The association between catastrophizing and craving in patients with chronic pain prescribed opioid therapy: a preliminary analysis

Withdrawal catastrophizing scale: initial psychometric properties and implications for the study of opioid use disorder and hyperkatifeia

Background: Discovery of modifiable factors influencing subjective withdrawal experience might advance opioid use disorder (OUD) research and precision treatment. This study explores one factor - withdrawal catastrophizing - a negative cognitive and emotional orientation toward withdrawal characterized by excessive fear, worry or inability to divert attention from withdrawal symptoms.Objectives: We define a novel concept - withdrawal catastrophizing - and present an initial evaluation of the Withdrawal Catastrophizing Scale (WCS).Methods: Prospective observational study (n = 122, 48.7% women). Factor structure (exploratory factor analysis) and internal consistency (Cronbach's α) were assessed. Predictive validity was tested via correlation between WCS and next-day subjective opiate withdrawal scale (SOWS) severity. The clinical salience of WCS was evaluated by correlation between WCS and withdrawal-motivated behaviors including risk taking, OUD maintenance, OUD treatment delay, history of leaving the hospital against medical advice and buprenorphine-precipitated withdrawal.Results: WCS was found to have a two-factor structure (distortion and despair), strong internal consistency (α = .901), and predictive validity - Greater withdrawal catastrophizing was associated with next-day SOWS (rs (99) = 0.237, p = .017). Withdrawal catastrophizing was also correlated with risk-taking behavior to relieve withdrawal (rs (119) = 0.357, p < .001); withdrawal-motivated OUD treatment avoidance (rs (119) = 0.421, p < .001), history of leaving the hospital against medical advice (rs (119) = 0.373, p < .001) and buprenorphine-precipitated withdrawal (rs (119) = 0.369, p < .001).Conclusion: This study provides first evidence of withdrawal catastrophizing as a clinically important phenomenon with implications for the future study and treatment of OUD.

Psychological profiles and prescription opioid misuse, craving, and withdrawal in people with chronic pain

BACKGROUND

The negative consequences of prescription opioid misuse and opioid use disorder make it relevant to identify factors associated with this problem in individuals with chronic pain. This cross-sectional study aimed at identifying subgroups of people with chronic pain based on their psychological profiles, prescription opioid misuse, craving, and withdrawal.

METHODS

The sample comprised 185 individuals with chronic pain. We performed hierarchical cluster analysis on impulsivity, anxiety sensitivity, pain acceptance, pain intensity, opioid misuse, craving, and withdrawal.

RESULTS

The four-cluster solution was the optimal one. Misuse, craving, and anxiety sensitivity were higher among people in the Severe-problems cluster than among people in the other three clusters. Withdrawal was the highest in the High-withdrawal cluster. Impulsivity was higher among people in the Severe-problems and High-withdrawal clusters than those in the Moderate-problems and Mild-problems clusters. Pain acceptance was higher among people in the Mild-problems cluster than among people in the other three clusters. Anxiety sensitivity and misuse were higher among people in the Moderate-problems cluster than among people in the Mild-problems cluster.

CONCLUSIONS

These results support that impulsivity, anxiety sensitivity, and pain acceptance are useful constructs to identify subgroups of people with chronic pain according to their level of prescription opioid misuse, craving, and withdrawal. The results of this study may help in selecting the early intervention most suitable for each of the identified profiles.

SIGNIFICANCE

The psychological profile of individuals with chronic pain, prescription opioid misuse, craving, and withdrawal is characterized by fearing anxiety-related symptoms due to the catastrophic interpretation of such symptoms and reacting impulsively to negative moods. In contrast, participants with high pain acceptance had less prescription opioid misuse, craving, and withdrawal. The profiles identified in this study could help clinicians select targets for intervention among profiles with similar needs and facilitate early interventions to prevent opioid misuse onset or aggravation.

The moderating effect of resting heart rate variability on the relationship between pain catastrophizing and depressed mood: an empirical study

Previous research indicated that pain catastrophizing-a negative emotional and cognitive response toward actual or anticipated pain-could contribute to pain intensity and could be associated with depressive symptoms not just in chronic pain patients but in healthy population as well. Accumulated evidence suggests that resting heart rate variability (HRV) as a putative proxy of emotion regulation could moderate the association of self-reported pain catastrophizing and depressed mood. In the present cross-sectional study, we investigated these associations in a healthy young adult sample controlling for the effect of trait rumination. Seventy-two participants (58 females, mean age = 22.2 ± 1.79 years ranging from 19 to 28 years old) completed the Pain Catastrophizing Scale, the Zung Self-Rating Depression Scale and the Ruminative Response Scale. Resting HRV was measured by time domain metric of HRV, the root mean square of successive differences (RMSSD). The results showed that the relationship between pain catastrophizing and depressive symptoms is significantly moderated by resting HRV (indexed by lnRMSSD). Specifically, in participants with higher resting HRV there was no significant relationship between the two investigated variables, while in participants with relatively low or medium HRV pain catastrophizing and depressed mood showed significant positive association. The relationship remained significant after controlling for sex, age and trait rumination. These results might indicate that measuring pain catastrophizing and depressive symptoms is warranted in non-clinical samples as well and higher resting HRV could have a buffer or protective role against depressive symptoms.

Adolescents and Young Adults With Sickle Cell Disease: Nociplastic Pain and Pain Catastrophizing as Predictors of Pain Interference and Opioid Consumption

OBJECTIVES

Some patients with sickle cell disease (SCD) have features of nociplastic pain. While research suggests that many patients with nociplastic pain consume more opioids due to opioid nonresponsiveness, little is known about the impact of nociplastic pain and pain catastrophizing on opioid consumption and pain interference among adolescents and young adults (AYA) with SCD. The purpose of this study was to (1) characterize nociplastic pain and pain catastrophizing among AYA with SCD, and (2) determine whether these characterizations are associated with subsequent opioid consumption and pain interference 1 month after characterization.

METHODS

Participants completed surveys characterizing nociplastic pain and catastrophizing at a routine clinic visit (baseline). Thereafter, participants received weekly text messages that included pain interference and opioid consumption surveys. Multipredictor 2-part models were used to evaluate the predictive relationships between baseline characterizations and subsequent pain interference, and opioid consumption.

RESULTS

Forty-eight AYA aged 14 to 35 completed baseline measures. Twenty-five percent of participants had scores suggestive of nociplastic pain. Greater nociplastic pain features significantly increased the odds of consuming opioids (odds ratio=1.2) and having greater interference from pain (odds ratio=1.46). Regression analyses found that greater baseline nociplastic pain characteristics were significantly associated with opioid consumption (β=0.13) and pain interference (β=0.061); whereas higher pain catastrophizing scores predicted less opioid consumption (β=-0.03) and less pain interference (β=-0.0007).

DISCUSSION

In this sample of AYA with SCD, features of nociplastic pain predicted higher subsequent opioid consumption and pain interference. Being aware of nociplastic pain features in patients with SCD may better guide individualized pain management.

