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In 2018 the United States National Survey on Drug Use and Health estimated that 164.8 million individuals aged 12 or older (60.2% of the US population) were 

 Of those 164.8 million, 139.8 million individuals drank alcohol, 58.8 million used a tobacco product, and 31.9 million used an illicit drug.

 Furthermore, the data reveals that 1 in 5 (~19.4%) individuals aged 12 and older took an illicit drug in the last year.

More granular examinations reveal that illicit drug activity was primarily driven by marijuana/cannabis use, with 43.5 million past-year users. The second most commonly used illicit drug was prescription pain relievers, often opioid-based, misused by 3.6 million individuals aged 12 years or older.

 Given widespread substance abuse, it is critical to be aware of both the cardiovascular risks that these substances pose and the challenges associated with managing cardiovascular complications.

World-wide, alcohol abuse is estimated to be 1 of the 4 most common, non-communicable diseases that is both 

 The widespread use of alcohol can be attributed to the globalization of its production and marketing, and its relative ease of access. Often, moderate alcohol consumption has been thought to lower risk of cardiovascular and all-cause mortality. The culmination of data suggests a half- to 1-standard drink (7 to14 grams pure ethanol) per day for women and 1 to 2 standard drinks for men (14 to 28 grams pure ethanol) can lead to roughly an 17-18% reduction in all-cause mortality.

 However, there are reasons to be skeptical of this data. Lower-risk drinkers may appear healthier than abstainers due to the fact that the abstainers are not drinking due to pre-existing medical conditions or disease(s) caused by prior excessive alcohol use. When adjusting for these factors, it appears the benefit may dissipate.

 The association between excessive drinking and various forms of cardiovascular disease is well defined, and an increased death rate has been observed with consumption of 2.5 drink/day in women or 4 drink/day in men.

The cardiovascular complications of alcohol can be divided into acute and chronic effects (

). It is also important to be aware many individuals who use alcohol abuse other substances and have additional risk factors that contribute to cardiovascular disease (

 The potential mechanism leading to hypertension include endothelial dysfunction, vasoconstriction, sympathetic activation, and activation of the renin-angiotensin-aldosterone system (RAAS). Furthermore, alcohol use may contribute to secondary causes of hypertension, including sleep apnea and renal atrophy.

 A multi-national meta-analysis has demonstrated a linear relationship between alcohol consumption and hypertension, with a risk factor that is 1.7 times higher with use of 50 grams/daily, and 2.5 times higher at 100 grams/daily.

 Management options include abstinence and use of RAAS inhibitors.1 In fact, blood pressure reductions of 7.2mmHg has been seen with up to 1 month of abstinence.

Binge drinking and/or heavy alcohol consumption has been linked to the development of a variety of acute cardiac arrhythmias, with atrial fibrillation (AF) being the most common.

 Mechanistically, alcohol may lead to direct autonomic effects as well as atrial remodeling overtime. In addition, as with hypertension, alcohol impacts other secondary risk factors for AF like obesity, electrolyte abnormalities, or sleep apnea.

 The key means of AF prevention is reducing or limiting alcohol consumption, but if AF occurs, the risk/benefit of anticoagulation should be considered. The adoption of a rate or rhythm control strategy should be considered too.

Regular, heavy alcohol use can lead to alcoholic cardiomyopathy (ACM), which accounts for 33% of all cases of non-ischemic cardiomyopathy, characterized by dilation and impaired contraction of 1 or both ventricles.

 The free radical generation accompanying alcohol use, along with activation of the RAAS and sympathetic nervous system, is thought to lead to ACM. After abstinence, patients who develop ACM and subsequent heart failure with reduced ejection fraction should be managed with guideline director medical therapy, including RAAS inhibitors, beta-blockers, and diuretics.

Cannabis, or marijuana, is increasingly used both recreationally and therapeutically 

 Particularly, the major chemical compounds excreting these effects are D-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). While the benefits of cannabis are numerous, few of them are cardiovascular-related, and cannabis’ true risk to the cardiovascular system is poorly understood. In terms of adverse cardiovascular consequences, THC appears to impart most of the negative impact, but larger and longer-term outcomes are lacking.

