Background & Aims

One-fifth of US adults suffer from chronic pain, which is associated with poor quality of life and poor mental health [4]. People with chronic pain are also at increased risk of tobacco and cannabis use. Using both tobacco and cannabis in the past 30 days (defined as co-use) is prevalent and associated with additive risk. Increased pain is associated with increased risk of co-use vs exclusive tobacco or cannabis use [2]. Substance use and pain may interact via a bidirectional, positive feedback loop, leading to increased substance use and worsened pain [1]. While bidirectional relationships between tobacco and pain have been demonstrated [3], pathways between pain, cannabis use, and co-use are understudied. With longitudinal survey data (2016-2021) from a US nationally representative study, we aimed to estimate the effect of substance use (exclusive and co-use of cannabis and tobacco) on later pain intensity and conversely, the effect of pain intensity on later substance use.

Methods

Data were from 30,575 adults in biennial surveys (2015-2021) of the US nationally-representative longitudinal cohort study: the Population Assessment of Tobacco and Health Study (n=65,686 pairs of consecutive surveys; T1 and T2). Participants rated past-week average pain intensity from 0 (no pain) to 10 (worst pain imaginable). Ratings >4/10 were deemed moderate/severe pain and ?4/10 deemed no/low pain. Four mutually exclusive substance use categories were defined based on past 30-day use: no cannabis/tobacco use; exclusive cannabis use; exclusive tobacco use; co-use. Sociodemographic variables were covariates. Bidirectional effects of tobacco/cannabis and pain were estimated in two analyses: 1) logistic regression assessing if T1 substance use affected moderate/severe pain at T2, with/without adjusting for T1 pain; and 2) multinomial model assessing if pain status at T1 affected substance use at T2, with/without adjusting for T1 substance use.

Results

Of 30,575 participants, 52% were female; 65% non-Hispanic White. Key findings: 1) Effect of T1 substance use on T2 pain: Compared to no cannabis/tobacco use at T1, co-use (OR: 2.28 [95% CI: 2.08-2.50]), exclusive tobacco use (2.01 [1.87-2.15]), and exclusive cannabis use (1.37 [1.14-1.64]) were all associated with moderate/severe pain at T2. Associations were robust to adjustment for T1 pain. 2) Effect of T1 pain on T2 substance use: Compared to no cannabis/tobacco use at T2, moderate/severe pain at T1 led to raised odds of co-use (2.47 [2.24-2.71]), exclusive tobacco use (2.16 [2.01-2.32]), and exclusive cannabis use (1.49 [1.31-1.71]). Compared to exclusive cannabis use at T2, moderate/severe pain at T1 led to raised odds of co-use (1.65 [1.45-1.88]) and exclusive tobacco use (1.45 [1.27-1.65]). Moderate/severe pain at T1 led to 1.14 (1.04-1.25) odds of co-use at T2, compared to exclusive tobacco use. Effects were robust to adjustment for T1 substance use.

Conclusions

Findings demonstrated bidirectional relationships between pain and the exclusive use and co-use of cannabis and tobacco. Additionally, results demonstrate that cannabis maybe situated in a positive feedback loop with pain, as has been previously demonstrated for tobacco. Furthermore, results indicate potential synergy in the co-use of cannabis and tobacco with respect to pain. Co-use was the most likely substance use pattern to lead to subsequent moderate/severe pain, and moderate/severe pain was more likely to lead to co-use than either exclusive cannabis or tobacco use. The acute analgesia offered by both the exclusive and co-use of cannabis and tobacco may increase use of these substances, which ultimately worsens pain in the long-term via central sensitization [5], perpetuating the cycle of pain and cannabis and tobacco use. Future research should incorporate additional information on pain (e.g. acuity/chronicity, self-efficacy) to better evaluate pain/co-use relations.

References

[1] Ditre JW, Zale EL, LaRowe LR. A Reciprocal Model of Pain and Substance Use: Transdiagnostic Considerations, Clinical Implications, and Future Directions. Annu Rev Clin Psychol 2019;15:503–528.
[2] Rubenstein D, McClernon FJ, Powers JM, Aston ER, Keefe FJ, Sweitzer MM. Pain is associated with exclusive use and co-use of tobacco and cannabis: Findings from Wave 5 (2018-2019) of the Population Assessment of Tobacco and Health Study. Addict Behav 2023;146:107814.
[3] Williams FMK, Elgaeva EE, Freidin MB, Zaytseva OO, Aulchenko YS, Tsepilov YA, Suri P. Causal effects of psychosocial factors on chronic back pain: a bidirectional Mendelian randomisation study. Eur Spine J 2022;31:1906–1915.
[4] Zelaya CE, Dahlhamer JM, Lucas JW, Connor EM. Chronic Pain and High-impact Chronic Pain Among U.S. Adults, 2019. NCHS Data Brief 2020:1–8.
[5] Zhang-James Y, Wyon E, Grapsas D, Johnson B. Daily cannabis use may cause cannabis-induced hyperalgesia. Am J Addict 2023;32:532–538.

Presenting Author

Dana Rubenstein

Poster Authors

Dana Rubenstein

BA

Duke University School of Medicine

Lead Author

E-mail

Michael Green

PhD

Lead Author

E-mail

Maggie Sweitzer

Duke University Medical Center

Lead Author

E-mail

Francis Keefe

Duke University

Lead Author

E-mail

F. Joseph McClernon

PhD

Duke University School of Medicine

Lead Author

E-mail

Topics

  • Epidemiology