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anaging patients with chronic pain without
initiating or exacerbating substance use dis-
orders is a significant challenge in healthcare.
The latest criteria for all substance use disorders can
be found in the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition. 1 A study of 705 adult
patients receiving care in a health network in North-
eastern Pennsylvania (who were prescribed opioid
medications for nonmalignant pain four or more times
in a 12-month period) found the lifetime prevalence
of opioid use disorders to be 35%.2 Furthermore, over-
dose deaths quadrupled between 1999 and 2015.3
By Elizabeth L. Pestka, MS, PMHCNS-BC, AGN-BC and Michele Evans, MS, PMHCNS-BC
Family history of substance use disorder
and chronic pain management
Abstract: The use of family history of substance use disorder information as part of a
comprehensive assessment of chronic pain can provide important data for treatment.
This case example illustrates assessment, patient education, and brief motivational
interviewing with referral to appropriate resources.
Lucian Milasan / Oksana Mironova / 123RF
Keywords: addiction, chronic pain, family history, risk reduction, substance use disorders
M
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Family history of substance use disorder and chronic pain management
Effective use of SBIRT has  demonstrated
considerable benefit to individuals and has
led to healthcare cost reductions.

Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.
Despite the fact that a family history of substance
use disorder is an established risk factor for personal
problems with substance use, a survey conducted by
the Hazelden Betty Ford Foundation found that 46%
of those (N = 1,028) who were prescribed pain medica
tions in the previous year reported that prescribers did
not ask about their personal or family substance use
history.4,5
Often, individuals with chronic pain and substance
use problems believe that only severe cases of addiction
need to be addressed. Screening, Brief Intervention,
and Referral to Treatment (SBIRT) is an evidence-
based, comprehensive, integrated approach for provid
ing intervention and services to individuals with, or at
risk for developing, substance use disorders. SBIRT is
designed to be used in healthcare, including trauma
centers and inpatient or outpatient care settings to
identify individuals with substance use issues. Effec
tive use of SBIRT has demonstrated considerable
 benefi t to individuals and has led to healthcare cost
reductions.6
The purpose of this article is to describe the use of
family history of substance use disorder as a compo
nent of comprehensive care in evaluating and manag
ing a patient with chronic pain. This case-based ap
proach will highlight important considerations,
describe the use of SBIRT in a chronic pain rehabilita
tion program, and discuss the process of NPs providing
evaluation, education, discussion, and support focused
on family history risk.
 Case example information
Mr. K, a 30-year-old male, presents for admission to
a 3-week interdisciplinary pain rehabilitation pro
gram. He reports he has had persistent chronic pain
on the right side of his neck, shoulder, and upper
back since age 24 following a motor vehicle accident.
He rates his pain intensity on a scale of 0 to 10 (with
10 being the worst pain imaginable) at 4 (least severe)
after taking opioid medication to the worst 10 (al
most unbearable)without medication. His medical
diagnoses are congenital lobar emphysema (which is
a rare respiratory disorder causing hyperinfl ation of
the lobes of the lungs) and recurrent bouts of pneu
monia. A right upper pulmonary lobectomy was
performed 2 years earlier and did not reduce his
chronic pain.
Prior pain management treatments included
spinal and trigger point injections, numerous pain
medication trials, physical therapy, biofeedback, heat,
ice, and herbal and mineral supplements. Pulmonary
experts determined that there were no further medi
cal interventions to relieve Mr. K's chronic pain and a
pain rehabilitation program would
be his best course of action. On ad
mission to the pain rehabilitation
program, Mr. K stated he had been
prescribed hydromorphone for the
past 4 years with a current 4 mg oral
dose every 6 hours as needed, gaba
pentin 2,100 mg per day in divided doses, lidocaine
patch 5% topically once per week (both gabapentin
and the lidocaine patch are FDA off-label for chronic
pain), and albuterol sulfate inhalation aerosol 108
mcg/actuation 2 puffs via inhalation once daily as
needed.
In addition, Mr. K has a complex mental health
history, including major depression, generalized anxi
ety disorder, posttraumatic stress disorder (PTSD),
attention-deficit hyperactivity disorder (ADHD), and
polysubstance use including cannabis (about one joint
daily to help with pain relief and stress management
in addition to consuming four to five alcoholic drinks
most Fridays and Saturdays with roommates). He
reports that his mother was a "severe alcoholic" who
was emotionally, verbally, and physically abusive, lead
ing to his diagnosis of PTSD. Following his father's
suicide when Mr. K was 15 years of age, he was hospi
talized on a psychiatric unit.