 Mechanistically, THC stimulates the sympathetic nervous system while concurrently inhibiting the parasympathetic nervous system, leading to increased heart rate and elevated blood pressure, which effects myocardial oxygen demand (

). Furthermore, it appears THC can lead to platelet activation and overtime associated endothelial dysfunction and oxidative stress. In addition, impurities in cannabis products can induce or exacerbate these effects.

Given this cardiovascular milieu, it is prudent to understand the short- and long-term outcomes; however, this collection of existing outcomes data is limited to due to its short-term nature. It is observational and retrospective, and it suffers from recall bias, lack of exposure determination, and the given age of the data may not reflect 

 In a combined analysis of 33 studies investigating cardiovascular risk and marijuana use, 28 studies reported an increased risk of acute coronary syndrome (ACS), with risk being highest recent use.

 Similarly, a study found a 3.3-fold increase in annual risk for cerebrovascular accidents (eg, strokes) in patients who use cannabis weekly or more often.

Management for the prevention and treatment of cannabis-induced cardiovascular disease needs to be better elucidated, but consists of limiting use, synthetic alternatives, education regarding the potential cardiovascular risk, enforcing primary cardiovascular prevention practices, and standard guideline-recommend therapy should a cardiac event occur.

 Finally, patients and clinicians should be aware of the various cytochrome enzymatic drug interactions associated with cannabis use.

 Specifically, cannabiodiol and THC inhibits CYP 3A4 and 2D6 to some degree, which could impact the effects of antidepressants, beta-blockers, warfarin, statins, and various other agents.

Worldwide, cocaine is among the most commonly used

 Furthermore, approximately 40% of all emergency department visits related to substance abuse can be attributed to cocaine.12 Many of the leading reasons for these visits include cardiovascular complications or complaints of chest pain.

 A multitude of studies have reported deleterious effects on the cardiovascular system, including ACS, cardiotoxicity, arrhythmias, and sudden cardiac death. Cocaine induces a variety of pathophysiological changes that lead to an array of downstream cardiovascular sequalae (

 As one would suspect, the major mechanisms are related to its sympathetic, surge-inducing myocardial supply/demand and eventual hypertrophy. Knowledge of these mechanisms can clue one into potential management strategies.

Management of a patient who presents with suspected cocaine-induced cardiovascular disease should include a through history and physical, vitals including temperature and pH, performance of electrocardiogram and monitoring of heart rhythm, and any other cardiac specific testing. Management can follow the general recommendations in 

. The recommendation is for non-selective beta-blocker (ie, carvedilol) therapy versus avoidance of beta-blocker or use of a beta1-selective agent (ie, metoprolol). A case report in 1985 suggested that selective B1-receptor blockade with intravenous propranolol lead to paradoxical hypertension due to unopposed a-receptor stimulation, which required 

 This report led many to avoid or caution against the use of beta-blockers as a class for cocaine-induced cardiovascular disease. However, subsequent review of retrospective and prospective data (including small cohorts and large observational data sets) has indicated either no harm or potential benefits from beta-blocker therapy.

 However, this data is limited by its heterogeneous nature. Ideally, there would be more prospective evidence confirming these results, but until this the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines allow the use of a non-selective beta-blocker in patients who are tachycardiac and/or hypertensive after cocaine use (Class I, Level of Evidence C).

Cardiovascular Impact and Management of Other Substances

The agents above were discussed in detail due to their frequent use, as outlined in the most recent National Survey on Drug Use and Health. However, there are a variety of other substances with 

Substance abuse can have a diverse array of cardiovascular consequences. There is still more to be understood about the true risks and optimal management. However, it is critical for clinicians to be aware of these risks and keep appraised of the most recent evidence. Clinicians should obtain a detailed history related to recreational drug use and educate patients who have substance abuse disorders about the cardiovascular impact. Finally, cardiovascular prevention and management should be considered within a holistic approach to each patient.

is a cardiovascular clinical pharmacist and adjunct assistant professor at the University of Kentucky College of Pharmacy. He is also director of Cardiovascular Services at Baptist Health Paducah.