Changes in Psychological Outcomes after Cessation of Full Mu Agonist Long-Term Opioid Therapy for Chronic Pain

Improved understanding of psychological features associated with full mu agonist long-term opioid therapy (LTOT) cessation may offer advantages for clinicians. This preliminary study presents changes in psychological outcomes in patients with chronic, non-cancer pain (CNCP) after LTOT cessation via a 10-week multidisciplinary program which included treatment with buprenorphine. Paired t-tests pre- and post-LTOT cessation were compared in this retrospective cohort review of data from electronic medical records of 98 patients who successfully ceased LTOT between the dates of October 2017 to December 2019. Indicators of quality of life, depression, catastrophizing, and fear avoidance, as measured by the 36-Item Short Form Survey, the Patient Health Questionnaire-9-Item Scale, the Pain Catastrophizing Scale, and the Fear Avoidance Belief Questionnaires revealed significant improvement. Scores did not significantly improve for daytime sleepiness, generalized anxiety, and kinesiophobia, as measured by the Epworth Sleepiness Scale, the Generalized Anxiety Disorder 7-Item Scale, and the Tampa Scale of Kinesiophobia. The results suggest that successful LTOT cessation may be interconnected with improvements in specific psychological states.

Low Back Pain Patients' Perceptions Regarding Their Own Radiology Reports: Pre-Intervention Survey

Purpose

While advanced medical technology and unlimited access to medical information might benefit and empower patients, these same advantages may pose some risks, especially in the cases where patients have direct access to advanced imaging studies. The aim of this work was to evaluate three domains related to patients with lower back pain: the patients' perceptions, misconceptions and the experience of anxiety-related symptoms following direct access to their thoraco-lumbar spine radiology report. An additional aim was the assessment of possible associations with catastrophization.

Patients and Methods

Patients who were referred to the spine clinic, following the completion of a CT or MRI of their thoraco-lumbar spine were surveyed. Patient perceptions of the importance of having direct access to their imaging report and of the concern they attribute to the medical terms found in their report were evaluated using a set of questionnaires. The medical terms severity scores were then correlated to a reference clinical score created for the same medical terms by spine surgeons. Lastly, patients' anxiety-related symptoms and Pain Catastrophizing Scale (PCS) after reading their radiology report were evaluated.

Results

Data from 162 participants (44.6% female), with mean age of 53.1 ± 15.6 years, were collected. Sixty-three percent of the patients stated that reading their report helped them gain better understanding of their medical condition and 84% agreed that having early access to the report helped improve communication with the physician. Patients' degree of concern associated with the medical terms in their imaging report ranged between 2.07 and 3.75, on a scale of 1-5. The patient's degree of concerns were significantly higher for six common medical terms and significantly lower in one, when compared to experts' opinions. A mean (± SD) of 2.86±2.79 anxiety-related symptoms was reported. The mean Pain Catastrophizing Scale (PSC) score was 29.18 ±11.86, ranging from 2 to 52. Both the degree of concerns and the number of symptoms reported were significantly associated with the PCS.

Conclusion

Direct access to radiology reports might provoke anxiety symptoms, especially in patients with a tendency for catastrophic thinking. Increasing awareness amongst spine clinicians and radiologist about possible risks associated with direct access to radiology reports could contribute to preventing patients' misconceptions and unnecessary anxiety-related symptoms.

Learning from addiction: Craving of prescription opioids in chronic pain sufferers

Prescription opioids are a primary driver of opioid-related deaths. Although craving is a substantial component of OUD, the degree to which craving leads to misuse among chronic pain patients on long-term prescription opioids is unknown. A clear understanding of the factors that lead to misuse in this vulnerable population is needed for the development of safe and effective practices for opioid taper. This narrative review summarizes the relevant literature on the role of craving in addiction and chronic pain through epidemiological and behavioral studies. The first part of this review examines the role of craving in predicting opioid use/misuse in individuals with chronic pain with and without OUD. The second part covers methods on how craving is evaluated experimentally using both subjective and objective measures and provides related findings. The overall goal of this review is to facilitate the development of a population-specific description of craving in those who use opioids to control chronic pain and to describe how it may be mechanistically linked to patterns of opioid (mis)use.

Craving of prescription opioids among veterans with chronic pain

ABSTRACT

The United States faces a crisis because of the high prevalence of chronic pain, concurrent opioid use disorder, and overdose deaths. Prescription opioids remain a primary driver of opioid-related deaths. Craving is a core symptom of addiction, yet the degree to which craving plays a role in prescription opioid use among patients with chronic pain is unknown. Understanding the degree to which craving should be considered in patients with chronic pain is critical for developing effective interventions for supporting patients through opioid tapering. The current work combines data collected from (1) 2152 veterans screened for eligibility at a pain specialty care clinic at the San Francisco VA Health Care System and (2) medical records obtained from the VA Corporate Data Warehouse. We found that prescription opioid craving among veterans with chronic pain was low, with 66.4% of the sample reporting no craving and 33.6% reporting craving. We also found that craving had a small association with morphine equivalent daily dose and pain severity but was more strongly associated with depression. Craving of prescription opioids among veterans with chronic pain is complex. Findings are discussed in relation to chronic pain symptoms, psychiatric comorbidities, and demographics.

Exploring the Relationship Between Endogenous Pain Modulation, Pain Intensity, and Depression in Patients Using Opioids for Chronic Low Back Pain

INTRODUCTION

Endogenous pain modulatory processes appear to play an important role in shaping pain-related outcomes, but we know relatively little about the influence of psychosocial factors on those pain modulatory processes. The primary objective of this study was to explore associations between endogenous pain modulation (ie, conditioned pain modulation, CPM; temporal summation, TS), chronic pain, and negative affective factors (ie, depression, anxiety symptoms) in a sample of participants with chronic low back pain (CLBP) treated with long-term daily opioids.

METHODS

Adults with opioid-treated CLBP (N=107) completed questionnaires assessing pain, pain symptoms, and psychological measures. CPM and TS were evaluated as predictors of pain intensity ratings (Brief Pain Inventory), with depression scores (Hospital Anxiety and Depression Scale, depression subscale) examined as potential moderators of those associations.

RESULTS

Moderation analyses demonstrated associations between CPM and back pain intensity ratings, moderated by depression symptom scores (B=-0.002, SE=0.0008, P<0.01) when controlling for daily opioid dose, with participants with higher depression scores showing a relatively stronger link between lower CPM and increased pain intensity ratings. Significant associations were observed between depression, pain intensity, and CPM-derived outcomes.

CONCLUSION

Our findings suggest that reduced pain-inhibitory capacity is associated with elevated self-reported pain intensity in adults with opioid-treated CLBP, particularly among those with higher severity of depression symptoms.

Emotional distress and pain catastrophizing predict cue-elicited opioid craving among chronic pain patients on long-term opioid therapy

BACKGROUND

Individuals who use illicit substances exhibit cue-elicited craving and autonomic cue-reactivity when exposed to cues associated with past drug use. However, little is known about this phenomenon among chronic pain patients on long-term opioid therapy (LTOT). Negative cognitive-emotional reactivity in general (e.g., distress) and cognitive-emotional reactivity specific to pain (e.g., pain catastrophizing) might drive cue-reactivity independent of pain severity. Here we examined emotional distress and pain catastrophizing as predictors of cue-reactivity among a sample of chronic pain patients receiving LTOT. We also tested whether associations between distress, catastrophizing, and cue-reactivity differed as a function of opioid misuse status.

