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Chronic pain may motivate drug use, potentially increasing the risk of non\u2010fatal overdose. We aimed to estimate the association between chronic pain and non\u2010fatal overdose in people who inject drugs.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Prospective cohort study of people who inject drugs recruited in community settings [the Hepatitis Cohort (HEPCO) study], with data collection every three months between August 2017 and November 2025.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Montreal, Canada.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>Participants were people who inject drugs (past 6\u2010month injecting), aged 18\u2009years or older, living in the greater Montreal area and speaking French or English.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Measurements<\/jats:title>\n                    <jats:p>The outcome was defined as having at least one non\u2010fatal overdose in the past 3 months, and the exposure was defined as experiencing chronic pain in the past 3 months. Covariates were age; gender; past 3\u2010month psychological distress (K10), housing status, opioid use, benzodiazepine use and opioid agonist treatment; past\u2010month days of alcohol use; and interview era (pre\u2010November 2020 vs. November 2020 onwards). A lagged analysis was conducted to explore temporality, based on chronic pain status reported at the visit preceding the outcome assessment. The analysis was not pre\u2010registered and the results should therefore be regarded as exploratory.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The primary analysis included 4790 study visits from 887 participants and 355 reports of non\u2010fatal overdose. At baseline, 81.4% of the sample was men, median age was 45\u2009years and 46.8% reported chronic pain in the past 3 months. Chronic pain in the past 3 months was associated with a 40% increase in past 3\u2010month non\u2010fatal overdose [adjusted prevalence ratio (PR) = 1.40; 95% confidence interval (CI) = 1.13\u20131.75]. Similar results were observed in the lagged analysis (adjusted PR = 1.52, 95% CI = 1.18\u20131.96).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Summary<\/jats:title>\n                    <jats:p>In a Montreal, Canada, cohort of people who inject drugs, chronic pain was associated with experiencing non\u2010fatal overdose. We interpret this finding within a reciprocal model of pain and substance use, in which chronic pain increases the likelihood of using drugs in ways that increase overdose risk, and pain is potentiated by drug use and withdrawal.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/add.70619","type":"journal-article","created":{"date-parts":[[2026,9,26]],"date-time":"2026-09-26T06:39:02Z","timestamp":1790404742000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The association between chronic pain and non\u2010fatal overdose in people who inject drugs: Longitudinal cohort study in Montreal, Canada, 2017 to 2025"],"prefix":"10.1111","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5602-4963","authenticated-orcid":false,"given":"Sarah","family":"Larney","sequence":"first","affiliation":[{"name":"Burnet Institute  Melbourne Australia"},{"name":"Centre de recherche du Centre hospitalier de l'Universit\u00e9 de Montr\u00e9al  Montr\u00e9al Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Geng","family":"Zang","sequence":"additional","affiliation":[{"name":"Centre de recherche du Centre hospitalier de l'Universit\u00e9 de Montr\u00e9al  Montr\u00e9al Canada"},{"name":"Department of Family Medicine and Emergency Medicine Universit\u00e9 de Montr\u00e9al  Montr\u00e9al Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Harika","family":"Dasari","sequence":"additional","affiliation":[{"name":"Centre de recherche du Centre hospitalier de l'Universit\u00e9 de Montr\u00e9al  Montr\u00e9al Canada"},{"name":"Department of Family Medicine and Emergency Medicine Universit\u00e9 de Montr\u00e9al  Montr\u00e9al Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7742-2717","authenticated-orcid":false,"given":"M. Gabrielle","family":"Pag\u00e9","sequence":"additional","affiliation":[{"name":"Centre de recherche du Centre hospitalier de l'Universit\u00e9 de Montr\u00e9al  Montr\u00e9al Canada"},{"name":"Department of Anaesthesiology and Pain Medicine Universit\u00e9 de Montr\u00e9al  Montr\u00e9al Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8415-3036","authenticated-orcid":false,"given":"Farzaneh","family":"Vakili","sequence":"additional","affiliation":[{"name":"Centre de recherche du Centre hospitalier de l'Universit\u00e9 de Montr\u00e9al  Montr\u00e9al Canada"},{"name":"Department of Family Medicine and Emergency Medicine Universit\u00e9 de Montr\u00e9al  Montr\u00e9al Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adelina","family":"Artenie","sequence":"additional","affiliation":[{"name":"Centre de recherche du Centre hospitalier de l'Universit\u00e9 de Montr\u00e9al  Montr\u00e9al 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