1. Center for Behavioral Health Statistics and Quality. Results from the 2018 National Survey on Drug Use and Health. September 7, 2018. Accessed January 7, 2021. 

https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2017/NSDUHDetailedTabs2017.pdf#page=1282&zoom=100,0,240

2. Day E, Rudd JHF. Alcohol use disorders and the heart. 

3. Di Castelnuovo A, Costanzo S, Bagnardi V, et al. Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies. 

4. Stockwell T, Zhao J, Panwar S, et al. Do "moderate" drinkers have reduced mortality risk? A systematic review and meta-analysis of alcohol consumption and all-cause mortality. 

5. Fernández-Solà J. Cardiovascular risks and benefits of moderate and heavy alcohol consumption. 

6. Taylor B, Irving HM, Baliunas D, et al. Alcohol and hypertension: gender differences in dose-response relationships determined through systematic review and meta-analysis. Addiction. 2009;104(12):1981-90.

7. Page RL, Allen LA, Kloner RA, et al. Medical marijuana, recreational cannabis, and cardiovascular health: A scientific statement from the American Heart Association. Circulation 2020; 142: e131-3152.

8. DeFilippis EM, Bajaj NS, Singh A, et al. Marijuana use in patients with cardiovascular disease: JACC review topic of the week. 

9. Richards JR, Bing ML, Moulin AK, et al. Cannabis use and acute coronary syndrome. 

10. Hemachandra D, McKetin R, Cherbuin N, Anstey KJ. Heavy cannabis users at elevated risk of stroke: evidence from a general population survey. 

11. Havakuk O, Rezkalla SH, Kloner RA. The cardiovascular effects of cocaine. 

12. Kim ST, Park T. Acute and chronic effects of cocaine on cardiovascular health. 

13. Ramoska E, Sacchetti AD. Propranolol-induced hypertension in treatment of cocaine intoxication. 

14. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndrome: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130: e344-e426.

15. Ghuran A, Nolan J. Recreational drug misuse: issues for the cardiologist. 

16. Chang S, Münster AB, Gram J, Sidelmann JJ. Anabolic androgenic steroid abuse: the effects on thrombosis risk, coagulation, and fibrinolysis. 

Some commonly used drugs and narcotics have serious cardiovascular effects.

The Cardiovascular Consequences of Drug Use

Opioid addiction has deep, troubling roots in American history. Not merely a plague of recent decades, the phenomenon of widespread opioid addiction dates back to the 19th century, when the Civil War sparked the United States’ first opiate addiction epidemic among ailing veterans. Nineteenth-century opiate addiction cases usually originated in doctors’ prescriptions, a disturbing parallel with today’s ongoing 

, which has roots in opioid overprescribing during the 1990s. The alarming parallels between the 19th- and 21st-century opioid crises in the United States are not limited to iatrogenesis, however. 

Both crises exhibit a history of troubling racial inequalities in access to opioids as well. Addiction was far more common among white Civil War veterans than Black veterans, who lacked equitable access to opiates, a pattern that presaged the opioid underprescribing experienced by Black Americans in recent decades.1 Thus, the history of the Civil War-era opiate addiction epidemic not only reveals the deep historical origins of iatrogenic opioid addiction in the United States, but also underscores how Black Americans have experienced longstanding racial inequalities in access to opioid medicines.

Historical Opioid Use Patterns in the Civil War Era

During the antebellum decades, addiction to rudimentary opiates such as laudanum and opium in gum, pill, and powdered forms was common among white Americans. Discussion of opiate addiction, often dubbed the “opium habit” or “slavery” to opiates, frequently appeared in medical journals, monographs, textbooks, and even newspapers beginning in the 1830s. Psychiatrists, physicians, and other Americans widely attributed opiate addiction to the sufferers’ mental illness, constitutional weakness, or moral failings. Consequently, Americans afflicted by the so-called opium habit were frequently victim-blamed, stigmatized, and even institutionalized.

