Day-to-day Hedonic and Calming Effects of Opioids, Opioid Craving, and Opioid Misuse Among Patients With Chronic Pain Prescribed Long-term Opioid Therapy

Leah Frimerman; Maria Verner; Amanda Sirois; Katherine Scott; Alice Bruneau; Jordi Perez; Yoram Shir; Marc O. Martel

Disclosures

Pain. 2021;162(8):2214-2224. 

In This Article

Discussion

The first objective of this study was to examine whether the potentially hedonic (ie, pleasurable) and calming effects of opioids were associated with 3 distinct types of opioid misuse behaviors among patients with chronic pain prescribed long-term opioid therapy: using more opioids than prescribed, using opioids for non-pain symptoms, and borrowing opioids. Results indicated that the hedonic and calming effects of opioids were not significantly associated with any of these opioid misuse behaviors. In our study, rates of opioid misuse behaviors were consistent with those observed in other studies (for a review, see 80) and patients' reports of pleasure and calmness feelings from opioid use were in the moderate range (ie, average daily levels: 37–43/100), suggesting that these non-significant associations are unlikely to be due to patient underreporting. Although preliminary, findings from this study suggest that psychological factors such as catastrophizing and affect (ie, high NA and low PA) as well as opioid craving are stronger determinants of prescription opioid misuse among patients with chronic pain than the hedonic and/or calming effects that may accompany the use of opioids.

Contribution of Hedonic and Calming Effects of Opioids to Opioid Craving

Analyses were conducted to examine the degree to which the hedonic and calming effects of opioids contributed to patients' daily levels of opioid craving. We found that higher reports of pleasure and calmness feelings were associated with higher levels of opioid craving. Albeit significant, it is important to point out that the magnitude of the associations between opioid effects (ie, hedonic and calming effects) and opioid craving observed in our study was weak to modest, with less than 5% and 20% of shared variance between these measures at the within-person and between-person levels, respectively. These significant but modest associations suggest that the pleasurable and/or calming effects of opioids cannot fully explain why patients with chronic pain crave opioids. This is further supported by findings from this study indicating that patients' daily levels of pain intensity, catastrophic thinking, NA, and PA made stronger contributions to opioid craving than the pleasurable or calming effects of opioids. Taken together, this set of findings suggests that opioid craving might be more strongly driven by patients' pain-related suffering and/or psychological states than the potentially hedonic or calming effects of opioids.

Moderators of the Association Between Opioid Effects and Opioid Craving

In this study, we examined whether the hedonic and calming effects of opioids were more strongly linked to opioid craving under certain conditions, such as when patients experienced day-to-day elevations in pain intensity. Results from multilevel moderation analyses first indicated that the pleasurable and calming effects of opioids were more strongly associated with opioid craving on days when patients experienced elevations in pain intensity. Although our results indicated that the pleasurable effects of opioids are not the primary determinants of opioid craving, it is possible that patients were more sensitive to the hedonic effects of opioids on days when pain was high, leading to higher levels of craving. Given that pain and pleasure are viewed to lie on opposite ends of the hedonic spectrum,[7,25,49,50] it is also possible that patients experiencing elevations in pain intensity craved the pleasurable effects of opioids due to a need to maintain hedonic homeostasis.[23,29,35] In terms of patients reporting being "calmed down by opioids", it is possible that calmness feelings induced by opioids contributed to alleviating the unpleasantness and/or aversiveness associated with pain,[46,61] and this could explain why feelings of calmness were more strongly associated with patients' desires and/or urges to use opioids (ie, opioid cravings) on days when pain was high.

Daily Affect and Catastrophizing

Results indicated that the hedonic and calming effects of opioids were more strongly linked to opioid craving on days when patients experienced elevations in NA. The co-occurrence of NA and chronic pain has long been recognized.[4,45,79] Given that feelings of pleasure and calmness can alleviate NA states such as anxiety or depressive symptoms,[3,32] this could explain why feelings of pleasure and calmness were more strongly associated with opioid craving on days when NA was high. Given the differential influence of positive and negative affective states on pain and substance use outcomes,[33,48,89] we also examined if these associations varied as a function of patients' daily levels of PA. The moderation effect of PA was not significant, but inspection of data revealed that patients' reports of pleasure and calmness were more strongly associated with opioid craving on days when patients experienced decreases in PA.

