Changes in Pain Sensitivity and Pain Modulation During Oral Opioid Treatment: The Impact of Negative Affect

Abstract

Objective. Opioids are frequently prescribed for chronic low back pain (CLBP), but there are broad individual differences in the benefits and risks of opioid therapy, including the development opioidinduced hyperalgesia. This study examined quantitative sensory testing (QST) data among a group of CLBP patients undergoing sustained oral opioid treatment. We investigated whether individual differences in psychological characteristics were related to opioid-induced changes in pain perception and pain modulation.Design. The six-month, open-label trial evaluated patients with low to high levels of negative affect (e.g., symptoms of distress, depression and anxiety); participants underwent QST at baseline (prior to initiating treatment) and during oral opioid treatment.Setting. A chronic pain management center.Patients. The 31 study participants had chronic discogenic back pain, with a pain intensity rating >3/10. Participants were divided into groups with high vs. low levels of Negative Affect (NA).Results. In the previously-published manuscript describing the clinical outcomes of the trial, high NA patients achieved only about half of the analgesic effect observed in the low NA group (Wasan AD, Michna E, Edwards RR, et al. Psychiatric comorbidity is associated prospectively with diminished opioid analgesia and increased opioid misuse in patients with chronic low back pain. Anesthesiology 2015;123:86172). The QST findings reported here suggested that tolerance to experimental (cold pressor) pain and conditioned pain modulation tended to decrease in the high NA group over the course of opioid treatment, while temporal summation of mechanical pain declined in the low NA group.Conclusions. These results reveal that while the low NA group seemed to exhibit a generally adaptive, analgesic pattern of changes during opioid management, the high NA group showed a pattern more consistent with opioid-induced hyperalgesic

Opioids for breathlessness: Psychological and neural factors influencing response variability

“…That is, individuals with high vs. low negative affect are less likely to experience opioid-induced relief of breathlessness. These results align with previous work in chronic pain, where it has been found that in addition to less effective analgesia, negative affective qualities are associated with dose escalation (27) and greater difficulty in reducing opioid medication use (28); factors that increase the potential for adverse opioid-related side effects (29). Interestingly, the hierarchical cluster analysis revealed a less tightly correlated 'baseline' cluster in COPD compared to the healthy volunteers.…”

“…Collectively, the results of these studies suggest that individuals with strong learned associations (priors) and negative affective comorbidities may be more likely to benefit from pulmonary rehabilitation than opioids for relief of breathlessness. Furthermore, it is possible that individuals with these strong associations and negative affective comorbidities may thus require higher opioid doses to experience adequate relief of breathlessness, as previously demonstrated in individuals with pain (6,27,28).…”

Deficits in autonomic indices of emotion regulation and reward processing associated with prescription opioid use and misuse

“…These studies suggest a linkage between emotion regulatory capacity and pain, yet it is unclear whether chronic pain patients who use and misuse opioids evidence emotion regulation deficits. In that regard, though previous research has demonstrated associations between opioid misuse and negative affectivity in chronic pain samples (Martel et al 2014; Wasan et al 2015; Edwards et al 2016), to our knowledge, no prior study has investigated emotion regulatory deficits among opioid-using and misusing chronic pain patients with a performance-based, biobehavioral measure of proactive emotion regulation.…”

Discogenic Back Pain: Literature Review of Definition, Diagnosis, and Treatment

“…Oral pharmaceutical management for analgesic purposes includes acetaminophen, NSAIDs, skeletal muscle relaxants, tramadol, steroids, and opioids. Opioids are frequently prescribed for back pain patients; however, because of their physical dependence and tolerance, long‐term opioid use is discouraged …”

“…Nonoperative management strategies have demonstrated good results, and some systematic reviews have shown even comparative clinical results to surgical treatment . On the other hand, opioid use should be restrictive because of the risk of developing opioid‐induced hyperalgesia, abuse, and misuse …”