MATERIALS AND METHODS

Patients receiving LTOT (N = 243) were classified as exhibiting aberrant behavior consistent with opioid misuse (MISUSE+, n = 145) or as using opioids as prescribed (MISUSE-, n = 97). Participants completed assessments of pain catastrophizing and emotional distress and then participated in an opioid cue-reactivity task one week later. Cue-elicited opioid craving and autonomic cue-reactivity were measured with craving ratings and high-frequency heart rate variability (HRV), respectively.

RESULTS

Distress and catastrophizing predicted cue-elicited craving and HRV, whereas pain severity did not. Misuser status moderated the relationship between emotional distress and self-reported craving, such that higher levels of distress predicted craving among the MISUSE+ group, but not among the MISUSE- group. No moderating effects were found for catastrophizing.

CONCLUSIONS

Findings suggest that although opioids are prescribed for analgesia, the exacerbating influence of negative cognitive-emotional reactivity, both in general and specific to pain, on cue-elicited opioid craving extends beyond the effects of pain severity alone.

Heightened autonomic reactivity to negative affective stimuli among active duty soldiers with PTSD and opioid-treated chronic pain

Within military populations, chronic pain conditions and posttraumatic stress disorder (PTSD) frequently co-occur, however, little research has examined the psychophysiological correlates of this comorbidity among active-duty soldiers. The current study examined physiological reactivity to negative affective stimuli among 30 active duty soldiers with chronic pain conditions treated with long-term opioid therapy. Participants completed a diagnostic interview and self-report measures. Then, their heart rate and skin temperature were recorded during an affective picture-viewing task. Soldiers with PTSD exhibited greater increases in the ratio of low-to-high frequency heart rate variability (LF/HF HRV) while viewing negative affective images than soldiers without PTSD. PTSD symptom severity was positively associated with LF/HF HRV reactivity and negatively associated with skin temperature reactivity. Additionally, opioid craving was associated with LF/HF HRV and skin temperature reactivity among soldiers with PTSD. Taken together, the results of the present study provide evidence for heightened sympathetic nervous system reactivity among soldiers with comorbid chronic pain and PTSD, underscoring the importance of intervening on potential risk factors for these conditions.

A bifactor structural model of the Hungarian Pain Catastrophizing Scale and latent classes of a clinical sample

Pain catastrophizing is an exaggerated cognitive-affective response to actual or anticipated pain, usually measured by the Pain Catastrophizing Scale (PCS). Our study aimed to test the bifactor measurement model of the Hungarian PCS and to identify a catastrophizing risk group with a clinically meaningful cut-off score.

The data of 404 chronic spine-related (neck, back and low-back) pain patients (mean age: 58.61 (SD = 14.34)) were used in our cross-sectional study. Besides pain-related and demographic data, pain catastrophizing and depressive symptoms were measured with questionnaires. Confirmatory factor analyses confirmed that the bifactor model outperformed the other tested measurement models, and the general catastrophizing factor was responsible for 81.5% of the explained variance. Using latent class analysis, we found that even moderately elevated pain catastrophizing score was related to more depressive symptoms and higher perceived pain intensity, and 22 score could be used as a cut-off score. Our results support the concept of global pain catastrophizing and the validity of the Hungarian PCS. Further studies are needed to evaluate the bifactor structure of this scale and the predictive value of the proposed cut-off score.

Anxiety and Fear Avoidance Beliefs and Behavior May Be Significant Risk Factors for Chronic Opioid Analgesic Therapy Reliance for Patients with Chronic Pain-Results from a Preliminary Study

OBJECTIVE

To describe differences between patients with chronic, non-cancer pain (CNCP) who were successfully able to cease full mu agonist chronic opioid analgesic therapy (COAT), and those who exhibited refractory COAT reliance, among those who participated in a multidisciplinary program designed for COAT cessation.

DESIGN

A retrospective review of electronic medical records (EMR) data was organized for preliminary analysis.

SETTING

A multicenter private practice specializing in CNCP, which received patient referrals from the surrounding geographical area of primary and specialty care offices in Northern California.

SUBJECTS

Data from 109 patients with CNCP who participated in a multidisciplinary program to cease COAT between the dates of October 2017 to December 2019 were examined.

METHODS

EMR data, pre-COAT cessation, of oral morphine milligram equivalence (MME) and validated questionnaire responses assessing anxiety and fear-based beliefs and behavior, as well as opioid misuse, were extracted and compared between those who successfully ceased COAT and those who did not.

RESULTS

Patients who were unsuccessful at COAT cessation reported significantly higher Fear Avoidance Beliefs Questionnaire (FAB) scores. No significant differences were found based on incoming MME amounts, Current Opioid Misuse Measure (COMM) or Tampa Scale of Kinesiophobia (TSK) scores. Pain Catastrophizing Scale (PCS) scores showed a split pattern with unclear significance.

CONCLUSIONS

Results suggest that fear avoidance beliefs and behavior, as measured by the FAB, play a significant role in refractory COAT reliance for patients with CNCP.

Day-to-day opioid withdrawal symptoms, psychological distress, and opioid craving in patients with chronic pain prescribed opioid therapy

BACKGROUND

Research has shown that opioid craving is one of the strongest determinants of opioid misuse in patients with chronic pain. To date, however, little is known on the factors that contribute to opioid craving in these patients. It is possible that patients' physical dependence to opioids, manifested by opioid withdrawal symptoms in between daily opioid doses, contribute to opioid craving. Physical dependence symptoms might also lead to psychological distress, which in turn might contribute to opioid craving. The first objective of this study was to examine the day-to-day association between opioid withdrawal symptoms and opioid craving among patients with chronic pain. We also examined whether negative affect and catastrophic thinking mediated this association.

METHODS

In this longitudinal study, chronic pain patients (n = 79) prescribed short-acting opioids completed daily diaries for 14 consecutive days. Diaries assessed a host of pain, psychological, and opioid-related variables.

RESULTS

Day-to-day elevations in opioid withdrawal symptoms were associated with heightened opioid craving (p < .001). Results of a multilevel mediation analysis revealed that this association was mediated by patients' daily levels of negative affect and catastrophizing (p < .001).

CONCLUSIONS

Our study provides valuable new insights into our understanding of factors that may contribute to prescription opioid craving among patients with chronic pain.

Mind-body approaches targeting the psychological aspects of opioid use problems in patients with chronic pain: evidence and opportunities

Opioids are commonly prescribed for the management of patients with chronic noncancer pain. Despite the potential analgesic benefits of opioids, long-term opioid therapy (LTOT) may be accompanied by problems such as opioid misuse and opioid use disorder (OUD). In this review, we begin with a description of opioid misuse and OUD and the patient-specific factors associated with these problems among patients with chronic pain. We will focus primarily on highlighting the predominant role played by psychological factors in the occurrence of opioid misuse and OUD in these patients. Several psychological factors have been found to be associated with opioid use problems in patients with chronic pain, and evidence indicates that patients presenting with psychological disturbances are particularly at risk of transitioning to long-term opioid use, engaging in opioid misuse behaviors, and developing OUD. The biological factors that might underlie the association between psychological disturbances and opioid use problems in patients with chronic pain have yet to be fully elucidated, but a growing number of studies suggest that dysfunctions in reward, appetitive, autonomic, and neurocognitive systems might be involved. We end with an overview of specific types of psychological interventions that have been put forward to prevent or reduce the occurrence of opioid misuse and OUD in patients with chronic pain who are prescribed LTOT.

