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Journal of Pediatric Psychology logoLink to Journal of Pediatric Psychology
. 2015 Jan 22;40(5):509–516. doi: 10.1093/jpepsy/jsu116

Alcohol and Tobacco Use in Youth With and Without Chronic Pain

Emily F Law 1,2,✉, Maggie H Bromberg 2, Melanie Noel 2, Cornelius Groenewald 1,2, Lexa K Murphy 2, Tonya M Palermo 1,2
PMCID: PMC4635627  PMID: 25617047

Abstract

Objective To compare rates of alcohol and tobacco use in youth with and without chronic pain and to identify risk factors for use. Methods Participants included 186 youth (95 mixed chronic pain; 91 without chronic pain; 12–18 years old) who reported current alcohol and tobacco use, pain intensity, activity limitations, loneliness, and depressive symptoms. Results Adolescents with chronic pain were less likely to use alcohol compared with adolescents without chronic pain (7.4% vs. 22%), and as likely to use tobacco (9% vs. 8%). Across groups, youth with higher depressive symptoms, less loneliness, and fewer activity limitations were more likely to endorse alcohol and tobacco use. Exploratory analyses revealed that risk factors for substance use differed among youth with and without chronic pain. Conclusions Chronic pain may not increase risk for tobacco and alcohol use in adolescents. Research is needed to understand use of other substances in this medically vulnerable population.

Keywords: adolescents, alcohol, chronic pain, substance use, tobacco

Introduction

Experimentation with alcohol and tobacco use is common during the adolescent years. Current alcohol and tobacco use (i.e., any use in the past month) is endorsed by 39% (U.S. Department of Health and Human Services, 2007) and 10% (Johnston, O’Malley, Bachman, & Schulenberg, 2014) of adolescents, respectively. Substance use during adolescence, a time when the prefrontal cortex is still developing, can have a substantial and long-lasting negative impact on behavioral and neurological development (Galvan, Poldrack, Baker, McGlennen, & London, 2011; Zeigler, Wang, Yoast, Dickenson, McCaffree, Robinowitz, & Sterling, 2005). For this reason, adolescence has been referred to as a critical developmental window/period for health risk behaviors (Galvan et al., 2011; Maldonado-Devincci, Badanich, & Kirstein, 2010; Matthews, 2010). Indeed, health risk behaviors including alcohol and tobacco use are often established during adolescence and can contribute to future risk of death and disability (CDC, 2014). Given the potential long-term devastating effects of adolescent alcohol and tobacco use, identification of correlates and patterns of use, particularly among vulnerable medical populations, is critical (Sawyer, Drew, Yeo, & Britto, 2007).

The nature and impact of alcohol and tobacco use in adolescence is different than adulthood; as such, a developmental perspective is necessary to understand patterns of use (Brook et al., 2008; Schulenberg & Maggs, 2002). First, adolescents cannot easily access alcohol and tobacco because they are not legally sold to minors; therefore, access is often obtained through peer connections (Harrison, Fulkerson, & Park, 2000; Hughes, Hughes, Atkinson, Bellis, & Smallthwaite, 2011). Second, unlike adults, adolescents’ motives for substance use are different. Whereas many adults drink alcohol to cope with their problems (Kuntsche, Knibbe, Gmel, & Engels, 2006a), the majority of adolescent alcohol use is fueled by social motives (Kuntsche, Knibbe, Gmel, & Engels, 2006b). Likewise, peer influences are one of the most robust predictors of tobacco use (Hoffman, Sussman, Unger, & Valente 2006). Social factors are thought to influence substance use in adolescence owing to normative developmental shifts toward autonomy from caregivers. Of particular interest is loneliness or unpleasant feelings arising from perceiving oneself as having inadequate social relations. Indeed, loneliness has been found to be associated with increased risk of alcohol, tobacco, and drug use among adolescents around the world (Page, 1990; Page, Allen, Moore, & Hewitt, 1993; Page, Dennis, Lindsay, & Merrill 2011; Stickley, Koyanagi, Koposov, Schwab-Stone, & Ruchkin, 2014). In addition to social drivers of substance use, depressed mood has also been established as a predictor of alcohol and tobacco use in adolescence (Crum et al., 2008; Mistry, Babu, Mahapatra, & McCarthy, 2014) and may underlie the relationship between loneliness and substance use in adolescence (Stickley et al., 2014). Research suggests that depressive symptoms may precede (Fergusson, Goodwin, & Horwood, 2003) and also be an impact (Boden, Fergusson, & Horwood, 2010) of substance use, suggesting a bidirectional relationship between the two.

