A recent review article published in Psychology Today and authored by Dr. Mark Gold examined evidence showing that substance use disorders (SUD) and withdrawal from addictive substances are associated with increased pain sensitivity, with implications for pain management, anesthesia, and clinical care.
The results of a new neuroimaging study revealed that men who temporarily stopped smoking before surgery experienced increased pain perception and higher postoperative opioid requirements compared with participants who did not smoke, confirming earlier evidence of reduced pain tolerance during short-term nicotine abstinence.
“This explains why abstinent smokers report more subjective pain and need higher postoperative analgesic doses,” wrote Dr. Gold. “Surgical teams often struggle with postoperative pain management, and this new evidence explains why their analgesic needs may exceed expectations. Nicotine replacement therapy (NRT) might mitigate withdrawal-hyperalgesia, and preliminary findings do show improved pain thresholds.”
Likewise, patients with preoperative opioid use often require substantially higher postoperative opioid doses due to tolerance and opioid-induced hyperalgesia, which complicates pain management and increases the risk of perioperative complications, longer hospital stays, and higher healthcare costs. Alcohol withdrawal is also associated with heightened pain sensitivity, with controlled human studies showing increased spontaneous pain during detoxification from heavy alcohol use, likely reflecting neuroadaptive changes resulting from chronic alcohol exposure and its analgesic effects.
Recent research also shows that cannabis use is commonly associated with increased pain sensitivity, which can complicate perioperative pain management and lead to higher-than-expected analgesic requirements. For instance, evidence from a large Cleveland Clinic study indicates that surgical patients who currently or recently used cannabis experience higher postoperative pain scores, increased opioid consumption, and greater anesthesia requirements compared with nonusers, particularly within the first 24 hours after surgery. “It’s crucial for patients to inform their health care providers about cannabis use before surgery to ensure proper pain management and anesthesia planning, as cannabis can significantly impact outcomes,” said Dr. Gold.
Dr. Gold concluded that when patients with substance use disorders report higher-than-expected pain, clinicians treat this as a physiological pain-management issue, using individualized, multimodal strategies and avoiding undertreatment based solely on substance use history. “Heightened pain during abstinence not only complicates pain management, anesthesiology, and surgical care, but also reinforces drug-taking by creating negative reinforcement loops sustaining addiction and undermining cessation,” he wrote.
