Craving of Prescription Opioids Among Veterans With Chronic Pain

Tiffany Toor; Emily Murphy; Alan N. Simmons; Sarah Palyo; Sara C. Librodo; Irina A. Strigo


Pain. 2022;163(10):2021-2030. 

In This Article

Abstract and Introduction


The United States faces a crisis because of the high prevalence of chronic pain, concurrent opioid use disorder, and overdose deaths. Prescription opioids remain a primary driver of opioid-related deaths. Craving is a core symptom of addiction, yet the degree to which craving plays a role in prescription opioid use among patients with chronic pain is unknown. Understanding the degree to which craving should be considered in patients with chronic pain is critical for developing effective interventions for supporting patients through opioid tapering. The current work combines data collected from (1) 2152 veterans screened for eligibility at a pain specialty care clinic at the San Francisco VA Health Care System and (2) medical records obtained from the VA Corporate Data Warehouse. We found that prescription opioid craving among veterans with chronic pain was low, with 66.4% of the sample reporting no craving and 33.6% reporting craving. We also found that craving had a small association with morphine equivalent daily dose and pain severity but was more strongly associated with depression. Craving of prescription opioids among veterans with chronic pain is complex. Findings are discussed in relation to chronic pain symptoms, psychiatric comorbidities, and demographics.


The high prevalence of chronic pain, along with co-occurring opioid use disorder (OUD) and overdose deaths, has led to a crisis in the United States and remains a national public health emergency. Among drug-related deaths, opioid overdose deaths constitute the highest number, reaching epidemic magnitudes. Particularly, prescription opioids constitute the primary source of opioid-related deaths (CDC, 2019). Over 17% of Americans filled at least one opioid prescription in the last year, with an average of 3.4 opioid prescriptions dispensed per patient (CDC, 2017). Additionally, as reported in 2017 by the Department of Veterans Affairs, 50% to 60% of veterans have chronic pain and 16.1% receive opioid therapy.[31]

A core symptom of addiction is craving,[22,45] as revealed by its recent addition to the diagnostic criteria for substance use disorders in the Diagnostic and Statistical Manual of Mental Disorders.[2] Craving is associated with continued drug use and can predict relapse.[29] Although, as noted in a public meeting by the U.S. Food and Drug Administration (FDA) in 2018, while craving is considered a significant component of OUD and is one of the diagnostic criteria, the degree to which craving contributes to the continued consumption of prescription opioids among patients with chronic pain is unknown. Studies have examined whether craving at treatment entry predicts outcomes after treatment,[7] with some supporting this association,[5,33] some finding no association,[1,12] and others finding associations only for particular craving types (eg, stress-induced craving).[34] Understanding whether we should consider craving or the reduction of craving in patients with chronic pain who are prescribed opioids is critical for developing effective treatment plans, including opioid tapering interventions.

Craving, as a concept, is subjective with disputed definitions[38] and, according to a recent viewpoint,[21] is incompletely understood, especially in patients with chronic pain. The sparse available literature displays that craving for prescription opioids varies among patients with chronic pain. In some patients, craving reinforces opioid use and is related to symptoms of chronic pain.[42] In others, pain symptoms do not serve as the driver; rather, opioid consumption is influenced more by the patient's emotional state.[40] Importantly, craving is not synonymous with OUD because some patients with chronic pain who are not diagnosed with OUD have reported craving, whereas others with OUD have not.[42,44] Subsequently, there are gaps in understanding whether (1) craving is present among patients with chronic pain who are prescribed opioids and (2) the degree to which craving reinforces prescription opioid use in patients with chronic pain. This study's goal was to examine craving in a large sample of veterans with chronic pain who were prescribed opioids and evaluate whether craving relates to prescribed opioid doses, functional status, or comorbid psychiatric diagnoses. Additionally, we explored the predictive relationship between clinical and demographic characteristics in veterans with chronic pain and craving as an outcome, using a computer-based classification model. The goal of this exploratory analysis was to understand the main contributors to reported craving in our sample.