Although much is known about alcohol and tobacco use during the period of adolescence, surprisingly little is known about these health behaviors among adolescents with chronic pain. Incidence of pediatric chronic pain peaks during adolescence (King et al., 2011), and can impact many domains of adolescent, parent, and family functioning (Palermo, 2000; Palermo & Chambers, 2005; Palermo & Eccleston, 2009). Adolescents who have chronic pain often continue on a trajectory of experiencing chronic pain and other physical and psychiatric symptoms into adulthood (Shelby et al., 2013; Walker, Sherman, Bruehl, Garber, & Smith, 2012). Alcohol and tobacco use among adults with chronic pain has been widely studied, yielding equivocal results (Ekholm, Grønbæk, Peuckmann, & Sjøgren, 2009; Rashiq & Dick, 2009). Recent large-scale longitudinal studies have examined alcohol and tobacco use in adulthood as risks for the future development of chronic pain in later adulthood. These studies have shown that tobacco increases (Kvalheim, Sandven, Hagen, & Zwart, 2013) and alcohol decreases (Mundal, Gråwe, Bjørngaard, Linaker, & Fors, 2014) risk. However, patterns and drivers of use may be different among adolescents with chronic pain. It has been hypothesized that adolescents with pain may be at risk for increased substance use owing to anxious searching for relief of symptoms (Eccleston, Fisher, Vervoort, & Crombez, 2012). Indeed, a relationship between increased adolescent alcohol and tobacco use and increased recurrent and chronic pain symptoms has been found in community samples (Jussila et al., 2014; Paananen et al., 2010). Nevertheless, research has yet to examine correlates of substance use in treatment-seeking youth with chronic pain. Given the higher expected severity of pain and presence of comorbidities (e.g., depressive symptoms) among treatment-seeking versus community samples of youth with chronic pain, there is a need for further research to understand the frequency of alcohol and tobacco use and relationship to pain symptoms in this population.

The context of adolescence for youth with chronic pain is different than their healthy counterparts. Owing to the negative social impact of living with chronic pain (Eccleston, Wastell, Crombez, & Jordan, 2008; Forgeron, Evans, McGrath, Stevens, & Finley, 2010; Logan, Simons, Stein, & Chastain, 2008; Roth-Isigkeit, Thyen, Stoven, Schwartzenberger, & Schmucker, 2005), these adolescents may have fewer opportunities to use illicit substances than youth without chronic pain. Whereas experimentation with alcohol and tobacco is common during adolescence (Johnston et al., 2014; U.S. Department of Health and Human Services, 2007), adolescents with chronic pain have been found to perceive themselves as being delayed in their development of independence and relationship confidence, and to have less opportunities for social exposure and normative social development (Eccleston et al., 2008). A systematic review of social functioning and peer relationships among youth with chronic pain revealed that these youth often have fewer friends, experience high rates of peer victimization, and are lonelier (Forgeron et al., 2010), which may be the result of pain-related interference with school participation (Logan et al., 2008; Roth-Isigkeit et al., 2005) and leisure activities. Moreover, youth report being isolated from their peers and feeling misunderstood and unsupported (Forgeron, Evans, McGrath, Stevens, & Finley, 2013). Adolescents with chronic pain also have elevated depressive symptoms (Campo et al., 2004; Kashikar-Zuck et al., 2008), a known risk factor for substance use. However, given that social motives and peer influences are primary drivers of alcohol and tobacco use among healthy youth (Harrison et al., 2000; Hughes et al., 2011), and social functioning is impaired among youth with chronic pain, adolescents with chronic pain might use substances to a lesser extent than youth without chronic pain.

