medications, or on other clinical factors, suggesting that impairment in pain-related variables may be due to reliance on cigarettes as a coping strategy for chronic pain.
• Results suggest that smokers with pain may benefit from interventions focused on reducing the use of cigarettes as a coping mechanism and increasing the use of alternative self-initiated coping strategies (e.g., cognitive self-talk, exercise, relaxation).

LIMITATIONS:

• This study used a single question to assess use of smoking as a coping strategy.
• Due to the cross-sectional design, it is not possible to determine causality; worse pain symptoms may lead smokers to use smoking as a coping strategy.
• Veterans in this study cohort experienced average pain severity scores in the mild-to-moderate range, so the results may not generalize to those with severe pain. Also, Veterans with hepatitis C virus and a history of psychiatric and substance use disorders were over-represented.

AUTHOR/FUNDING INFORMATION:
Dr. Dobscha is part of HSR&D's Portland Center for the Study of Chronic Comorbid Mental and Physical Disorders, located at the Portland VAMC.

Patterson AL, Gritzner S, Resnick MP, Dobscha SK, Turk DC, Morasco BJ. Smoking Cigarettes as a Coping Strategy for Chronic Pain is Associated with Greater Pain Intensity and Poorer Pain-Related Functioning. Journal of Pain March 2012;13(3)285-292.