In reality, Americans addicted to opiates could usually trace their troubles to medical care. Most opiate addiction in the 19th-century was iatrogenic, 

 from physicians’ prescriptions or medical advice.

 Opiates were standard remedies for hundreds of ailments, including dysentery, cholera, malaria, pneumonia, menstrual pain, painful injuries and wounds, and more. Surveying 30 antebellum American medical textbooks, 

commentaries and formularies, medical handbooks, medical dictionaries, and home health guides published between 1813 and 1858, I identified approximately 150 distinct ailments for which opiates were indicated. The figure fluctuates slightly depending on how one classifies certain illnesses, as many nineteenth-century medical diagnoses do not map precisely on to modern diagnoses.

 indicate that opiates were among the most commonly prescribed medicines of the 19th century. In a pre-germ theory era when typical medical interventions failed to effectively address the microorganisms at the root of many sicknesses, doctors and patients prized opiates as utilitarian remedies that effectively mitigated a legion of symptoms, regardless of cause. Indeed, as one enthusiastic medical student at the University of South Carolina 

, opium was “the ‘Magnum Dei Donum’”—or, the great gift of God—“of the 

In the aftermath of the Civil War (1861-1865), the phenomenon of opiate addiction reached epidemic levels for the first time in American history, developing into a major public health crisis with alarming social implications. This epidemic, the earliest opioid crisis in U.S. history, was driven initially by sick and injured Civil War veterans, who became the first distinct cohort in the nation to be widely associated with opiate addiction. The Civil War presented the greatest health disaster of the 19th century, prompting surgeons to rely more heavily than ever on opiates, including newly available hypodermic morphine injections.

 summed up the medical consensus of the day when it described opium as the most “indispensable drug on the battlefield—important to the surgeon, as gunpowder to the ordinance.”

Accordingly, military surgeons North and South prescribed opium pills and morphine injections liberally to ease pain stemming from gunshot wounds, amputations, and traumatic nerve injuries. Surgeons also doled out opium and laudanum to treat dysentery and diarrheal sicknesses, the most common health complaints of the war. Many soldiers, taking their cue from army surgeons, continued purchasing and consuming opiates after leaving the military, there being few legal restrictions on narcotics until the early 20th century. The Civil War thus sparked an unprecedented surge in iatrogenic opiate addiction, resulting in tens of thousands of cases of chronic addiction among veterans. Predictably, overdose deaths were frequent among veterans, and the medical literature of the period is 

 with cases of men whose lives were upended by addiction.

Black Civil War Soldiers and Opiate Addiction

Racial disparities were evident among Civil War veterans addicted to opiates, the majority of whom were disproportionately white. Although Black soldiers comprised approximately 10% of the U.S. army during the Civil War, they were not equally represented among the cohort of veterans who were addicted. In a sample of approximately 150 Civil War veterans who experienced opiate addiction in their postwar lives—the largest sample of any study to date, compiled from spotty, extant Civil War-era medical records—I could identify only 1 Black Civil War veteran who suffered from an opium habit.

Contemporary physicians and psychiatrists likewise noted a distinct racial gap in opiate addiction. In 1885, a physician reported that the Eastern North Carolina Insane Asylum had admitted an exceedingly rare case of “colored insane man” of whom “it was alleged that his insanity was caused from the opium habit.” The man’s case was worthy of note because “this was the only case of opium habit he [the doctor] had ever seen in the negro.”9 The next year, a white Alabama physician also 

 that “the opium habit is rare” among the Black population after the Civil War.10This racial gap persisted for decades.

Surveying the records of morphine maintenance clinics that dotted the United States from 1910s to 1920, historian David Courtwright 

 that while the southern white population experienced the highest rate of opiate addiction in the nation, few Black southerners appeared in the clinics’ records, although the facilities were ostensibly open to Black patients.