To fill gaps in the literature, we sought to (1) compare rates of alcohol and tobacco use in treatment-seeking youth with chronic pain compared with youth without chronic pain; and (2) determine the relationship between loneliness, depressive symptoms, pain, and activity limitations to adolescent alcohol and tobacco use, controlling for established demographic correlates (e.g., age, sex, income, race; Cleveland, Feinberg, Bontempo, & Greenberg, 2008; Droomers, Schrijvers, Casswell, & Mackenbach, 2003; Kloos, Weller, Chan, & Weller, 2009). We did not have hypotheses regarding overall rates of use; however, in light of literature suggesting greater social difficulties among youth with chronic pain, we hypothesized that adolescents with chronic pain would report drinking alcohol and using tobacco to a lesser degree than adolescents without chronic pain. Across groups, we predicted that greater loneliness, higher depressive symptoms, higher pain intensity, and fewer activity limitations would be related to increased risk for substance use. In exploratory analyses, we examined whether correlates of substance use differed between youth with and without chronic pain.

Methods

Participants

Participants were 186 adolescents aged 12–18 years; 95 adolescents had mixed chronic pain conditions, and 91 adolescents did not have chronic pain.

Participants in the chronic pain group were recruited from a multidisciplinary pediatric chronic pain clinic at a medical center in the Pacific Northwest via letters to their home and phone calls. Eligibility criteria included (a) pain present for the past 3 months occurring on a weekly basis, (b) received a new patient evaluation at the pain clinic within the past year, (c) aged 12–18 years, (d) no parent report of developmental delay, and (e) fluent in English. Two hundred thirty-eight families were approached for participation in this study. Of these, 108 refused: 59 never responded to our letter/phone calls; 49 spoke with study staff and subsequently declined to participate, with the most common reason being lack of interest. Twenty-six participants were found to be not eligible during screening, with the most common reason being not having experienced pain in the past 3 months. Within the chronic pain group, 104 participants were enrolled and 95 participants completed the study.

Participants without chronic pain were recruited via advertisements at stores, businesses, and community centers in the local metropolitan area, as well as peer referrals from participants in the chronic pain group. Eligibility criteria included (a) does not presently have chronic pain, (b) no serious chronic medical illness (e.g., diabetes, cancer), (c) no parent report of developmental delay, and (d) fluent in English. One hundred fifty-nine families approached the study team. Of these, 17 refused to participate, with the most common reason being lack of interest. Fifty participants did not meet eligibility criteria, 94 were enrolled, and 91 completed the study.

Procedures

The local institutional review board approved all study procedures. Potential participants were screened for eligibility via telephone. Eligible families who agreed to participate were provided with electronic copies of the consent, assent, and HIPPA forms, and verbal consent and assent were obtained over the phone. Once enrolled, participants were given the option of completing the survey online via a secure Web site, or via paper questionnaires mailed to their home. Parents and teens were instructed to complete their surveys separately to protect confidentiality and minimize influencing each other’s responses.

Parents reported on demographic information. Adolescents reported on pain intensity, activity limitations, social acceptance, depressive symptoms, current tobacco use, and current binge drinking. On completion of the survey, families were given gift cards to local stores.

Measures

Demographics

Parents reported on socioeconomic status and adolescents’ age, sex, and race.

Current Alcohol Use

Adolescents completed the CDC Youth Risk Behavior Survey (YRBS) 6-item Alcohol Use Scale. Adolescents were categorized as current drinkers or nondrinkers based on their response to the following item: “During the past 30 days, on how many days did you have at least one drink of alcohol?” Current drinking was defined as 1 or more days of drinking alcohol in the past 30 days.