Cognitive-Affective Transdiagnostic Factors Associated With Vulnerability to Alcohol and Prescription Opioid Use in the Context of Pain

The use of alcohol and prescription opioids is common among people in pain and poses significant public health burdens. This review identifies factors associated with motivation to use alcohol and prescription opioids in the context of pain. Pain-relevant, cognitive-affective, transdiagnostic vulnerability factors-expectancies/motives, pain catastrophizing, pain-related anxiety, distress intolerance, anxiety sensitivity, and perceived interrelations-were selected from theoretical conceptualizations of pain and substance use. Searches conducted in PubMed, PsycINFO, and Embase returned 25 studies that examined associations between identified variables of interest and the use of alcohol and prescription opioids in the context of pain. Consistent with a larger literature on pain and substance use, the studies included in this review demonstrated that people with chronic pain are motivated to use alcohol and opioids in response to negative affect and hold expectancies/motives for coping with pain. Vulnerabilities that engender difficulty managing aversive internal states (distress intolerance and anxiety sensitivity) and maladaptive responses to pain (pain-related anxiety and pain catastrophizing) also were implicated in motivation for alcohol and opioid use. Although one study found that pain-related anxiety was associated with co-use of alcohol and opioids, no studies examined simultaneous use. Future research directions that can explicate causal associations, identify patterns of alcohol and opioid co-use, clarify the role of pain in cessation processes, and inform treatment development are discussed.

Borderline Personality Disorder Features and Risk for Prescription Opioid Misuse in a Chronic Pain Sample: Roles for Identity Disturbances and Impulsivity

Although borderline personality disorder (BPD) is associated with both chronic pain and substance abuse, little research examines how BPD features in chronic pain patients may constitute a risk factor for misuse of prescription opioids, and no prior research has examined which particular component(s) of BPD might put chronic pain patients at risk-an oversight that undermines prevention and treatment of such problematic opioid use. In a cross-sectional study of patients in treatment for chronic pain (N = 147), BPD features were associated with several measures of prescription opioid misuse, even controlling for pain severity and interference. Specifically, the identity disturbances and self-harmful impulsivity facets of BPD were most consistently associated with opioid misuse, and exploratory analyses suggested that these factors may be interactive in their effects. Together, these results suggest that BPD features-especially unstable identity and self-harmful impulsivity-play a unique role in problematic prescription opioid use in chronic pain settings.

Pain Acceptance Creates an Emotional Context That Protects against the Misuse of Prescription Opioids: A Study in a Sample of Patients with Chronic Noncancer Pain

There is solid evidence of an association between several psychological flexibility processes, particularly pain acceptance, and adaptation to chronic pain. However, there are relatively few studies on the relationship between pain acceptance and opioid misuse in chronic pain patients. Thus, the aim of the present study was to test a hypothetical model in which pain acceptance would regulate pain sensations and pain-related thoughts and emotions, which would be related to opioid misuse. The sample comprised 140 chronic pain patients attending two hospitals. All patients were receiving pharmacological treatment, including opioid analgesics. Structural equation modelling analyses showed a significant association between higher pain acceptance and lower pain intensity and catastrophizing, and lower levels of anxiety and depression. Only higher anxiety and depression were significantly associated with increased opioid misuse. The results suggest that levels of anxiety, depression, and pain acceptance must be assessed before opioids are prescribed. Pain acceptance implies a relationship with internal events that protects against anxiety and depression and thus against opioid misuse. Acceptance and Commitment Therapy appears to be particularly appropriate for these patients.

Insights into the Neurobiology of Craving in Opioid Use Disorder

Purpose of review

Opioids remain the most potent form of pain relief currently available, yet have a high abuse liability. Here we discuss underlying neurobiological changes in Opioid Use Disorder (OUD) that likely contribute to drug craving, which in turn drives continued drug use and relapse.

Recent findings

Craving has emerged as a strong indicator in drug-seeking and relapse. Studies have demonstrated a number of allostatic changes in circuitry that facilitate learning of drug-stimuli relationships, thereby augmenting cue-triggered drug use and relapse.

Summary

This review will focus on key neurobiological changes in underlying circuitry observed during the initial and continued exposure to opioids that result in an increase in neural-reactivity to drug-related intrinsic and extrinsic drug cues, and to enhanced learning of drug-context correlations. This sensitized learning state may be an indication of the underlying framework that drives craving and ultimately, motivates increased salience of drug cues and drives drug-seeking.

Associations between Childhood Abuse and Chronic Pain in Adults with Substance Use Disorders

Both childhood abuse and chronic pain are common in people with substance use disorders (SUDs). Studies have found that exposure to childhood abuse is associated with chronic pain in adulthood; however, few studies have examined this association in people with SUDs. Objectives: This study aimed to characterize the association between childhood abuse and chronic pain presence and severity in adults with SUDs. Methods: Data were obtained from 672 treatment-seeking participants with SUDs on an inpatient detoxification unit. Regression models evaluated whether childhood physical or sexual abuse was associated with the likelihood of chronic pain and severity of several pain-related characteristics: pain catastrophizing, pain severity, and pain interference. Results: Childhood physical and sexual abuse were significantly associated with a greater likelihood of chronic pain in adulthood. In the adjusted analyses, childhood physical abuse was associated with worse pain severity, whereas childhood sexual abuse was associated with greater pain catastrophizing and worse pain interference. Conclusions: Childhood physical and sexual abuse were associated with a greater likelihood of chronic pain in adults with SUDs. Among those with chronic pain, exposure to childhood abuse was associated with a more severe symptom profile, characterized by greater pain severity, more catastrophic interpretations of pain, and more pain-related interference with daily life. People with SUDs and a history of childhood abuse may benefit from screening for pain and interventions to reduce pain catastrophizing. These findings highlight the importance of longitudinal research to understand mechanisms linking childhood abuse exposure to later pain and substance misuse.

Kappa Opioid Signaling at the Crossroads of Chronic Pain and Opioid Addiction

Pain is complex and is a unique experience for individuals in that no two people will have exactly the same physiological and emotional response to the same noxious stimulus or injury. Pain is composed of two essential processes: a sensory component that allows for discrimination of the intensity and location of a painful stimulus and an emotional component that underlies the affective, motivational, unpleasant, and aversive response to a painful stimulus. Kappa opioid receptor (KOR) activation in the periphery and throughout the neuroaxis modulates both of these components of the pain experience. In this chapter we focus on recent findings that KORs contribute to the emotional, aversive nature of chronic pain, including how expression in the limbic circuitry contributes to anhedonic states and components of opioid misuse disorder. While the primary focus is on preclinical pain models, we also highlight clinical or human research where there is strong evidence for KOR involvement in negative affective states associated with chronic pain and opioid misuse.