Mr. K subsequently received mental health coun
seling and therapy a number of times over the years,
but he is not currently meeting with any psychiatric
provider. He denies thoughts or plans related to
suicide. Psychiatric medications prescribed by his
primary care provider include lorazepam 0.5 mg at
bedtime as needed, which he takes most nights, and
amphetamine salt combination 30 mg daily for
ADHD.
He is single, never married, and does not have any
children. He lives in a house with two roommates.
Mr. K is not close to any family members except for
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Page 3
Family history of substance use disorder and chronic pain management
Often, individuals with chronic pain and
substance use problems believe that only
severe cases of addiction need to be addressed.

Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.
his paternal grandmother. He states that his "foster
family," who unoffi cially provided shelter and sup
ported him off and on over the years, is still supportive
of him, although he has not maintained steady contact
with them. Mr. K worked hard to attain a bachelor's
degree with the hope of becoming a teacher but is
currently working full time in customer service for a
telephone company, which he finds stressful and
unfulfi lling.
Mr. K's goals for the pain rehabilitation program
are to taper off of opioid medication and learn be
havioral skills to manage his chronic pain, increase
his ability to physically function, and gain a much
better quality of life. On admission, he stated his fu
ture looked "bleak" if he is unable to make changes in
his life.
 Comprehensive pain rehabilitation program
The pain rehabilitation program is a comprehensive,
interdisciplinary, 3-week outpatient program with the
primary goal of increasing overall functional ability
for a quality lifestyle. The 5-day (Monday through
Friday) 8-hour program includes physical and oc
cupational therapy and participation in educational
groups focused on cognitive behavioral therapy
(CBT), elimination of pain behav
iors, relaxation and stress manage
ment; management of depressive
and anxiety symptoms, strategies for
enhancing quality sleep, moderation
and modification of daily activities,
use of appropriate nonaddictive
medications for pain management, and reducing risks
for problematic substance use. RN care managers and
advanced practice registered nurses (APRNs) are in
tegral members of the interdisciplinary treatment
team.
Although Mr. K was skeptical about tapering off
of opioid medication and replacing this with behav
ioral strategies, he was willing to try this  approach, as
he felt like the pain rehabilitation program was his
"last hope" for a better life. He was gradually tapered
off of hydromorphone over a 10-day period and ex
perienced minimal opioid withdrawal symptoms. His
topical analgesic was also discontinued, as he stated it
did not seem to be helpful.
Mr. K continued taking 2,100 mg of gabapentin
daily even though this medication has some potential
for abuse but has less negative long-term effects and
better evidence for managing chronic pain.7 Addition
ally, lorazepam and amphetamine salt combination
were discontinued, as he became proficient with CBT,
mindful relaxation techniques, and sleep enhance
ment. Mr. K participated in all program activities and
gained a sense of hope as he increased his physical
strength and endurance as well as positive coping strat
egies to manage his chronic pain condition. Mr. K's
positive experience is similar to most of the pain re
habilitation program participants.8
As per the program's admission process, Mr. K
was asked by his RN care manager, "In your opinion,
have you had family members who had problems
with alcohol, drugs, or prescription medication that
caused health, relationship, job, or legal issues?"
He reported that his mother had severe alcohol use
disorder and was abusive and that his only sibling
(sister) had a lot of problems with alcohol, mari
juana, and prescription medications. Mr. K stated
that his maternal grandmother and an aunt and
uncle, as well as his paternal grandfather, had prob
lems with alcohol.
According to the program's established criteria of
two first-degree family members (or one fi rst-degree
and at least two second-degree family members with
substance use concerns), Mr. K had a high-risk family
history and was referred to a program that provides
additional focus on substance use risk reduction.9
Individuals are referred to this track based on family
history risk as well as personal substance use risk
factors, and Mr. K had both.
Mr. K did not think his family history of substance
use and his own personal use of prescribed opioids,
benzodiazepines, stimulants, daily use of cannabis, and
weekend use of alcohol were problematic. He justifi ed
this belief by stating that he did not drink alcohol to
the point of intoxication like his mother and that he
was employed. As part of the pain rehabilitation pro
gram, Mr. K attended groups led by APRNs on sub
stance use risk reduction and shared that he was sur
prised that the heritability estimates for nicotine,
alcohol, and drug dependence are 50% to 60%; family
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Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.