Current Tobacco Use

Adolescents completed the CDC YRBS 11-item Tobacco Use Scale (CDC, 2011). Adolescents were categorized as current tobacco users or nonusers based on their response to the following items: “During the past 30 days, on how many days did you … smoke cigarettes?; … use chewing tobacco, snuff or dip such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen?; … smoke cigars, cigarillos, or little cigars?” Current tobacco use was defined as any tobacco use in the past 30 days.

Loneliness

Adolescents complete the 20-item UCLA Loneliness Scale (Russell, 1996), which assesses satisfaction with social relationships (e.g., “How often do you feel close to people?”) along a 4-point scale (1 = never, 4 = always), with higher scores indicating greater feelings of loneliness. This measure has demonstrated strong reliability and validity in adolescent populations (Mahon, Yarcheski, & Yarcheski, 2004).

Depressive Symptoms

Adolescents completed the 33-item Mood and Feelings Questionnaire (MFQ; Angold et al., 1995), which assesses symptoms of depression on a 3-point scale (1 = not true, 3 = true), with higher scores indicating greater depressive symptoms. The MFQ has demonstrated good validity and internal consistency in adolescents (Kent, Vostanis, & Feehan, 1997).

Pain Intensity and Frequency

Adolescents rated usual pain intensity over the past 3 months on an 11-point numerical rating scale (NRS; 0 = no pain, 10 = worst pain possible). The NRS has been widely used among adolescents and demonstrated good validity and reliability (von Baeyer, 2009). Pain frequency over the past 3 months was assessed using a 7-point scale (1 = not at all, 7 = daily).

Activity Limitations

Adolescents completed the 21-item Child Activity Limitations Interview (CALI-21) to assess activity limitations owing to pain (Palermo, Lewandowski, Long, & Burant, 2008). Adolescents rated the difficulty they experienced in participating in activities owing to pain (e.g., “going to school,” “doing things with friends”) on a 5-point Likert scale (0 = not difficult to 4 = extremely difficult). A total score is obtained by summing all items, with higher scores indicating greater activity limitations. The CALI-21 has demonstrated good internal consistency and high cross-informant reliability (Palermo et al., 2008).

Data Analysis Plan

Descriptive statistics were used to evaluate demographics of the sample and rates of alcohol and tobacco use, and to determine differences in alcohol and tobacco use, loneliness, depression, pain, and activity limitations between youth with and without chronic pain. A dichotomous substance use variable was computed by coding the presence or absence of tobacco or alcohol use as 0 (no tobacco or alcohol use) or 1 (positive tobacco and/or alcohol use). Logistic regression was used to examine loneliness, depressive symptoms, pain intensity, and activity limitations as predictors of substance use, controlling for study group and demographic covariates (income, race, sex, age). For logistic regression analyses, race was dichotomized for ease of interpretation (White vs. non-White). Based on the guidelines by Peduzzi and colleagues (1996), the minimum number of participants to detect a moderate effect in our primary logistic regression analysis was 128. In exploratory analyses, the same logistic regression model was then tested separately within the chronic pain group and the pain-free group. Predictors with a 95% confidence interval (CI) that did not cross 1.0 were interpreted as significant.

Results

Descriptive Statistics

Participants included 95 adolescents with mixed chronic pain conditions between the ages of 12 and 18 years (M = 15.60 years, SD = 2.6), and 91 adolescents without chronic pain recruited from the community (M = 15.10 years, SD = 2.0). Sample characteristics are shown in Table I. Participants in both groups were primarily female (71%) and White (80%). Adolescents with and without chronic pain did not differ on age or sex; however, participants without chronic pain were more likely to have parents with a higher income, χ2 (5, N = 173) = 23.83, p < .0001, and the ethnic composition of the two groups differed, χ2 (5, N = 181) = 11.63, p < .05, with more White participants in the chronic pain group (83%) compared with the group without chronic pain (76%). Youth with and without chronic pain reported similar levels of loneliness, t(170) = −0.50, p = .62. As expected, youth with chronic pain reported significantly higher depressive symptoms, t(172) = 2.60, p = .01; pain intensity, t(180) = 10.83, p < .0001; and activity limitations, t(158) = 13.52, p < .0001, than youth without chronic pain (Table I).

