The downward spiral of chronic pain, prescription opioid misuse, and addiction: Cognitive, affective, and neuropsychopharmacologic pathways
Open accessAbstract
Prescription opioid misuse and addiction among chronic pain patients are emerging public health concerns of considerable significance. Estimates suggest that more than 10% of chronic pain patients misuse opioid analgesics, and the number of fatalities related to nonmedical or inappropriate use of prescription opioids is climbing. Because the prevalence and adverse consequences of this threat are increasing, there is a pressing need for research that identifies the biobehavioral risk chain linking chronic pain, opioid analgesia, and addictive behaviors. To that end, the current manuscript draws upon current neuropsychopharmacologic research to provide a conceptual framework of the downward spiral leading to prescription opioid misuse and addiction among chronic pain patients receiving opioid analgesic pharmacotherapy. Addictive use of opioids is described as the outcome of a cycle initiated by chronic pain and negative affect and reinforced by opioidergic-dopamingeric interactions, leading to attentional hypervigilance for pain and drug cues, dysfunctional connectivity between self-referential and cognitive control networks in the brain, and allostatic dysregulation of stress and reward circuitry. Implications for clinical practice are discussed; multimodal, mindfulness-oriented treatment is introduced as a potentially effective approach to disrupting the downward spiral and facilitating recovery from chronic pain and opioid addiction.
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Meditation's health benefits are more pronounced for pain and pain-related conditions (such as opioid misuse, stress, depression, and anxiety) than for other health outcomes.
“In contrast to other health outcomes, the health-promoting effects of meditation are most pronounced for pain and pain-related comorbidities, including opioid addiction and misuse,155–158 stress,37, 138 depression,159–161 and anxiety.31, 162, 163”
From Mindfulness meditation-based pain relief: a mechanistic account (2016) · cites this paper as [155]
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Self-citationLow dispositional mindfulness predicts self-medication of negative emotion with prescription opioids
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Self-citationOpioid Analgesics and Nicotine: More Than Blowing Smoke
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Cognitive and socio-cognitive functioning of chronic non-medical prescription opioid users
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Self-citationThe dynamic interaction between pain and opioid misuse
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Pain volatility and prescription opioid addiction treatment outcomes in patients with chronic pain.
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Laboratory-induced stress and craving among individuals with prescription opioid dependence
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Substance-related disorders: A review of prevalence and correlates among patients with chronic pain
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- Authors
- Garland, E. L., Froeliger, B., Zeidan, F., Partin, K., & Howard, M. O.
- Affiliations
- University of Utah (US)
- Medical University of South Carolina (US)
- Wake Forest University (US)
- University of North Carolina at Chapel Hill (US)
- Corresponding author
- Garland, Eric L.
- Venue
- Neuroscience & Biobehavioral Reviews
- Publisher
- Elsevier BV
- Published
- 2013-12
- Volume
- 37
- Issue
- 10
- Pages
- 2597-2607
- ISSN
- 0149-7634 (ISSN-L)
- PMC
- PMC3967721
- OpenAlex
- W2110728022
- Cited by
- 277
- References
- 189
- Citations by year
- 2026: 14 · 2025: 19 · 2024: 16 · 2023: 21 · 2022: 25 · 2021: 27 · 2020: 47 · 2019: 28 · 2018: 12 · 2017: 22 · 2016: 17 · 2015: 14 · 2014: 15
- FWCI
- 2.19
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Neuroscience & Biobehavioral Reviews (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Carolina Digital Repository (University of North Carolina at Chapel Hill) (submittedVersion)
- UNC Libraries
- Funders
- Fahs-Beck Fund for Research and Experimentation
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Opioid Use
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Keywords
- chronic pain, prescription opioid misuse, opioid use disorder, downward spiral, opioid analgesia, negative affect, opioid-dopamine interaction, drug cue reactivity, cognitive control network, mindfulness-based interventions, multimodal therapy
- MeSH terms
- Analgesics, Opioid, Cognition Disorders, Humans, Opioid-Related Disorders, Mood Disorders, Chronic Pain, Prescription Drug Misuse
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