 This enduring racial gap in the opiate addiction rate stemmed largely from racist 19th-century medical beliefs about Black bodies, coupled with substandard medical care provided to Black Civil War troops. Nineteenth-century psychiatry posited that, among other causes, opiate addiction stemmed from mental overstimulation, which led to insanity and substance abuse. Such overstimulation could only occur among intelligent, sensitive white Americans, according to Civil War-era psychiatrists. In contrast, white medical authorities 

 that Black Americans were too “simple-minded” to experience mental overstimulation, precluding them from insanity and opiate addiction.

According to J.D. Roberts, a North Carolina doctor, Black bodies lacked “the same delicate nervous organization” as whites, and thus “d[id] not demand the form of stimulant conveyed in opium” as did whites. Black people, Roberts claimed, also had a “general ignorance” of medical care, an assertion implying that Black Americans lacked the knowledge to care for their health needs by self-medicating with opiates, as whites often did.9 This constellation of racist beliefs was developed by antebellum white southerners to justify keeping Black people enslaved and to ward off abolitionist critiques.12 After the Civil War, apologists of Jim Crow fine-tuned these beliefs and used them to explain why white Civil War veterans had opiate addiction more often than Black veterans.

In reality, the relative infrequency of opiate addiction among Black Civil War veterans and other African Americans during the late 19th century stemmed from structural racism in medicine and health care. Undertreatment for pain and subpar medical care in the military left Black veterans far less likely to become addicted to opiates than their white counterparts. Just as white doctors believed that Black Americans were less liable to mental overstimulation than whites, so too did these physicians believe that Black bodies were less sensitive to pain.

 Consequently, Black Americans were much less likely to be prescribed opiate painkillers during the Civil War.

Prescription records from the war are exceptionally rare, and none are extant for Black regiments. But anecdotal evidence suggests that army surgeons, who were overwhelmingly white, often refrained from prescribing opiates to wounded Black soldiers because they believed that Black men were not troubled by pain. One white surgeon assigned to a Black regiment refused to give painkillers to a soldier whose foot was partly severed by shrapnel. Under such circumstances the standard of care for white soldiers was morphine, given early and often. But when confronted, the surgeon claimed that the wounded man in question “was not suffering much pain,” despite the gruesome nature of the wound.

 The surgeon in this episode—and likely countless similar, unrecorded incidents—seems to have been motivated by the mainstream contemporary medical belief that Black men were impervious to painful injuries that would have debilitated white soldiers and warranted opiates.

Doctors also seem to have avoided giving opiates to Black soldiers debilitated by diarrhea, although surgeons usually administered opiates to white soldiers afflicted by the same illnesses. Surgeons knew that well-timed, liberal administration of opiates could, and often did, stave off soldiers’ deaths by dehydration, the risk of poisoning or addiction notwithstanding. Consequently, the mortality rate for diarrheal sicknesses among white troops—for whom surgeons prescribed opiates liberally—was a relatively low 17.3%. In contrast, the mortality among Black troops was 33.9%, nearly double that of white soldiers.

 This excessive mortality suggests that Black soldiers did not have access to prescription opiates, the standard of care for diarrheal ailments.

Black soldiers’ lack of access to opiate analgesics and antidiarrheals was typical, not exceptional, when considered within the broader scheme of Civil War medicine. Indeed, scholars have documented pervasive racism in Civil War military and humanitarian medicine, which diminished the quality of medical care accessible by Black Americans and resulted in thousands of avoidable Black deaths during the Civil War and its aftermath.

Persistent Racial Inequalities in the Opioid Crisis, Past and Present

A troubling undercurrent of racial inequality runs through the United States’ historical and ongoing opioid crises. Racial disparities in access to essential opioid medicines has been a persistent feature in American health care, both during the Civil War era and in recent decades. Amidst the ongoing opioid crisis, multiple studies have found that Black Americans are less likely to suffer from prescription opioid addiction than white Americans. This trend is because, like Black Civil War veterans in the late 19th century, African Americans today have less access to prescription opioid painkillers than white Americans. Persistent 

 in opioid prescribing rates have been so extreme that, until recently, white Americans were about 

 to die from prescription opioid overdose as African Americans.