Table I.

Demographics

Full sample (n = 186) Chronic pain (n = 95) Healthy (n = 91) p
Income (n, %) .0001
 <$10,000 5 (2.7) 3 (3.2) 2 (2.2)
 $10, 000–$29,999 12 (6.5) 11 (11.6) 1 (1.1)
 $30, 000–$49,999 22 (11.8) 16 (16.8 6 (6.6)
 $50,000–$69,999 30 (16.1) 18 (18.9) 12 (13.2)
 $70,000–$100,000 41 (22) 17 (17.9) 24 (26.4)
 >$100,000 63 (33.9) 20 (21.1) 43 (47.3)
Race (n, %)
 White 148 (79.6) 79 (83.2 69 (75.8) .04
 Asian 12 (6.5) 3 (3.2) 9 (9.9)
 African American 4 (2.2) 2 (2.1) 2 (2.2)
 Alaska Native 3 (1.6) 3 (3.2) 0
 Hawaiian or Pacific Islander 2 (1.1) 2 (2.1) 0
 Other 12 (6.5) 3 (3.2) 9 (9.9)
Sex (n, % female) 135 (72.6) 68 (71.6) 67 (73.6) .76
Age (M years, SD) (range 12–18 years) 15.35 (2.31) 15.57 (2.60) 15.11 (1.95) .18
Depressive symptoms (M, SD) (range = 0–66) 15.40 (12.62) 17.76 (12.98) 12.87 (11.78) .01
Loneliness (M, SD) (range = 20–80) 43.99 (11.79) 43.55 (12.49) 44.45 (11.07) .62
Pain frequency (n, %)
 Not at all 23 (12.4) 1 (1.1) 22 (24.2) .0001
 <1 time per month 25 (13.4) 3 (3.2) 22 (24.2)
 1–3 times per month 27 (14.5) 2 (2.1) 25 (27.5)
 1 time per week 8 (4.3) 2 (2.1) 6 (6.6)
 2–3 times per week 20 (10.8) 15 (15.8) 5 (5.5)
 3–6 times per week 11 (5.9) 7 (7.4) 4 (4.4)
 Daily 70 (37.6) 64 (67.4) 6 (6.6)
Pain intensity (M, SD) (range = 0–10) 4.58 (2.37) 6.02 (1.75) 3.05 (1.96) .0001
Substance use (n, %)
 No use 140 (75.3) 77 (81.1) 63 (69.2) .04
 Current tobacco use 15 (8.1) 8 (8.4 7 (7.7) .86
 Current alcohol use 27 (14.5) 7 (7.4 20 (22.0) .005
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Rates of Current Alcohol and Tobacco Use in Youth With and Without Chronic Pain

As hypothesized, adolescents with chronic pain were less likely to drink alcohol as compared with peers without chronic pain (7.4% vs. 22%, respectively), χ2 (1, N = 175) = 7.94, p < .01 (Table I). However, contrary to our hypothesis, adolescents with chronic pain were as likely to use tobacco compared with their peers without chronic pain (9% vs. 8%, respectively), χ2 (1, N = 170) = 0.03, p > .05.

Overall, rates of current alcohol and tobacco use were low across groups. Of the 30 youth (16.2%) in the full sample who endorsed current alcohol or tobacco use, 20 youth (10.8%) used either alcohol or tobacco and 10 youth (5.4%) used both. The number of youth who used one versus both substances did not significantly differ between groups, χ2 (2, N = 170) = 4.71, p = .10.