Family history of substance use disorder and chronic pain management
Targeted family pedigree for substance use disorders
d. 50's
Alcohol
Nicotine
Alcohol
Alcohol
Alcohol
d. 39 (suicide)
Nicotine
Nicotine
Opioids
Alcohol
Cannabis
Stimulants
Nicotine
Opioids
Nicotine
Mr. K
30
28
Cannabis
Cannabis
Opioids
Opioids
= Substance Use Disorder
Benzodiazepines Benzodiazepines
Stimulants
Stimulants
Mr. K reports that all family
Alcohol
Alcohol
members with substance use
disorders began use in their
teenage years.
d. 68
Alcohol
Nicotine
pedigrees shared and diagrammed in the groups really
made him think about his genetic risks (see Targeted
family pedigree for substance use disorders).10
Stigma related to substance use disorders is re
duced by understanding that everyone has genetic
risks for a number of medical problems, and for
some individuals, that is substance use. Mr. K was
intrigued by education and discussion on brain
functioning and how some individual's brains have
a number of inherited variations of genes in the
dopamine reward system that can increase their risk
for substance use disorders.11 In addition, exposure
to any substances, even prescribed opioid medica
tions, can increase risk for ongoing substance use
problems.12
APRNs are vigilant about keeping substance use
risk reduction groups confidential, nonjudgmental,
supportive, and positive. Powerful participant life
stories are shared during groups to personally il
lustrate genetic and environmental risk factors and
how individual resilience and behavioral changes
can support reducing risks for problems with sub
stance use. Mr. K shared his life story in group and
stated it was enlightening and helpful for him to
understand how his family history of substance use
disorders and the traumatic events of his childhood
and life had impacted him.
Participants with chronic pain agree on admission
to the pain rehabilitation program to abstain from
using any mood-altering substances during the 3
weeks of intensive programming. For Mr. K, an ad
mission urine drug abuse survey (DAS) confi rmed
the presence of hydromorphone and lorazepam,
which were prescribed; tetrahydrocannabinol (THC),
the principal psychoactive constituent of cannabis,
which he reported smoking almost daily, was also
confirmed. A follow-up DAS obtained at the begin
ning of the program's third week was negative for
opioids and lorazepam but positive for THC at a level
higher than on admission. This was an unexpected
fi nding and indicated a risk of an ongoing problem
with substance use.
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Page 5
Family history of substance use disorder and chronic pain management
Using family history of substance use disorder as
part of a chronic pain assessment may provide
important data for multimodal treatments.

Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.
An APRN was able to use motivational inter
viewing, focusing on Mr. K's high-risk family his
tory of substance use disorders and his own personal
use, including the use of cannabis during the pro
gram. Having information on multiple risk factors,
including family history, helped
make a more compelling case for
behavior change. Mr. K was ini
tially resistant to focused attention
on his substance use but gradually
acknowledged that he was at high
risk for ongoing problems.
Mr. K was referred for a substance use disorder
evaluation, which resulted in a recommendation for
enrollment and participation in an intensive residen
tial addiction program. He subsequently completed
the program and was open to recommendations for
follow-up care and community support groups to
maintain sobriety.
 Importance of family history
Milne and colleagues studied the predictive value of
family history information on severity of illnesses
with data collected at numerous points in time from
981 subjects in New Zealand between ages 11 and
32.13 The research focused on individuals with a di
agnosis of depression, anxiety disorder, alcohol de
pendence, or drug dependence and concluded that a
positive family history was associated with the pres
ence of the disorder, a recurrent course of illness,
worse impairment, and greater use of healthcare ser
vices. Study findings indicated that highlighting the
importance of a high-risk family history and provid
ing supportive, nonjudgmental interventions under
pins improved overall outcomes.13 This study also
supports taking a shared family environment into
consideration.
Many individuals with chronic pain are unable to
participate in extensive rehabilitative programs. Some
individuals with risk factors for substance use
disorders, including family history of substance use
disorders, will benefi t from an increased awareness
of these risks and can make behavioral changes with
brief motivational interventions. The SBIRT approach
for early substance use disorder identifi cation and
appropriate intervention is endorsed by the Offi ce of
National Drug Control Policy.6 SBIRT screening can
quickly assess risk factors, including problematic
personal use of substances and family history of
substance use disorders by using questions similar to
the ones used in this case report.
