Exploring the potential role of mesocorticolimbic circuitry in motivation for and adherence to chronic pain self-management interventions

Abstract

Adherence to pain self-management strategies is associated with favorable psychobehavioral outcomes among individuals with chronic pain. Substantive adherence to treatments teaching these adaptive skills proves challenging, resulting in poor individual and societal outcomes. Evidence demonstrates motivation for behavior change as a key predictor of treatment adherence. Despite behavioral techniques that target motivation, however, nonadherence persists as a barrier to positive clinical outcomes in chronic pain. Understanding the neurobiological mechanisms underlying treatment motivation might highlight novel avenues for augmentative therapies. The purpose of this review is to present theory and evidence that the mesocorticolimbic system (i.e., brain circuitry associated with reward processing and motivation) contributes to treatment motivation among chronic pain patients, ultimately influencing adherence. We review evidence for motivation as a key adherence determinant, detail neuroimaging findings relating mesocorticolimbic circuitry and motivation, and discuss data supporting mesocorticolimbic dysfunction among chronic pain patients. We propose a neurobehavioral model for adherence to pain self-management interventions, listing testable hypotheses. Finally, we discuss potential research and intervention implications from the proposed model.

Dopaminergic Regulation of Reward System Connectivity Underpins Pain and Emotional Suffering in Migraine

“…It might then influence patients to modify their behavior to prevent future attacks or to mitigate pain intensity. 65 Thus, this finding also corroborates the importance of cognitive-behavioral therapies in migraine treatment. 66 , 67 …”

Best Evidence Rehabilitation for Chronic Pain Part 5: Osteoarthritis

“…Although psychosocial factors predicting treatment motivation amongst those with chronic pain have been probed, physiological mechanisms potentially subserving these processes have not been examined. For example, a potentially important physiological mechanism of treatment motivation is mesocorticolimbic function [285]. This neural system—colloquially referred to as “the reward system”—has been extensively associated with motivational processes and reward learning in humans and animal models [286,287,288,289].…”

Meditation practice, mindfulness and pain-related outcomes in mindfulness-based treatment for episodic migraine

“…Given that the NAc and prefrontal cortex (including the vmPFC) have been strongly implicated in motivated behavior (Cardinal et al, 2002;Di Domenico & Ryan, 2017;Knutson et al, 2001), demonstrating augmented intrinsic connectivity during reward motivation (Ballard et al, 2011), these findings suggest that motivational factors may contribute to patient engagement in meditation practice during mindfulness-based treatment. Further, they provide support for the neurobehavioral model of pain, mesocorticolimbic circuitry, and treatment adherence (Letzen et al, 2019), in that mesocorticolimbic functioning significantly predicted treatment adherence and outcomes. Notably, both functional hypoconnectivity and hyperconnectivity have been theorized…”

“…In healthy samples, personality factors (i.e., openness, conscientiousness) and positive affect may support meditation uptake, while depressive symptoms, perceived stress and neuroticism may interfere (Barrett et al, 2019). In the chronic pain context, the neurobehavioral model of pain, mesocorticolimbic circuitry, and treatment adherence (Letzen et al, 2019) identifies mesocorticolimbic system functioning as a neurobiological mechanism underlying treatment motivation and adherence, and thus a potentially informative predictor of meditation practice engagement. Specifically, the mesolimbic system (i.e., neurons in the ventral tegmental area that project to the nucleus accumbens [NAc], thalamus, amygdala and hippocampus) and its cortical projections (i.e., to the anterior cingulate cortex, ventromedial prefrontal cortex [vmPFC] and orbitofrontal cortex) are activated in the context of approach and avoidance behaviors, respectively (Cardinal et al, 2002;Salamone, 1994;Salamone & Correa, 2012).…”

“…We hypothesized that greater mesocorticolimbic dysfunction would predict greater baseline pain, reduced meditation practice duration, and lesser treatment gains. We did not specify a priori the direction of FC (i.e., hypoconnectivity versus hyperconnectivity), as both hyper-and hypoconnectivity in mesocorticolimbic circuits have been associated with psychological dysfunction (Fornito & Bullmore, 2015) and been theorized to reflect mesocorticolimbic system dysfunction in chronic pain (Letzen et al, 2019). Second, we investigated the relationship between meditation practice and headache outcomes, mindfulness and pain catastrophizing.…”