Emotion regulation as a transdiagnostic factor underlying co-occurring chronic pain and problematic opioid use

Chronic pain is a common and costly condition, and some people with chronic pain engage in problematic opioid use. There is a critical need to identify factors underlying this co-occurrence, so that treatment can be targeted to improve outcomes. We propose that difficulty with emotion regulation (ER) is a transdiagnostic factor that underlies the co-occurrence of chronic pain and problematic opioid use (CP-POU). In this narrative review, we draw from prominent models of ER to summarize the literature characterizing ER in chronic pain and CP-POU. We conclude that chronic pain is associated with various ER difficulties, including emotion identification and the up- and down-regulation of both positive and negative emotion. Little research has examined ER specifically in CP-POU; however, initial evidence suggests CP-POU is characterized by difficulties with ER that are similar to those found in chronic pain more generally. There is great potential to expand the treatment of ER to improve pain-related outcomes in chronic pain and CP-POU. More research is needed, however, to elucidate ER in CP-POU and to determine which types of ER strategies are optimal for different clinical presentations and categories of problematic opioid use. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Neuropeptide and cytokine regulation of pain in the context of substance use disorders

Substance use disorders (SUDs) are frequently accompanied by affective symptoms that promote negative reinforcement mechanisms contributing to SUD maintenance or progression. Despite their widespread use as analgesics, chronic or excessive exposure to alcohol, opioids, and nicotine produces heightened nociceptive sensitivity, termed hyperalgesia. This review focuses on the contributions of neuropeptide (CRF, melanocortin, opioid peptide) and cytokine (IL-1β, TNF-α, chemokine) systems in the development and maintenance of substance-induced hyperalgesia. Few effective therapies exist for either chronic pain or SUD, and the common interaction of these disease states likely complicates their effective treatment. Here we highlight promising new discoveries as well as identify gaps in research that could lead to more effective and even simultaneous treatment of SUDs and co-morbid hyperalgesia symptoms.

Effects of craving on opioid use are attenuated after pain coping counseling in adults with chronic pain and prescription opioid addiction

OBJECTIVE

Risk for prescription opioid addiction is an endemic public health concern, especially for adults with chronic pain. This study examined craving as a mediator from pain to opioid use outcomes during prescription opioid addiction treatment and tested whether counseling in pain coping skills moderated the effects of craving on treatment outcomes.

METHOD

Secondary analysis on a sample (N = 148) randomized to standard or enhanced counseling for 12 weeks with adjunct opioid maintenance medication. Multilevel analyses examined mediated effects between weekly pain, craving, and opioid use, and tested the interaction between craving and a counseling module on pain coping skills.

RESULTS

Greater pain predicted greater craving (β = 0.25, p < .001), which predicted next-week opioid use (β = 0.17, p < .001). A statistically significant indirect effect of craving (β = 0.04, 95% CI [0.02, 0.06]) mediated 95% of the total effect from pain to opioid use. A significant interaction (b = -0.22, p < .01) revealed that after receiving the pain coping module, the association between craving and next-week opioid use was reduced, with greater exposure to the module associated with stronger effects (b = -0.12, p < .01).

CONCLUSION

More severe pain predicts greater opioid use due to the association between pain and cravings. Pain coping skills counseling suppressed the association between cravings and opioid use. For adults with chronic pain receiving treatment for prescription opioid addiction, interventions that address cravings through behavioral pain coping skills may be crucial for achieving optimal treatment outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Concurrent and lagged associations of prescription opioid use with pain and negative affect in the daily lives of chronic pain patients

OBJECTIVE

Prescribed opioids for chronic pain management contribute significantly to the opioid crisis. There is a need to understand the real-world benefits that, despite risks, lead chronic pain patients to persist in opioid use. Negative reinforcement models of addiction posit that individuals use substances to reduce aversive states but have seldom been applied to prescribed opioids. Using ecological momentary assessment, we examined reciprocal associations between opioid use and physical pain, for which opioids are prescribed, and negative affect (NA), for which they are not.

METHOD

Chronic low back pain patients on long-term opioid therapy (n = 34) without significant past-year opioid misuse reported multiple times daily via smartphone over 2 weeks (nobservations = 2,285). We hypothesized that pain and NA would be positively associated with subsequent opioid use, and that use would be negatively associated with subsequent pain and NA.

RESULTS

Time-lagged multilevel models indicated that participants were more likely to use opioids and in larger doses following elevated pain and NA. There was also an interaction of concurrent pain and NA on opioid dose. In turn, participants reported reduced pain and NA following larger doses. Additionally, individuals at high risk for opioid misuse, compared with low risk, took larger doses following pain, but also experienced smaller subsequent pain and NA reductions.

CONCLUSIONS

Opioid use was bidirectionally associated with pain and NA. Findings fit negative reinforcement models associated with risk of developing opioid use disorder. Educating patients and providers about negative reinforcement may help reduce opioid use and opioid-associated risks. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A systematic review of structural and functional MRI studies on pain catastrophizing

Objectives: Pain catastrophizing is reliably associated with pain reports during experimental pain in healthy, pain-free subjects and in people with chronic pain. It also correlates with self-reports of clinical pain intensity/severity in a variety of disorders characterized by chronic pain in adults, adolescents and children. However, processes, through which it exerts its effects are yet unclear. In this paper, our primary aim was to synthesize neuroimaging research to open a window to possible mechanisms underlying pain catastrophizing in both chronic pain patients and healthy controls. We also aimed to compare whether the neural correlates of pain catastrophizing are similar in these two groups.

Methods: PubMed and the Web of Science were searched for magnetic resonance imaging (MRI) studies that explored neural correlates of pain catastrophizing.

Results: Twenty articles met the inclusion criteria. The results of our review show a connection between pain catastrophizing and brain areas tightly connected to pain perception (including the somatosensory cortices, anterior insula, anterior cingulate cortex and thalamus) and/or modulation (eg, the dorsolateral prefrontal cortex). Our results also highlight that these processes - in relation to pain catastrophizing - are more pronounced in chronic pain patients, suggesting that structural and functional brain alterations (and perhaps mechanisms) related to pain catastrophizing may depend on prior and/or relatively stable/constant pain experience. However, we also found methodological issues and differences that could lead to divergent results.

Discussion: Based on our results, pain catastrophizing might be related to salience detection, pain processing, and top-down attentional processes. More research is recommended to explore neural changes to specific types of catastrophizing thoughts (eg, experimentally induced and/or state). Furthermore, we provide ideas regarding pain catastrophizing studies in the future for a more standardized approach.

