CANUE: A Theoretical Model of Pain as an Antecedent for Substance Use

Abstract

Background Pain and substance use are frequently comorbid and have been shown to exert bidirectional effects. Self-medication of pain and distress via substance use is common and can be understood via negative reinforcement, ultimately strengthening the pathway between pain to substance use over time. As such, a testable model of the potentially modifiable candidate mechanisms that underlie the pain to substance use pathway is needed. Purpose This review proposes a testable model of pain as an antecedent to substance use to guide future research and inform clinical practice. Methods An integrative review of current evidence regarding pain, substance use, and associated risk factors (i.e., negative affect, pain-related attitudes, negative urgency, and substance use outcome expectancies) was conducted. Results The Catastrophizing, Anxiety, Negative Urgency, and Expectancy (CANUE) model highlights modifiable risk factors for self-medicating pain with substance use, including increased negative affect and maladaptive pain-related attitudes (i.e., pain catastrophizing, pain anxiety, and fear of pain), negative urgency, and substance-related outcome expectancies for pain relief and enhanced pain coping. Conclusions Targeted behavioral and psychological interventions that address these factors may facilitate more adaptive pain-coping responses, thereby reducing the impacts of pain on substance use. Systematic research is needed to evaluate the validity and clinical utility of this model.

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

“…The constructs of interest in this review were derived from theoretical frameworks of motivation and pain–substance use relations, with a focus on cognitive-affective constructs that are hypothesized mechanisms of the pain–to–substance use pathway and have been implicated as vulnerabilities to multiple psychiatric disorders. 5 , 9 , 64 Of particular interest were constructs that are hypothesized causal mediators by which the acute pain experience may serve as a proximal determinant of substance administration, or constructs that may function as moderators (e.g., exacerbating or amplifying existing determinants) or serve to make substance use more salient or incentivized in the context of pain. Modifiable cognitive-affective constructs (briefly described below) were selected as the focus because these constructs have the potential to serve as integrated behavioral targets and to better inform future research and intervention development efforts.…”

“… 61 – 63 Indeed, the role of pain as a proximal antecedent to substance use is of growing empirical interest, as highlighted by a recently published Catastrophizing, Anxiety, Negative Urgency, and Expectancy (CANUE) model that emphasizes the influence of negative affect in motivation to self-medicate one’s pain with a variety of addictive substances. 64 Thus, the reciprocal model of pain and substance use predicts that acute pain serves as a proximal determinant of substance use behavior, and that via repeated exposures and reinforcement, relations between pain and substance use may become more robust in the context of chronic or persistent pain. 5 …”

“…Given the high degree of co-occurrence and significant individual/societal costs associated with alcohol and prescription opioid use, the goal of this review is to explicate potentially modifiable factors that are associated with motivation to use and co-use alcohol and prescription opioids in the context of pain. 4 , 5 , 64 The need to examine pain as a determinant of alcohol and prescription opioid use is further supported by evidence that nearly 25% of patients enrolled in both pain and inpatient substance use treatment programs have endorsed using alcohol to cope with pain, with many citing pain as the primary impetus for hazardous drinking and other substance use. 65 , 66 Similarly, a systematic review of opioid misuse and chronic pain found that approximately 21% to 29% of patients prescribed opioids for chronic pain engage in misuse (i.e., use other than prescribed).…”

“… 67 The CANUE model further suggests that people with chronic pain may be most motivated to self-medicate with substances when they also hold maladaptive pain-related cognitions or are otherwise vulnerable to impulsive behavior when distressed. 64 Indeed, researchers have highlighted several cognitive-affective transdiagnostic constructs (e.g., expectancies, pain-related anxiety, distress intolerance) implicated in the development, maintenance, and exacerbation of bidirectional relations between pain and substance use. 5 , 9 , 64 …”

“… 64 Indeed, researchers have highlighted several cognitive-affective transdiagnostic constructs (e.g., expectancies, pain-related anxiety, distress intolerance) implicated in the development, maintenance, and exacerbation of bidirectional relations between pain and substance use. 5 , 9 , 64 …”