The relative infrequency of opiate addiction among Black Americans when compared with white Americans has been touted as a “protection” shielding African Americans from the 

 of the opioid crisis.20 But considered in historical context, such rhetoric misses the mark. While it is true that during the Civil War-era opioid crisis and that of today, iatrogenic opioid addiction has been less prevalent among Black Americans than whites, this racial disparity should not be celebrated as a metaphorical silver lining. Instead, the relative infrequency of prescription opioid addiction among African Americans in the last century and a half merely reveals the longstanding, destructive influence of structural racism in American health care that has been, and continues to be, manifested in Black Americans’ unequal access to essential opioid medicines.

Special thanks to Greg Eghigian, PhD, History of Psychiatry Editor for 

is Postdoctoral Scholar, George and Ann Richards Civil War Era Center, Pennsylvania State University, State College, PA. His website is 

1. Jones JS. Opium Slavery: Veterans and Addiction in the American Civil War Era. PhD Dissertation, Binghamton University, 2020.

Preventing and Treating Narcotic Addiction—A Century of Federal Drug Control

The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820-1885.

 Cambridge, MA: Harvard University Press; 1986.

Nineteenth century drug therapy: computer analysis of the 1854 prescription file of a Burlington pharmacy

5. Wilson TD. On the effects of opium upon the system. 1857, Waring Historical Library Inaugural Theses Collection, Waring Historical Library, Medical University of South Carolina, Charleston, South Carolina, 2. Accessed February 23, 2021. 

http://digital.library.musc.edu/cdm/compoundobject/collection/wit/id/2776/rec/10

Marrow of Tragedy: The Health Crisis of the American Civil War

. Baltimore, Maryland; Johns Hopkins University Press: 2013.

A Manual of Military Surgery. Prepared for the Use of the Confederate States Army.

 Richmond, Virginia: Ayres & Wade; 1863. Accessed February 23, 2021. 

https://collections.nlm.nih.gov/bookviewer?PID=nlm:nlmuid-0257706-bk#page/4/mode/2up

Opium Slavery: Civil War Veterans and Opiate Addiction

9. Roberts JD. Opium Habit in the Negro. 

10. Tipton F. The Negro Problem from a Medical Standpoint. 

 1886:569-570. Accessed February 23, 2021. 

https://archive.org/details/101710951.nlm.nih.gov/page/n1/mode/2up

The Hidden Epidemic: Opiate Addiction and Cocaine Use in the South, 1860-1920

Aberration of Mind: Suicide and Suffering in the Civil War-Era South,

 Chapel Hill: University of North Carolina; 2018: 85-88.

Medical Bondage: Race, Gender, and the Origins of American Gynecology.

 Athens: The University of Georgia Press; 2017.

Washington, Eagles on Their Buttons: A Black Infantry Regiment in the Civil War.

 Columbia: University of Missouri Press; 1999:22-23.

Intensely Human: The Health of the Black Soldier in the American Civil War.

 Baltimore, Maryland: Johns Hopkins University Press; 2008:11.

 Sick from Freedom: African-American Illness and Suffering During the Civil War and Reconstruction.

 New York: Oxford University Press, 2012.

Trends in Black and White Opioid Mortality in the United States, 1979–2015

Racial/Ethnic Differences in Prevalence Trends for Heroin use and Non-Medical use of Prescription Opioids Among Entrants to Opioid Treatment Programs, 2005-2016

 Baltimore, Maryland: Johns Hopkins University Press, 2014:194-195.

A ‘Rare Case Where Racial Biases’ Protected African-Americans

Black soldiers’ lack of access to opiate analgesics and antidiarrheals was typical, not exceptional, when considered within the broader scheme of Civil War medicine.




Race and Opioids: Lessons From the Civil War-Era Opioid Addiction Crisis

Robert DeLuca, RPh, president of Orexo US, talks about the new and upcoming digital therapeutic, 

, and its aim to help close the gap in care for patients with opioid use disorder. You can learn more by visiting 

. Modia™ is expected to be available later this year.

is President of Orexo US and has more than 25 years of industry experience at several multinational pharmaceutical companies. In addition to his demonstrated track record of success in the pharmaceutical industry with a combined background in global commercial operations, marketing, market access, and sales, DeLuca is also a New Jersey licensed pharmacist. He practiced retail pharmacy for 3 years post licensure prior to entering the corporate arena. DeLuca also is on the St. John’s College of Pharmacy Advisory Board and has memberships in the Academy of Managed Care Pharmacy (AMCP) and in the American Pharmacists Association.

