Elsevier

Current Opinion in Psychology

Volume 5, October 2015, Pages 42-49
Current Opinion in Psychology

Chronic pain, negative affect, and prescription opioid abuse

https://doi.org/10.1016/j.copsyc.2015.03.020Get rights and content

Highlights

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    Chronic pain is a growing public health concern.

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    There has been a dramatic increase in prescriptions of analgesic opioids in the United States.

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    Psychiatric co-morbidity is frequently associated with opioid misuse, abuse, and/or diversion.

  • •

    Many screening questionnaires currently exist to assess a patient's risk for opioid misuse.

  • •

    Behavioral interventions can be effective in improving opioid compliance.

Chronic pain is an international health issue that is influenced by both physical and psychological factors. This article outlines the benefits and complications of opioid medications in chronic pain treatment and explores the roles of negative affect and craving in exacerbating chronic noncancer pain. The role of psychiatric comorbidity and use of validated assessment tools helpful in identifying those individuals who are at greatest risk for opioid misuse are discussed. Additionally, interventional treatment strategies for chronic pain patients who are at risk for opioid misuse are presented. Specific behavioral interventions are also reviewed such as frequent monitoring, motivational counseling, periodic urine screens and opioid checklists designed to improve compliance with prescription opioids among persons treated for chronic pain.

Section snippets

Introduction: background and overview of pain issues

Chronic pain is considered a public health priority due to its high prevalence globally. It is estimated that over 10% of the world's population are afflicted with chronic pain [1], and in the United States alone, 100 million people experience chronic pain annually, which is more than cancer, diabetes, and coronary heart disease combined [2••]. Chronic pain accounts for 21% of emergency department visits, 25% of annual missed workdays, and $560 to $635 billion in annual direct and indirect

Overview of opioids for pain

Brief definitions of key terms used in this article can be useful in clarifying issues around use of opioids prescribed for chronic pain. Definitions for substance misuse, substance abuse, addiction, physical dependence, tolerance, and aberrant drug-related behavior are presented in Table 2.

Addiction encompasses compulsive use of the drug that leads to physical, psychological, and social harm to the user. It is generally understood to be a chronic condition from which recovery is possible.

Negative affect and pain

Negative affect is characterized by negative emotionality, high distress, dissatisfaction, nervousness, and anger [28]. Persons high on negative affect present with depression, anxiety, recurrent worried thoughts and irritability. Affective disorders encompassing depression or anxiety are frequent co-morbidities among chronic pain patients [3], [29], [30], [31], [32]. Some have suggested that chronic pain can cause depression [33], [34], that depression can increase chronic pain [35], and that

Risks factors for prescriptions opioid abuse

Patients who are typically at a lower risk for misusing opioids include those who are older, are generally compliant, have a record of rarely misusing any medication, show stable mood, and display rationality and thoughtfulness. Conversely, risk factors for opioid misuse include (1) family or personal history of substance abuse, (2) younger age, (3) history of criminal activity and/or legal problems, (4) frequent contact with high-risk individuals or environments, (5) history of previous

Risk assessment strategies

Many physicians struggle with providing appropriate pain relief for patients while minimizing the misuse of prescription opioids. In response, concerted efforts have been made to identify those individuals at risk for abuse of prescription opioids [81], [82]. Structured interview measures have been published for assessment of alcoholism and drug use disorder based on DSM-IV criteria [83], [84], but these measures have not been validated in individuals with chronic pain. Such assessments may not

Interventions for high risk patients

Potential solutions to the continuing rise in opioid abuse, misuse, and diversion have become an ongoing focus in regulatory, legal, and governmental action. Prescription Drug Monitoring Programs (PDMPs), one of the first diversion control tools established, monitor and analyze electronic prescription data transferred from pharmacies and practitioners. PDMPs are one facet of a universal precautions approach that has been implemented clinically over recent years. Universal precautions assumes a

Future considerations

As we become an aging population, greater attention will be given to managing medical comorbidities, which include chronic pain. The practice of managing persons with chronic pain will likely change within the next ten to twenty years. First, research into genetics testing holds much promise for the identification of markers for potential mood disorder and pain. There will likely be breakthroughs and a greater understanding of the role of inherited predispositions for chronic pain based on

Summary and conclusions

Chronic pain including chronic noncancer pain is a multifaceted global health problem that requires multiple modes of intervention. Despite the apparent physical pathology of pain, it has been implicated that psychiatric comorbidities such as depression and anxiety disorders significantly affect pain intensity, level of functioning, and pain outcome. Corresponding to the dramatic increase in opioid prescriptions, psychiatric comorbidity is now associated with opioid misuse, abuse, and/or

Conflict of interest statement

There are no conflicts of interest to the best of the author's knowledge.

References and recommended reading

Papers of particular interest, published within the period of review, have been highlighted as:

  • • of special interest

  • •• of outstanding interest

References (110)

  • J. Celestin et al.

    Pretreatment psychosocial variables as predictors of outcomes frollowing lumbar surgery and spinal cord stimulation: a systematic review and literature synthesis

    Pain Med

    (2009)
  • S. Sonne et al.

    Substance abuse and bipolar comorbidty

    Psychiatry Clin North Am

    (1999)
  • H. Myrick et al.

    Gabapentin treatment of alcohol withdrawal

    Am J Psychiatry

    (1998)
  • A. Grattan et al.

    Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse

    Annals Family Med

    (2012)
  • L.R. Webster et al.

    Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the opioid risk tool

    Pain Med

    (2005)
  • A.D. Wasan et al.

    Craving of prescription opioids in patients with chronic pain: a longitudinal outcomes trial

    J Pain

    (2012)
  • M. Skinner et al.

    Craving's place in addiction theory: contributions of the major models

    Neurosci Biobehav Rev

    (2010)
  • S. Hyman et al.

    Stress and drug-cue-induced craving in opioid-dependent individuals in naltrexone treatment

    Exp Clin Psychopharmacol

    (2007)
  • R. Sinha et al.

    Stress-induced cocaine craving and hypothalamic-pituitary-adrenal responses are predictive of cocaine relapse outcomes

    Arch Gen Psychiatry

    (2006)
  • S. Tiffany et al.

    The clinical significance of drug craving

    Annals N Y Acad Sci

    (2012)
  • L. Chen et al.

    Altered quantitative sensory testing outcome in subjects with opioid therapy

    Pain

    (2009)
  • W.M. Hooten et al.

    Associations between heat pain perception and opioid dose among patients with chronic pain undergoing opioid tapering

    Pain Medicine

    (2010)
  • J.E. Helzer et al.

    The Diagnostic Interview Schedule: its development, evaluations, and use

    Soc Psychiatry Psychiatric Epidem

    (1988)
  • R. Robinson et al.

    Screening for problematic prescription opioid use

    Clin J Pain

    (2001)
  • D. Gourlay et al.

    Universal precautions in pain medicine: a rational approach to the treatment of chronic pain

    Pain Med

    (2005)
  • E. Michna et al.

    Urine toxicology screening among chronic pain patients on opioid therapy: frequency and predictability of abnormal findings

    Clin J Pain

    (2007)
  • D.S. Goldberg et al.

    Pain as a global public health priority

    BMC Public Health

    (2011)
  • Institute of Medicine

    Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research

    (2011)
  • M.R. Bair et al.

    Depression and pain comorbidity: a literature review

    Arch Int Med

    (2003)
  • J.R. Caldwell et al.

    Treatment of osteoarthritis pain with controlled release oxycodone or fixed combination oxycodone plus acetominophen added to nonsteroidal antiinflammatory drugs: a double blind, randomized, multicenter, placebo controlled trial

    J Rheum

    (1999)
  • C. Maier et al.

    Morphine responsiveness, efficacy and tolerability in patients with chronic non-tumor pain — results of a double-blind placebo-controlled trial (MONTAS)

    Pain

    (2002)
  • J.N. Katz et al.

    Predictors of surgical outcome in degenerative lumbar spinal stenosis

    Spine

    (1999)
  • American Academy of Pain Medicine et al.

    The use of opioids for the treatment of chronic pain: a consensus statement from the American Academy of Pain Medicine and American Pain Society

    Clin J Pain

    (1997)
  • L.M. Lourenço et al.

    Abuse-deterrent and tamper-resistant opioids: how valuable are novel formulations in thwarting non-medical use?

    Expert Opin Drug Deliv

    (2013)
  • B. Bhamb et al.

    Survey of select practice behaviors by primary care physicians on the use of opioids for chronic pain

    Curr Med Res Opin

    (2006)
  • American Academy of Pain Medicine et al.

    Definitions related to the use of opioids for the treatment of pain: a consensus document from the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine

    ASAM

    (2001)
  • American Psychiatric Association

    American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders

    (1994)
  • A. Leshner

    What does it mean that addiction is a brain disease?

    Monitor Psychol

    (2001)
  • W. Arkinstall et al.

    Efficacy of controlled-release codeine in chronic non-malignant pain: a randomized, placeo-controlled clinical trial

    Pain

    (1995)
  • P.M. Peloso et al.

    Double blind randomized placebo control trial of controlled release codeine in the treatment of osteoarthritis of the hip or knee

    J Rheumatol Suppl

    (2000)
  • J.S. Gimbel et al.

    Controlled-release oxycodone for pain in diabetic neuropathy: a randomized controlled trial

    Neurology

    (2003)
  • C.P.N. Watson et al.

    Controlled-release oxycodone relieves neuropathic pain: a randomized controlled trial in painful diabetic neuropathy

    Pain

    (2003)
  • P.M. Peloso et al.

    Analgesic efficacy and safety of tramadol/acetaminophen combination tablets (Ultracet) in treatment of chronic low back pain: a multicenter, outpatient, randomized, double blind, placebo controlled trial

    J Rheumatol

    (2004)
  • A. Furlan et al.

    Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects

    Can Med Assoc J

    (2006)
  • E. Kalso et al.

    Opioids in chronic non-cancer pain: systematic review of efficacy and safety

    Pain

    (2004)
  • A.M. Trescot et al.

    Opioid guidelines in the management of chronic non-cancer pain

    Pain Phys

    (2006)
  • A.M. Gilson et al.

    The burden of the nonmedical use of prescription opioid analgesics

    Pain Med

    (2009)
  • Coalition Against Insurance Fraud:Prescription for peril

    How Insurance Fraud Finances Theft and Abuse of Addictive Prescription Drugs

    (2007)
  • D. Watson et al.

    Negative affectivity: the disposition to experience aversive emotional states

    Psychol Bull

    (1984)
  • L. McWilliams et al.

    Depression and anxiety associated with three pain conditions: results from a nationally representative sample

    Pain

    (2004)
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