Predictors of Substance Use Across Groups

Logistic regression was used to test whether psychosocial and pain-related factors were associated with current substance use in the full sample while controlling for demographic factors. Group status (pain vs. healthy), demographic covariates (income, race, sex, age), loneliness, depressive symptoms, pain intensity, and activity limitations were entered as predictors in a single step in the logistic regression model. The dependent variable was the dichotomous substance use variable (0 = no tobacco or alcohol use, 1 = positive tobacco and/or alcohol use). As shown in Table II, age, loneliness, depressive symptoms, and activity limitations were associated with substance use, generally in the predicted directions. Older age was associated with a twofold increase in risk for substance use, odds ratio (OR) = 2.24, 95% CI = 1.51–3.34. A one-unit increase in depressive symptoms was associated with a 1.12-fold increase in risk for substance use, 95% CI = 1.05–1.20. A one-unit increase in activity limitations was associated with a decrease in risk for substance use by a factor of 0.91, 95% CI = 0.85–0.99. However, in the unexpected direction, a one-unit increase in loneliness was associated with a 0.94 decrease in risk for substance use, 95% CI = 0.89–0.99. Nagelkerke’s R2 indicated that the final model accounted for 48% of the variability in substance use across groups.

Table II.

Hierarchical Logistic Regression Examining Risk Factors for Current Tobacco and Alcohol Use Among the Full Sample

Predictor OR CI (95%) Nagelkerke R2
Group 0.89 0.16–4.97
Income 0.71 0.43–1.16
Sex 1.30 0.34–5.04
Age 2.24 1.51–3.34
Race 0.67 0.16–2.76
Loneliness 0.94 0.89–0.99
Depressive symptoms 1.12 1.05–1.20
Pain intensity 0.78 0.52–1.18
Activity limitations 0.91 0.85–0.99
0.48
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Results from this analysis partially supported our hypothesis. After controlling for group status and demographic factors, higher depressive symptoms and lower activity limitations were associated with a higher likelihood for current substance use. However, contrary to our hypothesis, higher loneliness was associated with a decreased risk for substance use and pain intensity was not associated with substance use.

Exploratory Analysis: Predictors of Substance Use Within Groups

To explore whether a different pattern of associated factors emerged within each group, separate logistic regression models were conducted for youth with and without chronic pain (Table III). Demographic covariates (income, race, sex, age), loneliness, depressive symptoms, pain intensity, and activity limitations were entered as predictors in a single step in the logistic regression model. The dependent variable was the dichotomous substance use variable (0 = no tobacco or alcohol use, 1 = positive tobacco and/or alcohol use).

Table III.

Exploratory Hierarchical Logistic Regression Models Examining Risk Factors for Current Tobacco and Alcohol Use by Group

Chronic pain
 Healthy
Predictor OR 95% CI Nagelkerke R2 OR 95% CI Nagelkerke R2
Income 1.22 0.54–2.35 0.70 0.27–1.76
Sex 3.13 0.41–23.56 0.53 0.05–5.38
Age 2.13 1.11–4.10 3.19 1.47–6.92
Race 2.03 0.17–24.95 0.26 0.02–2.88
Loneliness 1.01 0.93–1.10 0.88 0.79–0.99
Depressive symptoms 1.06 0.96–1.17 1.20 1.03–1.40
Pain intensity 1.27 0.66–2.46 0.56 0.25–1.24
Activity limitations 0.86 0.76–0.98 0.95 0.76–1.19
0.35 0.70
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Youth Without Chronic Pain

Among youth without chronic pain, age, depressive symptoms, and loneliness were associated with substance use (Table III). Older age was associated with a threefold increase in risk for substance use, OR = 3.19, 95% CI = 1.47–6.91. A one-unit increase in depressive symptoms increased the risk for substance use by a factor of 1.20, 95% CI = 1.02–1.40. A one-unit increase in loneliness decreased risk for substance use by a factor of 0.88, 95% CI = 0.79–0.99. Pain intensity and activity limitations were not associated with substance use among youth without chronic pain. Nagelkerke’s R2 indicated that the final model accounted for 70% of the variance in substance use among youth without chronic pain.