What digital therapeutic treatment for opioid use disorder will soon be available to complement psychiatric care? 

Effectively Treating Opioid Use Disorder

The association between smoking cigarettes and the risk of developing serious and potentially fatal health problems (most notably cardiovascular diseases, pulmonary diseases, and cancer), has long been accepted fact. However, an additional health problem that may also be associated with smoking has often been overlooked: pain.

Two recent papers indicate a strong association between smoking and pain.

 Among the review’s important findings is that those who suffer from chronic pain are substantially more likely to smoke than are those who do not suffer from chronic pain. Although smoking rates continue to decline in the latter group, this does not appear to be occurring in those with pain.

Cigarette smoking has been cited as a risk factor for a wide variety of painful conditions, including back pain, 

, and diabetic peripheral neuropathy. Smoking appears to be associated with both the development and severity of pain.

The second paper specifically studied the most likely locations of pain among individuals who smoke. The 

 examined data from a 2003 to 2004 National Health and Nutrition Examination Survey, which contained data from comprehensive bodily pain questionnaires in addition to questions on other health issues, including tobacco use.

 The study compared 1054 participants who smoked tobacco with 1316 participants who did not.

Those who smoked were found to be more likely to suffer chronic pain. Although the likelihood of pain was increased throughout the body, the study found that spine pain, and especially low back pain, had the strongest association with smoking. The second strongest association was between 

 and smoking. Smoking was also associated with both trunk pain, which included the chest and abdomen, and limb pain. (All statistical associations were drawn from Smuck et al.

This is an interesting and perhaps an unexpected finding. Because of the association between smoking and cardiovascular and cerebrovascular problems, it is easy to see why headaches would be fairly common among individuals who smoke. However, it might be reasonably expected that pain in the trunk and 

 would be more common than pain in the spine. The authors suggest that vascular factors may play a greater role in back pain than is often thought.

, which are becoming more popular, are any less associated with pain than traditional cigarettes remains an unanswered question.

From personal experience treating patients with chronic pain who also smoke, I know that helping them with smoking cessation attempts can be challenging. Although most patients are often well aware of the risks associated with smoking, their pain and its impact on their lives may make it more difficult for them to quit. Their pain may make them feel restricted, and their ability to participate in previously enjoyable activities is limited. Smoking is among the few such activities in which they can still indulge. They may also feel that smoking helps them cope with the pain.

 may have some analgesic effects, but abstaining from smoking may 

 individuals to suffer hyperalgesia, a lowering of the pain threshold.

 Thus, those who smoke may receive temporary relief from tobacco use, and their pain may get worse when they try to stop.

Additionally, depression and anxiety are frequent 

 among those with chronic pain, and their presence can also contribute to the challenge of getting patients to stop smoking.

Ultimately, all evidence points to the importance of convincing patients with chronic pain who also smoke that tobacco is not helpful. Indeed, tobacco may be significantly exacerbating their pain and adding to their misery.

The multitude of challenges can understandably make it difficult to persuade patients with chronic pain to stop using tobacco. Unfortunately, only a 

 of studies have sought to investigate the best treatments for attaining this goal.

Although no single optimal treatment has yet been identified, it appears that while nicotine replacement therapy can be useful, the 

 that are most successful are those that address both the pain and the smoking using psychotherapeutic interventions.

 In this way, treating tobacco use disorder and comorbid chronic pain is similar to the treatment of pain and iatrogenic opioid use disorder, where both problems must be managed together to be successful in treating either.