Anxiety sensitivity and opioid misuse among opioid-using adults with chronic pain

Background: The opioid epidemic is a significant public health crisis, and this problem is particularly prevalent among individuals with chronic pain. Accordingly, there is an urgent need for interventions to mitigate the risk for opioid misuse and opioid use disorder among people with pain. Given that mental health problems, specifically anxiety, are common among people who misuse opioids, it is important to examine factors that link mental health problems with opioid misuse to ultimately inform the development of novel interventions. Anxiety sensitivity, a transdiagnostic vulnerability factor defined as the fear of anxiety-related physical sensations, may be one important mechanism in elevated opioid misuse among persons with chronic pain. Objective: Therefore, the current cross-sectional study examined anxiety sensitivity (and construct sub-facets) as a predictor of opioid misuse among adults with chronic pain. Method: Adults reporting chronic pain and prescription opioid use completed an online survey. Results: Anxiety sensitivity was associated with multiple aspects of opioid misuse, including current opioid misuse, severity of opioid dependence, and number of opioids used to get high. The magnitude of effects ranged from medium to large. Associations between anxiety sensitivity and opioid misuse were observed over and above the variance accounted for by age, sex, income, education, perceived health, and pain severity. Conclusion: These findings suggest that anxiety sensitivity may be an important treatment target among adults with chronic pain who misuse opioids. Future research should continue to explore the explanatory relevance of anxiety sensitivity in opioid misuse among individuals with chronic pain.

Craving in Opioid Use Disorder: From Neurobiology to Clinical Practice

Opioid use disorder (OUD) is a major public health issue that has reached epidemic levels in some parts of the world. It is a chronic and complex neurobiological disease associated with frequent relapse to drug taking. Craving, defined as an overwhelmingly strong desire or need to use a drug, is a central component of OUD and other substance use disorders. In this review, we describe the neurobiological and neuroendocrine pathways that underpin craving in OUD and also focus on the importance of assessing and treating craving in clinical practice. Craving is strongly associated with patients returning to opioid misuse and is therefore an important treatment target to reduce the risk of relapse and improve patients' quality of life. Opioid agonist therapies (OAT), such as buprenorphine and methadone, can significantly reduce craving and relapse risk, and it is essential that patients are treated optimally with these therapies. There is also evidence to support the benefits of non-pharmacological approaches, such as cognitive behavioral therapy and mindfulness-based interventions, as supplementary treatments to opioid agonist therapies. However, despite the positive impact of these treatments on craving, many OUD patients continue to suffer with negative affect and dysphoria. There is a clear need for further studies to progress our understanding of the neurobiological basis of craving and addiction and to identify novel therapeutic strategies as well as to optimize the use of existing treatments to improve outcomes for the growing numbers of patients affected by OUD.

Determining Pain Catastrophizing From Daily Pain App Assessment Data: Role of Computer-Based Classification

This study compared persons with chronic pain who consistently reported that their pain was worsening with those who reported that their pain was improving or remaining the same per daily assessment data from a smartphone pain app. All participants completed baseline measures and were asked to record their progress every day by answering whether their overall condition had improved, remained the same, or gotten worse (perceived change) on a visual analogue scale. One hundred forty-four individuals with chronic pain who successfully entered daily assessments were included. Those persons who were classified as worse showed significantly higher pain intensity scores, greater activity interference, higher disability and mood disturbance scores, and higher scores on the Pain Catastrophizing Scale both at baseline and after 3 months (P < .001). Repeated measures analyses and multilevel modeling of perceived change data over different time intervals of 20 assessments over 40 days, 10 assessments over 20 days, and 5 assessments over 10 days were examined. These analyses demonstrated that group classification of better, same, and worse could be reliably determined, even with as few as 5 assessments. These results support the use of innovative mobile health technology to identify individuals who are prone to catastrophize about their pain. Perspective: This study demonstrated that daily assessment of overall perceived change with a smartphone pain app was positively correlated with the Pain Catastrophizing Scale and capturing short-term daily assessment trends data using computer-based classification methods might be a future way to help to identify individuals who tend to catastrophize about their pain.

Development and Validation of an Eight-Item Brief Form of the SOAPP-R (SOAPP-8)

Objective

Although the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) has become a widely used screener for aberrant opioid-related behavior in adults, the length of the instrument may limit its utility. The purpose of the current study was to develop a short form of the SOAPP-R by retaining as few items as possible while maximizing predictive accuracy.

Methods

Participants (N = 555), recruited from pain clinics, completed the 24-item SOAPP-R and participated in a five-month follow-up visit to evaluate aberrant drug-related behaviors. Opioid aberrant-related behavior was determined through self-report, physician report, and urine toxicology screen. The optimal subset of SOAPP-R items to predict aberrant opioid-related behavior was identified empirically by employing the LASSO selection method and the leave-one-out cross-validation (LOOCV) method offered in the GLMSELECT procedure in SAS 9.4 in conjunction with content expertise.

Results

Eight items were identified before the selection method stopped. The receiver operating characteristic curve generated from the predicted probabilities from the model produced an area under the curve (AUC) value greater than the AUC value produced by the 24-item SOAPP-R total score and yielded a sensitivity of 0.74 and a specificity of 0.66.

Conclusions

These results provide strong preliminary support for the SOAPP-8 as a brief screening tool of aberrant opioid-related behavior in chronic pain patients.

Daily Opioid Use Fluctuates as a Function of Pain, Catastrophizing, and Affect in Patients With Sickle Cell Disease: An Electronic Daily Diary Analysis

Chronic opioid therapy is a common treatment regimen for patients with sickle cell disease (SCD), a chronically painful recessive hemoglobinopathy. The collective risk profile of chronic opioid therapy necessitates an understanding of which pain-related factors, such as affect and pain catastrophizing, are associated with the ebbs and flows of opioid use in daily life, a topic that has received very little attention among patients with any type of chronically painful condition, including SCD. We therefore investigated the variability of day-to-day patterns of short- and long-acting opioid use and their associations with pain and pain-related cognitive and affective processes in daily life among patients with SCD using a nightly electronic diary (N = 45). Opioid use was self-reported and converted into oral morphine equivalents for analysis, which was conducted with mixed effects modeling. Results indicated that greater pain and pain catastrophizing were associated with greater use of short-acting opioids, and negative affect was associated with greater use of long-acting opioids. Additionally, the association of pain and short-acting opioid use was moderated by pain catastrophizing, showing that opioid use was elevated when patients catastrophized about their pain, even if they reported low levels of pain. These findings suggest that monitoring pain-related cognitive and affective variables may be a useful approach to understanding risk for problematic opioid use in patients with daily pain.

PERSPECTIVE

The present study shows that pain and pain-related cognitive and affective variables are associated with daily variation in prescription opioid use in SCD. The findings may have broad implications for tracking and defining risk for prescription opioid misuse in patients with daily pain.

The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain

The recently proposed Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)-American Pain Society (APS) Pain Taxonomy (AAPT) provides an evidence-based, multidimensional, chronic pain classification system. Psychosocial factors play a crucial role within several dimensions of the taxonomy. In this article, we discuss the evaluation of psychosocial factors that influence the diagnosis and trajectory of chronic pain disorders. We review studies in individuals with a variety of persistent pain conditions, and describe evidence that psychosocial variables play key roles in conferring risk for the development of pain, in shaping long-term pain-related adjustment, and in modulating pain treatment outcomes. We consider "general" psychosocial variables such as negative affect, childhood trauma, and social support, as well as "pain-specific" psychosocial variables that include pain-related catastrophizing, self-efficacy for managing pain, and pain-related coping. Collectively, the complexity and profound variability in chronic pain highlights the need to better understand the multidimensional array of interacting forces that determine the trajectory of chronic pain conditions.

