Fibromyalgia, Pain, and Substance Use Disorders

Key points

• Fibromyalgia affects between 4 and 10 million and 60 million people suffer from > 3months of pain
• Opioid, Cannabis, and Alcohol Use Is Particularly Risky Self-Medication in Pain
• This Is Especially True in FM’s nociplastic pain- brain pathways involved in FM are also involved in addiction.
• Fibromyalgia and chronic pain create a “fertile breeding ground” for self-medication and iatrogenic addiction. . Fibromyalgia involves abnormal pain processing; the brain struggles to turn off pain signals. Many brain pathways involved in fibromyalgia are also involved in addiction.

  Addiction occurs through a cycle of central sensitization, inadequate relief, and the psychological burden of the condition. People with fibromyalgia (FM), like people with substance use disorders (SUDs), report suffering stigma during healthcare consultations, including feeling invalidated, discouraged, and judged by clinicians. Is FM a valid diagnosis? And do some with FM develop SUDs? Yes to both.

  Addiction occurs through a cycle of central sensitization, inadequate relief, and the psychological burden of the condition. People with fibromyalgia (FM), like people with substance use disorders (SUDs), report suffering stigma during healthcare consultations, including feeling invalidated, discouraged, and judged by clinicians. Is FM a valid diagnosis? And do some with FM develop SUDs? Yes to both.

• Approximately 3 to 6 % of people in the U.S. suffer fromfibromyalgia, many more women than men. Systematic reviews indicate that most physicians (≈ 84%) believe that FM is a clinical condition, not dismissing it entirely. But most find FM difficult to diagnose or treat, struggling to differentiate it from other conditions with overlapping symptoms. Physician uncertainty and diagnostic discomfort may confirm patient perceptions of being misunderstood.

restorative sleep, debilitating fatigue, and cognitive dysfunction. Looking at the broader picture, chronic pain and substance use disorders co-occur frequently; about 40% of individuals experiencing chronic pain meet the criteria for SUDs.

When medications yield partial or inconsistent relief, FM patients may use self-medication strategies, such as alcohol or cannabis. Unfortunately, FM pain is daily and classified as nociplastic pain, a chronic pain arising from altered CNS function rather than tissue damage or inflammation. Unlike the pain of an injury or arthritis, FM pain is a whole-body, often unrelenting condition that increases the risks for SUDs.

Roland Staud, M.D., professor of medicine at the University of Florida, and colleagues have demonstrated that FM patients have (increased sensitivity to pain (hyperalgesia), yet modulate pain input as effectively as healthy controls, suggesting amplified pain in the central nervous system. It’s somewhat comparable to a “systems overload” situation. But unlike your laptop or phone running amok, you can’t turn it off and then back on to reset it; you can’t turn the body off.

Recent functional MRI work demonstrated a persistent altered neural state in FM, heightened activity in anxiety and autonomic-related circuits, increased eye pupil size, and augmented pain sensitivity.

FM is also a diagnosis of exclusion. There are no confirmatory laboratory/imaging tests. Laboratory testing (complete blood count, erythrocyte sedimentation rate, C-reactive protein, thyroid function) with normal results excludes inflammatory, autoimmune, or endocrine disorders, but doesn’t define the underlying diagnosis when it’s FM.

The current American College of Rheumatology (ACR) criteria for FM diagnosis require the presence of chronic widespread pain for at least three months and assessment of patient symptom burden using the Widespread Pain Index (WPI) and Symptom Severity Scale (SSS). These instruments quantify pain distribution, fatigue, unrefreshing sleep, cognitive dysfunction, and associated complaints

Patients with FM commonly report flu-like aching—“I hurt all over”—accompanied by fragmented sleep, exhaustion, impaired concentration, and fluctuating pain levels. Functional capacity is often substantially compromised. Depression and anxiety affect up to half of FM patients; bipolar and trauma-related symptoms are also overrepresented. The clinical picture is chronic pain and distress. I created a figure (left) to illustrate the problem.

Some patients turn to substances to cope with pain and accompanying emotional distress, such as depression and anxiety. Self-medication often occurs; it isn’t driven by drug experimentation or seeking euphoria. It is caused by the need for pain relief.

When substances rapidly remove pain “noise,” and affective distress, a self-sustaining cycle of use is created.

Persistent distress increases the appeal of substances providing even transient relief. Drugs of abuse are addictive enough, but repeated pairing of rapid symptom reduction with substances further strengthens drug reinforcement learning.

Opioids illustrate this dynamic. There is no convincing evidence that opioids effectively treat FM pain, and chronic use may increase pain through opioid-induced heightened sensitivity to pain (hyperalgesia). Nonetheless, opioids transiently blunt distress and provide brief pain relief. Reinforcement occurs through short-term dampening of suffering, not disease modification.

Clinically, FM may magnify patient-perceived value of opioids or sedatives, alcohol, and cannabis, because they reduce pain arousal and emotional distress—especially in patients with co-occurring mood or trauma-related disorders. For patients, temporary pain relief is better than nothing. Note that chronic pain conditions in general are associated with higher substance use rates, including polysubstance use. Pain increases exposure and reinforcement; polysubstance use elevates substance use disorder risk, in an unhappy cycle

Depression, anxiety, trauma-related symptoms, and sleep disturbance are core components of FM and are independent SUD risk factors. Using alcohol, “weed,” or other substances for pain relief creates a self-perpetuating loop: short-lived relief reinforces repeated use, while underlying symptom generators persist. Over time, escalation in dose, frequency, or polysubstance combinations may follow.

Opioids, Marijuana, and Alcohol

Opioid use disorder (OUD) is the most frequent SUD with CP. Patients with FM are 50% more likely to use opioids on a regular or high-dose basis compared to those with other pain conditions. Long-term opioid therapy in FM is linked with increased depression, sleep disorders, and suicidal ideation. Among individuals with opioid use disorder, FM apparently accelerates pain-related addiction and relapse.

Cannabis use is highly prevalent in the FM community; nearly 50% of patients report use since diagnosis. “Medical” and recreational cannabis in the U.S. have become alternative pain therapeutics. In population-based and veteran samples, adults with chronic pain were significantly more likely to have cannabis use disorder (CUD) than their non-pain counterparts. One study found that three in 10 individuals experiencing CP reported using cannabis for pain.

Alcohol misuse remains a recognized risk in chronic pain populations. A study utilizing the U.S. National Inpatient Sample showed that while AUD-related hospitalizations increased across several musculoskeletal conditions (gout, rheumatoid arthritis, osteoarthritis, low-back pain), the rate of increase was highest in fibromyalgia patients

Evidence-Based Management

First-line treatment for FM emphasizes nonpharmacologic strategies: aerobic exercise, yoga, sleep optimization, cognitive-behavioral approaches, and education. FDA-approved pharmacologic options include duloxetine, milnacipran, and pregabalin. In addition, recently-approved (2025) sublingual drug Tonmya, was the first new fibromyalgia treatment approved in 15 years. Phase-3 clinical trials involving nearly 1,000 adults demonstrated that Tonmya led to significant improvements in chronic pain and other core FM symptoms by specifically targeting nonrestorative sleep.