Of course, this raises the important issue of who treats pain and how it is treated. (For more information on psychiatry and pain, see 

Psychiatric TimesTM November 2020 Special Report

For the most part, the management of chronic pain has been under the aegis of anesthesiology, followed by physiatry and neurology, with psychiatry far down the list. However, the order of these specialties would be reversed if we asked which is best able to aid in smoking cessation. One doubts that there are many anesthesiologists, physiatrists, or neurologists who have expertise in treating patients with nicotine addiction.

As a result, it is difficult for patients with chronic pain who smoke to find health care professionals qualified to treat both issues. If it appears to patients that smoking and pain are 2 separate problems that require different medical specialties to treat them, it may make it more difficult to convince them that the issues are actually entangled. Nonetheless, the evidence suggests that managing 1 issue may aid in managing the other.

This article was posted ahead of print on November 11, 2020, and has since been updated. -Ed

Pain, nicotine, and tobacco smoking: current state of the science

2. Smuck M, Schneider BJ, Ehsanian R, et al. 

Smoking is associated with pain in all body regions, with greatest influence on spinal pain

Nicotine deprivation increases pain intensity, neurogenic inflammation, and mechanical hyperalgesia among daily tobacco smokers

Nicotine withdrawal and stress-induced changes in pain sensitivity: a cross-sectional investigation between abstinent smokers and nonsmokers

Anxiety and depression in bidirectional relations between pain and smoking: implications for smoking cessation

A reciprocal model of pain and substance use: transdiagnostic considerations, clinical implications, and future directions

7. Hooten WM, LaRowe LR, Ditre JW, et al. 

Effects of a brief pain and smoking cessation intervention in adults with chronic pain: a randomized controlled trial

Two recent papers look at the subtle and surprising links between smoking and pain in different parts of the body. 

Pain and Smoking: Is There an Association?

Cannabis is gaining wider acceptance as a therapeutic for mental health issues. California-based Royal Emerald Pharmaceuticals is currently pursing Federal Drug Administration approval to research, develop, and manufacture medicines derived from cannabidiol (CBD) and tetrahydroncannabinol (THC).

In this Mental Health Minute, founder and CEO of Royal Emerald Pharmaceuticals Mark Crozier reveals the motivation behind his quest to make non-addictive medicines for PTSD, pain, anxiety, depression, opiate addiction, and other conditions.

is the Founder and CEO of Royal Emerald Pharmaceuticals. Crozier has 40 years of experience in the military and law enforcement with the bulk his career

was spent in criminal intelligence. He is a former Army Ranger and a retired federal police chief.

Would you prescribe non-addictive cannabis treatments? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

Research on a new kind of cannabis treatment prepares to move forward. 

Cannabis-Based Medicine Without the Addiction Risks?

, half of full time college students aged 18 to 22 consumed alcohol this past month, and 33% of them engaged in binge drinking during this same time frame.

 as consumption of 5 or more standard drinks on 1 occasion for males, or 4 or more for females, bringing blood alcohol concentration to 0.08 grams of alcohol per deciliter or higher.

 These drinking patterns lead to serious health and safety risks, including death from unintentional injuries such as motor vehicle crashes,

 suicide attempts and other mental health issues, legal charges, and, over the long term, damage to the liver and other organs.

Academic performance is also compromised, with 1 in 4 students endorsing academic difficulties (ie, missing class or falling behind on assignments) due to alcohol consumption.

 to perform poorly on tests or projects compared to those who drink but do not binge (40% vs 7%) and 5 times more likely to have missed a class.

Are people with high "neuroticism-depression" likely to drink more than the average person when stressed? We may be getting closer to the answer. 

Addiction & Substance Use

The Cardiovascular Consequences of Drug Use

Race and Opioids: Lessons From the Civil War-Era Opioid Addiction Crisis

Effectively Treating Opioid Use Disorder

Pain and Smoking: Is There an Association?

Cannabis-Based Medicine Without the Addiction Risks?

Neuroticism-Depression: What Is It and Does It Play a Role in College Drinking?

Cannabis & Significant Effects on the Wiring of the Brain

Treating Trauma and Addiction Simultaneously

Poll: Prescribing Cannabis

Professional Opinion: Cannabis