Brief intervention focuses on increasing aware
ness of a problem or potential problem by nonjudg
mentally summarizing problematic personal use
of substances and/or family history risks; this is
followed by providing educational interventions,
such as the supportive and informative publications
available at the Substance Abuse and Mental Health
Services Administration (SAMHSA) website (www.
samhsa.gov). Motivational interviewing can help to
facilitate referral to appropriate evaluation and treat
ment for those who need more extensive interven
tions.6 Information regarding treatment locations,
admission criteria, and cost is also available at the
SAMHSA website.
Bernstein and colleagues found evidence that using
even brief interventions that raise awareness of prob
lems supported abstinence from heroin and cocaine
use at a 6-month follow-up interview without spe
cialty addiction treatment.14 Shetty and colleagues
concluded that personalized, motivational interven
tion for patients with facial injuries reduced existing
substance use behaviors.15
 Case revisited
Mr. K came to the pain rehabilitation program with
persistent chronic pain for the past 6 years, and the
intensity had gradually increased. He also had a com
plex mental health history, including multiple psy
chiatric diagnoses and problematic polysubstance
use. He reported a high-risk family history for sub
stance use disorders and daily use of an opioid, ben
zodiazepine, and cannabis. His goals for the pain
rehabilitation program were to taper off of opioid
and benzodiazepine medications and to learn behav
ioral skills to increase his ability to physically func
tion and gain a better quality of life.
After successful discontinuation of targeted medi
cations and participation in all program activities,
Mr. K had positive improvements in his physical func
tioning, endurance, and cognitive coping skills.
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Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.
Family history of substance use disorder and chronic pain management
However, a DAS near the end of the program revealed
an increase in his THC level, which was incompatible
with the program expectation of no mood altering
substance use. Motivational interviewing focused on
his high-risk family history of substance abuse, his
past and present personal use, and the need for ad
ditional support to maintain a healthy, substance-free
lifestyle.
Mr. K was initially resistant to attention focused
on his substance use and offered excuses, but he
gradually gained awareness of the need for evaluation
for substance use disorder treatment. Mr. K was re
ferred for evaluation and subsequently completed an
intensive residential addiction program. He com
pleted the program and was open to recommenda
tions for follow-up care and community support
groups. Comprehensive evaluation and treatment
related to chronic pain and substance use gave Mr. K
the best chance for long-term, successful manage
ment of his chronic conditions.
 Implications for practice
Using family history of substance use disorder as part
of a chronic pain assessment may provide important
data for multimodal treatments. A recent study of
individuals with chronic pain by Pestka and col
leagues found that response to just one question
related to family history of substance use indicating
high risk is associated with other substance use risk
factors, including a higher depression screening score,
higher pain catastrophizing screening score, and
more  frequently reported past and current use of
substances.16
Efforts to identify patients with chronic pain at
high risk of poor outcomes, including risk for a
substance use disorder, can offer an opportunity
for brief motivational interviewing and a means
to direct patients who may benefit from further
interventions to appropriate risk reduction or treatment
resources.
Given the current opioid crisis, it is imperative that
APRNs embrace strategies to help reduce opioid use
disorder and only prescribe these medications appro
priately for short-term use. The CDC has established
guidelines for prescribing opioid medications (www.
cdc.gov/drugoverdose/prescribing/guideline.html).
When providing care for a patient who has been ex
posed to opioid medications for an extended period
of time, it is important to consider motivational
interviewing to guide them in the direction of com
prehensive pain rehabilitation centers or other sup
portive resources.
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prevalence and correlates. Subst Abuse Rehabil. 2015;6:83-91.
3. Hedegaard H, Warner M, Minino AM. Drug overdose deaths in the United
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dopamine genes influences responsivity of the human reward system. Proc
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Psychiatry. 2009;66(7):738-747.
14. Bernstein J, Bernstein E, Tassiopoulos K, Heeren T, Levenson S, Hingson R.
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Elizabeth L. Pestka is a clinical nurse specialist at the Pain Rehabilitation Center,
Mayo Clinic, Rochester, Minn.
Michele Evans is a clinical nurse specialist at the Pain Rehabilitation Center,
Mayo Clinic, Rochester, Minn.
The authors have disclosed no financial relationships related to this article.
DOI-10.1097/01.NPR.0000532765.76132.5c
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