Smoking and its Effect on Pain
Kristian Delgado, M.D.
The question of how smoking affects pain is complicated and multifactorial. It is true that patients who smoke are more likely to develop low back or other types of chronic pain. Additionally, those that smoke are more likely to report higher pain levels, they are also more likely to use higher levels of analgesic or pain medicines, and their pain is likely to have a greater impact on their daily life. Several studies have shown links between moderate to heavy smoking (one or more packs per day) and disability related to pain. Several Finnish studies found teenage smoking was a significant risk factor for developing pain, this trend was also dose responsive. People that smoked more were more likely to develop pain than those who smoked less.
There are several epidemiological studies that show trends within the population. We now know that those who smoke are at risk of developing painful conditions. Smoking is a risk factor for osteoporosis, lumbar disc disease and poor bone healing. We also know that smoking impairs wound healing, thus those that smoke take longer to heal following injury and may have associated chronic pain. In addition to increasing the risk for painful conditions, people who smoke were found to have a greater intensity of pain as well as more areas of pain within their body, in comparison to non-smokers. Smokers are more likely to report functional and life impairment related to their pain and appear to have worse outcomes in terms of disability related to their pain.
Some people report that smoking a cigarette can decrease their immediate pain. In fact, it has been shown that the nicotine found in cigarettes has been shown to temporarily decrease pain. Several studies have shown that giving patients nicotine before surgery led to decreased pain and decreased use of opioids in their post-operative period. These studies were based on non-smokers only. The effect was not seen in those who were already using cigarettes on a regular basis. Those who smoke regularly may have a reduced sensitivity to the effect of nicotine on pain. Smoking long term is problematic for controlling pain due to the development of tolerance. The nicotine levels in the body are only steady for about one hour, meaning someone would need to keep smoking continuously to help with pain. Over time this would have less and less effect even if they continued to smoke hourly. Lastly those withdrawing may experience depressed mood, anxiety, stomach upset and irritability.
Smoking has also been shown to be an independent risk factor for opioid use. In smoking patients being treated for pain, opioids were more likely to be used. Additionally, those already on opioids were more likely to need higher doses of their medication to control their pain than non-smokers. What this amounts to is that while the nicotine found in cigarettes may provide some initial benefit for pain control in non-smokers, overall it will make pain much more difficult to treat.
There is evidence that smoking is not directly related to the perceived pain level. It is associated with increasing levels of depression. Depression is highly associated with chronic pain and vice versa, chronic pain is associated with higher levels of depression. Among those with depression, the rate of smoking is significantly higher than the rest of the population, as high as 45%. Like smoking, depression has been found to be associated with increased chronic pain conditions including low back and neck pain.
Smoking is associated both with developing pain and seems to have a greater impact on pain in those who develop chronic pain. We know that those who smoke are more likely to have some level of depression, and those with depression are more likely to have pain. Those using chronic pain medications are also more likely to need more medicine to treat their pain and are less likely to improve with treatment. We know from a physical standpoint smoking interferes with the body’s ability to heal itself, and lastly we know that smoking has been associated with higher use of narcotic or opioid prescriptions which have their own risks and complications.
A recent analysis looked at data from 2 universities with over 5000 patients who were being seen for spine related pain. Those patients who stopped smoking before beginning therapy for their pain or quit during the course of treatment had lower overall pain scores and greater functional improvement. Those who continued to smoke were unlikely to have improvement in pain or function and were more likely to have disability related to their pain.
Some people are able to quit just by making up their minds to do so. For most, this is difficult and they may need additional resources. The first conversation you may want to have is with your primary care physician. Having that partnership may provide you the support and resources you need to quit. Many people may feel that if they stop and start again, that they have failed, but it is important to remember that many people need more than one attempt at quitting. Your doctor may be able to provide you with a medication that could help. There are nicotine replacement strategies with gum and/or patches. There are also plans that help with cutting down and stopping in a gradual process. Online and phone resources for support are www.smokefree.gov/ or through the CDC website http://www.cdc.gov/TOBACCO/quit_smoking/how_to_quit/ or the American Lung Association website http://www.lung.org/stop-smoking/how-to-quit/
At Integrated Pain Associates, we successfully treat many types of chronic pain through a targeted, multi-disciplinary approach. We are conveniently located throughout Central Texas with locations in Killeen, Waco, and Temple. Contact us for more information or to schedule an appointment.
Shi, Yu, Toby N. Weingarten, Carlos B. Mantilla, W. Michael Hooten, and David O. Warner. “Smoking and pain: pathophysiology and clinical implications.” Anesthesiology 113, no. 4 (2010): 977-992.
Hooten, W. Michael, Yu Shi, Halena M. Gazelka, and David O. Warner. “The effects of depression and smoking on pain severity and opioid use in patients with chronic pain.” Pain 152, no. 1 (2011): 223-229.
Behrend, Caleb, Mark Prasarn, Ellen Coyne, MaryBeth Horodyski, John Wright, and Glenn R. Rechtine. “Smoking cessation related to improved patient-reported pain scores following spinal care.” The Journal of Bone & Joint Surgery 94, no. 23 (2012): 2161-2166.