PERSPECTIVE

The AAPT is an evidence-based chronic pain classification system in which psychosocial concepts and processes are essential in understanding the development of chronic pain and its effects. In this article we review psychosocial processes that influence the onset, exacerbation, and maintenance of chronic pain disorders.

Development and Validation of a Daily Pain Catastrophizing Scale

To date, there is no validated measure for pain catastrophizing at the daily level. The Pain Catastrophizing Scale (PCS) is widely used to measure trait pain catastrophizing. We sought to develop and validate a brief, daily version of the PCS for use in daily diary studies to facilitate research on mechanisms of catastrophizing treatment, individual differences in self-regulation, and to reveal the nuanced relationships between catastrophizing, correlates, and pain outcomes. After adapting the PCS for daily use, we evaluated the resulting 14 items using 3 rounds of cognitive interviews with 30 adults with chronic pain. We refined and tested the final daily PCS in 3 independent, prospective, cross-sectional, observational validation studies conducted in a combined total of 519 adults with chronic pain who completed online measures daily for 14 consecutive days. For study 1 (N = 131), exploratory factor analysis revealed adequate fit and-unexpectedly-unidimensionality for item responses to the daily PCS. Study 2 (N = 177) correlations indicated adequate association with related constructs (anger, anxiety, pain intensity, depression). Similarly, results for study 3 (N = 211) revealed expected correlations for daily PCS and measures of daily constructs including physical activity, sleep, energy level, and positive affect. Results from complex/multilevel confirmatory factor analysis confirmed good fit to a unidimensional model. Scores on the daily PCS were statistically comparable with and more parsimonious than the full 14-item version. Next steps include evaluation of score validity in populations with medical diagnoses, greater demographic diversity, and in patients with acute pain.

PERSPECTIVE

This article describes the development and validation of a daily PCS. This daily measure may facilitate research that aims to characterize pain mechanisms, individual differences in self-regulation, adaptation, and nuanced relationships between catastrophizing, correlates, and pain outcomes.

Pain Catastrophizing Moderates Relationships between Pain Intensity and Opioid Prescription: Nonlinear Sex Differences Revealed Using a Learning Health System

BACKGROUND

Pain catastrophizing is a maladaptive response to pain that amplifies chronic pain intensity and distress. Few studies have examined how pain catastrophizing relates to opioid prescription in outpatients with chronic pain.

METHODS

The authors conducted a retrospective observational study of the relationships between opioid prescription, pain intensity, and pain catastrophizing in 1,794 adults (1,129 women; 63%) presenting for new evaluation at a large tertiary care pain treatment center. Data were sourced primarily from an open-source, learning health system and pain registry and secondarily from manual review of electronic medical records. A binary opioid prescription variable (yes/no) constituted the dependent variable; independent variables were age, sex, pain intensity, pain catastrophizing, depression, and anxiety.

RESULTS

Most patients were prescribed at least one opioid medication (57%; n = 1,020). A significant interaction and main effects of pain intensity and pain catastrophizing on opioid prescription were noted (P < 0.04). Additive modeling revealed sex differences in the relationship between pain catastrophizing, pain intensity, and opioid prescription, such that opioid prescription became more common at lower levels of pain catastrophizing for women than for men.

CONCLUSIONS

Results supported the conclusion that pain catastrophizing and sex moderate the relationship between pain intensity and opioid prescription. Although men and women patients had similar Pain Catastrophizing Scale scores, historically "subthreshold" levels of pain catastrophizing were significantly associated with opioid prescription only for women patients. These findings suggest that pain intensity and catastrophizing contribute to different patterns of opioid prescription for men and women patients, highlighting a potential need for examination and intervention in future studies.

Factors associated with prescription opioid misuse in a cross-sectional cohort of patients with chronic non-cancer pain

OBJECTIVE

To examine demographic features, psychosocial characteristics, pain-specific behavioral factors, substance abuse history, sleep, and indicators of overall physical function as predictors of opioid misuse in patients presenting for new patient evaluation at a tertiary pain clinic.

METHODS

Overall, 625 patients with chronic non-cancer pain prospectively completed the Collaborative Health Outcomes Information Registry, assessing pain catastrophizing, National Institutes of Health Patient-Reported Outcomes Measurement Information System standardized measures (pain intensity, pain behavior, pain interference, physical function, sleep disturbance, sleep-related impairment, anger, depression, anxiety, and fatigue), and substance use history. Additional information regarding current opioid prescriptions and opioid misuse was examined through retrospective chart review.

RESULTS

In all, 41 (6.6%) patients presented with some indication of prescription opioid misuse. In the final multivariable logistic regression model, those with a history of illicit drug use (odds ratio [OR] 5.45, 95% confidence interval [CI] 2.48-11.98, p<0.0001) and a current opioid prescription (OR 4.06, 95% CI 1.62-10.18, p=0.003) were at elevated risk for opioid misuse. Conversely, every 1-h increase in average hours of nightly sleep decreased the risk of opioid misuse by 20% (OR 0.80, 95% CI 0.66-0.97, p=0.02).

CONCLUSION

These findings indicate the importance of considering substance use history, current opioid prescriptions, and sleep in universal screening of patients with chronic non-cancer pain for opioid misuse. Future work should target longitudinal studies to verify the causal relationships between these variables and subsequent opioid misuse.

Prescription Opioid Craving: Relationship With Pain and Substance Use-Related Characteristics

BACKGROUND

Craving is associated with prescription opioid use in opioid-addicted pain patients.

OBJECTIVES

This study evaluated the relationship between craving for prescription opioids and selected pain and substance use characteristics.

METHOD

In this cross-sectional study, patients (N = 106) being treated for opioid dependence were recruited from one of three sites from December 2012 to April 2013. Participants completed the multi-dimensional Desire for Drugs Questionnaire to assess craving, and other questionnaires to assess pain, substance use, and demographic characteristics. Data were analyzed using Pearson product-by-moment correlations, ANOVAs, and multiple linear regressions.

RESULTS

At the bivariate level, desire-and-intention to use prescription opioids and craving for relief from negative states were positively associated with both pain severity and interference. Linear regression analyses revealed significant positive associations between Desire-and-Intention subscale scores and obsessive thoughts and compulsive behaviors associated with prescription opioids and pain severity. Negative Reinforcement subscales scores were positively associated with obsessive thoughts and compulsive behaviors associated with prescription opioids and the outcome expectancies of pain reduction, but not pain severity.

CONCLUSIONS/IMPORTANCE

This study extended previous research assessing the link between pain and craving by demonstrating that desire-and-intention, but not craving for the negative reinforcing effects are associated with pain severity after considering various substance use characteristics. Additional research is needed to clarify the relationship between pain and aspects of craving while also considering pain-specific covariates. This study highlights that the multi-dimensionality of craving is an important aspect to consider when clinicians and researchers evaluate the relationship between pain and craving.