Youth With Chronic Pain

An identical exploratory logistic regression was conducted to examine factors associated with substance use among youth with chronic pain (Table III). Similar to findings for youth without chronic pain, older age was the only demographic factor associated with increased risk for substance use among youth with chronic pain, OR = 2.13, 95% CI = 1.11–4.10. A different pattern of psychological and pain-related risk factors for substance use emerged for youth with chronic pain relative to findings for youth without chronic pain. No association was found between depression, loneliness or pain intensity with substance use among youth with chronic pain. However, a one-unit increase in activity limitations was associated with a decreased risk for substance use among youth with chronic pain, OR = 0.86, 95% CI = 0.76–0.98. Nagelkerke’s R2 indicated that the final model accounted for 35% of the variance in substance use among youth with chronic pain.

Discussion

This study is the first to examine rates of alcohol and tobacco use among treatment-seeking youth with chronic pain compared with youth without chronic pain. As expected, results indicated that rates of current alcohol use were significantly lower among youth with chronic pain (7.4%) as compared with youth without chronic pain (22%). Contrary to our hypotheses, rates of tobacco use were similar between groups (9% vs. 8%). Overall, the rate of current alcohol use in this sample was lower than the national average for adolescents (39%; U.S. Department of Health and Human Services, 2007), whereas the rate of tobacco use was similar (10%, Johnston et al., 2014). These results suggest that the period of risk for initiating health risk behaviors may not occur during adolescence for youth with chronic pain, but may be delayed to the young adult or adult years for these patients. Longitudinal research is needed to examine rates of substance use across the life span among individuals with chronic pain to identify the “critical period” for initiating these behaviors and to understand the psychosocial and pain-related factors that contribute to these health risks.

Although the rates of tobacco and alcohol use in this sample were generally low, thereby limiting variability within the sample, we conducted preliminary analyses to examine the potential contributions of loneliness, depression, pain, and activity limitations to adolescents’ substance use across groups. Our hypothesis was partially supported. As expected, after controlling for established demographic factors, youth with higher depressive symptoms were more likely to endorse current substance use and youth with greater activity limitations were less likely to endorse current substance use. However, contrary to our hypothesis, greater loneliness was associated with a decreased risk for substance use. Furthermore, no association was found between pain intensity and substance use across groups. Interpretation of these results is limited by the relatively small number of youth across groups who endorsed substance use. However, it could be that higher loneliness is reflective of less social interactions with peers, the context in which adolescents are most likely to access substances and engage in their use (Harrison et al., 2000; Hughes et al., 2011). Similarly, activity limitations may limit amount of time spent with peers and thereby reduce access to substances. Larger, multisite studies are needed to better understand social motives of substance use among adolescents with chronic pain and how these factors relate to pain intensity and pain-related activity limitations.

An exploratory aim of the present study was to understand potential similarities and differences in patterns of predictors of substance use among youth with and without chronic pain to inform future work in this area. Although these results must be interpreted cautiously, given the small number of youth endorsing substance use within each group, it is interesting to note that these exploratory analyses revealed a different pattern of risk factors for substance use among youth with and without chronic pain. Whereas higher depressive symptoms and less loneliness were found to be risk factors for substance use among youth without chronic pain, these socio-emotional factors were not significantly associated with substance use in youth with chronic pain. The only risk factor that emerged from our model for the chronic pain group was activity limitations, with greater activity limitations protecting against substance use among youth with chronic pain.