Finally, we found that the hedonic and calming effects of opioids were more strongly linked to opioid craving on days when patients reported elevations in catastrophizing. This finding remained significant even after accounting for patients' daily levels of pain intensity and NA, 2 variables that have consistently been associated with catastrophizing.[22,64,76] This finding suggests that specific aspects of catastrophizing that are unrelated to patients' pain intensity and affective/emotional states might have led patients to crave the pleasurable and/or calming effects of opioids.

Clinical Implications

Findings from this study could have implications for the management of patients who are prescribed opioids. First, our findings suggest that the pleasurable or calming effects of opioids are unlikely to directly contribute to prescription opioid misuse. However, our findings showed that these opioid effects are associated with heightened opioid craving, a clinically relevant variable that has been associated with prescription opioid misuse in chronic pain patients,[12,53] as in this study. Although treatment efforts aimed at preventing the pleasurable and/or calming effects may be futile, cognitive behavioral treatment interventions designed to increase patients' awareness that these effects may contribute to opioid craving and, in turn, to opioid misuse might be useful.[57] Patients should also become cognizant that pleasurable and/or calming effects of opioids may lead to desires and urges to use opioids particularly when they experience elevations in pain intensity, catastrophizing, or NA. Although pain relief represents the primary reason reported by patients for their desire to use opioids,[2,43,52] the present findings suggest that the regulation of affective states through the pleasurable or calming effects of opioids might also partially underlie patients' desires to use opioids. In addition to cognitive-behavioral treatment, patients who crave the pleasurable or calming effects of opioids could also possibly benefit from mindfulness-based interventions that are designed to enhance PA as well as endogenous hedonic tone, such as through the Mindfulness-Oriented Recovery Enhancement program (MORE).[27,30,31,34] Studies have shown that enhanced endogenous hedonic tone and PA through Mindfulness-Oriented Recovery Enhancement interventions can lead to reductions in opioid craving and opioid misuse among patients with chronic pain.[27,28]

Study Limitations

A number of limitations must be considered when interpreting findings from this study. First, despite the use of a longitudinal diary study design that allowed us to examine day-to-day interrelations between pain, psychological, and opioid-related variables, these variables were assessed only once daily. Second, patients were prompted to provide diary reports at a fixed time every day. Although this is a commonly used diary method,[8,66,73] this might have introduced a certain degree of predictability and may have influenced the nature of patients' reports. Third, the items used in this study to assess the hedonic and calming effects of opioids are similar to those that have been used in other daily diary studies to assess subjective effects associated with the use of substances,[13,67,68] but future work in this area should consider using additional items to capture a broader range of opioid subjective effects that may be experienced among long-term opioid users. Finally, future studies should also explore the protective factors that might contribute to preventing the occurrence of opioid craving and opioid misuse behaviors. For instance, factors such as daily coping efforts[1,44] and social support[20,39] are known to play an important role in the context of chronic pain, but the contribution of these variables to opioid craving and opioid misuse has received little attention and should be considered in future studies.

Summary

Despite the above limitations, findings reported in this study provide valuable new insights into our understanding of the factors that may contribute to opioid craving and opioid misuse among patients with chronic pain. Our findings suggest that the hedonic or calming effects of opioids are unlikely to directly contribute to prescription opioid misuse. Our findings suggest that the hedonic and calming effects of opioids may contribute to opioid craving, but only under certain conditions, such as when patients experience day-to-day elevations in pain intensity, catastrophizing, or NA. To our knowledge, this was the first study to systematically investigate the contribution of hedonic and calming effects of opioids to opioid craving on a day-to-day basis among patients with chronic pain who are prescribed long-term opioid therapy. Further research in this area might ultimately contribute to preventing opioid use problems among patients with chronic pain who are prescribed long-term opioid therapy.

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