Neurobiology of opioid dependence in creating addiction vulnerability

Opioid drugs are potent modulators of many physiological and psychological processes. When given acutely, they can elicit the signature responses of euphoria and analgesia that societies have coveted for centuries. Repeated, or chronic, use of opioids induces adaptive or allostatic changes that modify neuronal circuitry and create an altered normality — the “drug-dependent” state. This state, at least that exhibited by those maintained continuously on long-acting opioid drugs such as methadone or buprenorphine, is generally indistinguishable from the drug-naïve state for most overt behaviors. The consequences of the allostatic changes (cellular, circuit, and system adaptations) that accompany the drug-dependent state are revealed during drug withdrawal. Drug cessation triggers a temporally orchestrated allostatic re-establishment of neuronal systems, which is manifested as opposing physiological and psychological effects to those exhibited by acute drug intoxication. Some withdrawal symptoms, such as physical symptoms (sweating, shaking, and diarrhea) resolve within days, whilst others, such as dysphoria, insomnia, and anxiety, can linger for months, and some adaptations, such as learned associations, may be established for life. We will briefly discuss the cellular mechanisms and neural circuitry that contribute to the opioid drug-dependent state, inferring an emerging role for neuroinflammation. We will argue that opioid addictive behaviors result from a learned relationship between opioids and relief from an existing or withdrawal-induced anxiogenic and/or dysphoric state. Furthermore, a future stressful life event can recall the memory that opioid drugs alleviate negative affect (despair, sadness, and anxiety) and thereby precipitate craving, resulting in relapse. A learned association of relief of aversive states would fuel drug craving in vulnerable people living in an increasingly stressful society. We suggest that this route to addiction is contributive to the current opioid epidemic in the USA.

Day-to-day pain symptoms are only weakly associated with opioid craving among patients with chronic pain prescribed opioid therapy

BACKGROUND

Over the past decade, there has been a substantial rise in the use of opioids for the treatment of chronic noncancer pain. Despite the potential benefits of opioid therapy, the rise in the use of opioids has been accompanied by escalating rates of prescription opioid misuse and addiction. There is now a growing body of evidence indicating that opioid craving (i.e., the subjective desire to consume opioids) is one of the strongest determinants of opioid misuse among patients with chronic pain prescribed opioids. Although research has elucidated some of the factors associated with opioid craving, the contribution of patients' levels of pain to opioid craving remains unclear.

OBJECTIVE

The main objective of this study was to examine the day-to-day association between pain and opioid craving.

METHODS

In this longitudinal cohort study, patients with chronic pain prescribed opioid therapy completed baseline measures and were then asked to provide daily reports of pain intensity and opioid craving for a period of 14 days.

RESULTS

Multilevel analyses indicated that day-to-day elevations in patients' levels of pain were associated with heightened opioid craving. That is, on more painful days, patients reported higher levels of craving. Within-person changes in pain intensity, however, explained less than 5% of the variance in patients' reports of craving.

CONCLUSION

Findings from this study suggest that patients with chronic pain do not crave their opioid medications simply because they experience high levels of pain. The theoretical and clinical implications of our findings are discussed.

Risk for Opioid Misuse Among Emergency Department Cancer Patients

OBJECTIVES

One of the most challenging areas of emergency medicine practice is the management and treatment of severe and persistent pain, including cancer-related pain. Emergency departments (EDs) in the United States frequently provide care for patients with cancer and an increasing concern is the potential for opioid misuse in this patient group. The authors determined the risk for opioid misuse among ED cancer patients with pain and assessed demographic and clinical factors associated with increased misuse risk. The Texas state prescription monitoring program was also queried for evidence of multiple opioid prescriptions for comparing low- and high-risk groups.

METHODS

The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) was administered to assess risk for opioid misuse among cancer patients presenting to the ED of a comprehensive cancer center in the United States. Eligibility criteria included: 1) presentation for treatment of chronic cancer-related pain while taking a prescribed schedule II opioid for analgesia, 2) age of 18 years or older, 3) ability to speak English, and 4) ability to understand the study and give written informed consent.

RESULTS

Of 934 ED patients screened for the study, 290 were eligible and 209 participated (72% response rate). On the basis of the recommended SOAPP-R cutoff score of 18, a total of 71 of the 209 patients (34%) were categorized as having a high risk of misuse. Of note, 15% and 4% of all patients reported past or current use of illicit substances, respectively. The total number of annual opioid prescriptions (17.8 vs. 12.6; p = 0.023) differed between the high- versus low-risk groups. Multivariable analyses showed that depression (odds ratio [OR] = 3.06, 95% confidence interval [CI] = 1.45 to 6.48; p = 0.003), poor coping (OR = 1.08, 95% CI = 1.03 to 1.13; p = 0.001), and illicit substance use (OR = 28.30, 95% CI = 2.97 to 269.24; p = 0.029) were significantly associated with high risk of opioid misuse.

CONCLUSIONS

The risk of opioid misuse among cancer patients is substantial. Screening for opioid misuse in the ED is feasible.

Thought suppression as a mediator of the association between depressed mood and prescription opioid craving among chronic pain patients

Emerging research suggests that prescription opioid craving is associated with negative mood and depression, but less is known about cognitive factors linking depressive symptoms to opioid craving among adults with chronic pain. The present cross-sectional study examined thought suppression as a mediator of the relation between depression and prescription opioid craving in a sample of chronic pain patients receiving long-term opioid pharmacotherapy. Data were obtained from 115 chronic pain patients recruited from primary care, pain, and neurology clinics who had taken prescription opioids daily or nearly every day for ≥90 days prior to assessment. In this sample, 60 % of participants met DSM-IV criteria for current major depressive disorder. Depressed mood (r = .36, p < .001) and thought suppression (r = .33, p < .001) were significantly correlated with opioid craving. Multivariate path analyses with bootstrapping indicated the presence of a significant indirect effect of thought suppression on the association between depressed mood and opioid craving (indirect effect = .09, 95 % CI .01, .20). Sensitivity analyses showed a similar indirect effect of suppression linking major depressive disorder diagnosis and opioid craving. Attempts to suppress distressing and intrusive thoughts may result in increased craving to use opioids among chronic pain patients with depressive symptoms. Results highlight the need for interventions that mitigate thought suppression among adults with pain and mood disorders.

The Psychological Evaluation of Patients with Chronic Pain: a Review of BHI 2 Clinical and Forensic Interpretive Considerations

Pain is the most common reason why patients see a physician. Within the USA, it has been estimated that at least 116 million US adults suffer from chronic pain, with an estimated annual national economic cost of $560-635 billion. While pain is in part a sensory process, like sight, touch, or smell, pain is also in part an emotional experience, like depression, anxiety, or anger. Thus, chronic pain is arguably the quintessential biopsychosocial condition. Due to the overwhelming evidence of the biopsychosocial nature of pain and the value of psychological assessments, the majority of chronic pain guidelines recommend a psychological evaluation as an integral part of the diagnostic workup. One biopsychosocial inventory designed for the assessment of patients with chronic pain is the Battery for Health Improvement 2 (BHI 2). The BHI 2 is a standardized psychometric measure, with three validity measures, 16 clinical scales, and a multidimensional assessment of pain. This article will review how the BHI 2 was developed, BHI 2 concepts, validation research, and an overview of the description and interpretation of its scales. Like all measures, the BHI 2 has strengths and weaknesses of which the forensic psychologist should be aware, and particular purposes for which it is best suited. Guided by that knowledge, the BHI 2 can play a useful role in the forensic psychologist's toolbox.