At present, motives for alcohol and tobacco use among individuals with chronic pain are not well-understood. Our exploratory analyses indicate that different social and emotional factors may impact risk for substance use among youth with and without chronic pain. For example, substance use among youth with chronic pain may be driven by other known correlates of pain and disability in children that were not examined in this study, such as pain catastrophizing, anxiety sensitivity, and avoidance (Asmundson, Noel, Petter, & Parkerson, 2012). Based on the small number of youth with chronic pain endorsing substance use in this study, we recommend that future research focus on examining such drivers of substance use across the life span of individuals with chronic pain. It is possible that motives for and drivers of substance use change with the course of chronic pain as individuals age.

Finally, there are important health risk behaviors not examined in this study that are particularly relevant for youth with chronic pain, including use of over-the-counter analgesics, opioids, and marijuana. For example, prescription opioid abuse and overdose has become a major public health concern in the United States and around the globe (Becker, Sullivan, Tetrault, Desai, & Fiellin, 2008; CDC, 2012), and individuals with chronic pain may be particularly vulnerable to this health risk. Indeed, research has shown that the majority of nonmedical opioid use among adolescents is to relieve pain (Young, McCabe, Cranford, Ross-Durow, & Boyd, 2012), likely because these “self-treaters” are not receiving adequate medical attention nor deriving benefit from their medications as prescribed. Moreover, among youth with chronic pain, risk for opioid use is substantially increased with the presence of a comorbid mental health disorder, including depression (Richardson et al., 2012). Research is needed to understand the frequency and predictors of use and misuse of these substances among children, adolescents, and young adults with chronic pain to identify critical periods for prevention and intervention efforts.

This study has several limitations. First, results from this study may not be generalizable to all youth with and without chronic pain. Recruitment was conducted primarily by mailings and advertisements for a study about health behaviors. It is possible that families of youth who engage in substance use were less likely to respond to this recruitment approach, and therefore could be underrepresented in this sample. Second, although parents and adolescents were asked to complete measures separately and privately, it is possible that some adolescents may have modified their responses owing to concerns about confidentiality. Future studies could address this concern by conducting assessments at school, in clinic, or another private setting. Finally, there are many potential psychosocial and behavioral risk factors for substance use during adolescence that were not examined in this study. For example, having a parent with problematic substance use is a well-established risk factor for adolescent’s own substance use (Biederman, Faraone, Monuteaux, & Feighner, 2000; Johnson & Leff, 1999); however, the influence of parent substance use on child alcohol and tobacco use in this sample is unknown.

Despite these limitations, results from this study raise several issues relevant to the clinical care of youth with chronic pain. These findings indicate that youth with chronic pain may be at a relatively low risk for self-medication with alcohol and tobacco. Furthermore, psychosocial risk factors that are common among youth with chronic pain (e.g., depressive symptoms) do not appear to increase the likelihood of alcohol or tobacco use. However, screening for alcohol and tobacco use as well as other substances (e.g., over-the-counter analgesics, opioids, marijuana) should continue as part of standard practice for clinicians serving youth with chronic pain. Problematic substance use among youth with chronic pain would certainly warrant further clinical attention, given potential negative effects on physical health, cognitive development, emotional well-being, and pain-related outcomes.

In conclusion, this preliminary investigation suggests that rates of alcohol and tobacco use are relatively low among youth receiving treatment for chronic pain, and that correlates of alcohol and tobacco use among youth with and without chronic pain may be different. Furthermore, these findings reinforce the importance of considering substance use among youth with chronic pain in a developmental and socio-ecologic context. Youth with chronic pain are at risk for continued pain into adulthood, and thus may incur higher risk over time for substance use-related problems. Further research is needed to identify psychosocial and pain-related risk factors for initiating and maintaining substance use among individuals with chronic pain. Individuals with chronic pain represent a medically vulnerable population, and prevention and treatment of substance use in this population deserves further attention.

Funding

This study was supported by the Hearst Foundation Grant from the Center for Child Health, Behavior and Development at Seattle Children’s Research Institute (PI: Law).

Conflicts of interest: None declared.

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