Research roundup: Opioid addiction

This issue addresses clinical considerations for psychologists who may see patients with opioid misuse.

Use of opioids in the United States has reached epidemic proportions in recent years. According to the Centers for Disease Control and Prevention (CDC), opioids killed more than 28,000 people in 2014; more than any other year on record. At least half of all opioid deaths involve a prescription opioid.

Despite more frequent opioid prescription, there has been no overall change in the amount of pain reported by Americans. The Department of Health and Human Services has developed a “National Pain Strategy” and the CDC recently released guidelines for prescribing opioids for chronic pain

A study by the American Medical Association found that out of 472,000 participants between the ages of 18 and 64 who took part in the 2003-2013 National Surveys on Drug Use and Health, three-fourths of those who need help with prescription opioid dependence are not receiving it. In order to achieve long-term recovery, patients may need psychological treatment as well as medication-assisted therapies.

In addition to reviewing the following research summaries, psychologists are encouraged to explore the literature more completely to determine what may be useful to them in practice.

Garland, E.L., Manusov, E.G., Froeliger, B., Kelly, A., Williams, J.M., & Howard, M.O. (2014). Mindfulness-oriented recovery enhancement for chronic pain and prescription opioid misuse: Results from an early-stage randomized controlled trial. Journal of Consulting and Clinical Psychology, 82(3), 448-459.
Summary

Abuse of and addiction to prescription opioids is on the rise among those suffering from chronic pain, with more than 1 in 10 chronic pain patients presenting with serious physical and mental health issues indicative of opioid misuse. Cognitive, affective and behavioral functioning can become dysregulated, leading to even greater suffering than the chronic pain patient was contending with prior to opioid abuse.

Recognizing the need for treatments that concurrently address chronic pain and opioid addiction, the authors of this study conducted a randomized controlled trial of Mindfulness-Oriented Recovery Enhancement (MORE). MORE incorporates mindfulness training, cognitive reappraisal skills and positive emotion regulation in order to adjust the attentional biases, habit behavior, affective dysregulation and automatic stress responses that are rooted in the feedback loop of chronic pain and addiction.

One-hundred and fifteen participants were randomized into either MORE or the traditional support group (SG), and received eight weeks of treatment. The traditional support group involved patients talking about issues applicable to chronic pain and long-term opioid use, similar to the topics addressed in MORE. Outcomes from both treatments were measured pre- and post-treatment, as well as at a three-month follow-up. Changes in pain sensitivity and interference were appraised with the Brief Pain Inventory (BPI). The Current Opioid Misuse Measure was used to assess any alterations in the opioid use disorder status. Additionally, craving for opioids, stress, nonreactivity, reinterpretation of pain sensations and reappraisal were also measured.

Participants in the MORE treatment group reported significantly greater reductions in pain severity and pain interference than those in the SG treatment group. These results continued at the three-month follow-up. In addition, the MORE participants experienced increased nonreactivity and reinterpretation of pain sensations and were more likely to no longer meet the criteria for opioid addiction up to three months post-treatment than those who received SG.

Jones, R.E., Spradlin, A., Robinson, R.J., & Trageser, S.L. (2014). Development and validation of the opioid prescription medication motives questionnaire: A four-factor model of reasons for use. Psychology of Addictive Behaviors, 28(4), 294-298. Doi: 10.1037/a0037783.
Summary

The authors of this study sought to establish evidence for a measure that can aid in understanding the motives behind prescription opioid misuse, which could help guide prevention and treatment efforts. Prescription opioid motives used in previous studies were found to map closely to literature focusing on alcohol motives. Therefore, the authors adapted items from the Drinking Motives Questionnaire-Revised that address the factors of enhancement, coping and social motives to create their own 19-item measure called the Opioid Prescription Medication Motives Questionnaire. 

The questionnaire was completed by 111 male and 226 female undergraduate students. Questions aimed to measure frequency, quantity, context of use, consequences and dependence features, misuse and motives for use.

Items concerning frequency, quantity and context of use asked participants to report on the number and frequency of pills consumed in a three-month period (for example, every day, every other day). Additionally, participants were asked about the context in which pills were taken.

Consequences and dependence factors examined the ramifications of prescription opioid use. The questions were modeled after the Brief Michigan Alcoholism Screening Test.

The Revised Screener and Opioid Assessment for Patients with Pain and the Prescription Opioid Misuse Index were used to measure opioid misuse.

Confirmatory factor analysis showed that prescription opioid motives can be broken down into four factors — enhancement, coping, social and pain. The factors that most significantly predicted the use of prescription opioids among this sample were pain and coping, suggesting these factors may make individuals more at risk for developing habits of misuse when prescribed opioids.

Worley, M.J., Heinzerling, K.G., Shoptaw, S., & Ling, W. (2015). Pain volatility and prescription opioid addiction treatment outcomes in patients with chronic pain. Experimental and Clinical Psychopharmacology, 23(6), 428-435. Doi: 10.1037/pha0000039.
Summary

The authors of this study examined the correlation between the level and volatility of pain and treatment outcomes.

One-hundred forty-nine participants over the age of 18 who met DSM-IV criteria for prescription opioid addiction and also suffered from chronic pain received 12 weeks of Buprenorphine/naloxone (BUP/NLX), and were randomized to either an enhanced counseling or standard medical management group.

Abstinence from opioid use by the last two to three weeks of the study was considered a successful outcome. Opioid and non-opioid drug use during treatment was measured with self-report and confirmed by urine drug screen. Participants took the BPI — Short Form, so the authors could assess subjective pain severity. Baseline demographic and clinical characteristics were gathered with the Addiction Severity Index-Lite and the Pain and Opiate Analgesic Use History questionnaire. Dose of BUP/NLX was captured with use of a drug dispensing and compliance log. The Clinical Opiate Withdrawal Scale measured opiate withdrawal symptoms and severity.

The authors found that participants with a one standard deviation increase in pain over time of treatment were 44 percent less likely to achieve abstinence from opioid use by the end of treatment. Overall, however, participants reported significant decreases in subjective pain while on BUP/NLX and receiving counseling for opioid addiction, regardless of whether they received the enhanced or standard counseling. Greater pain volatility could serve as an important marker for opioid use than initial pain severity.

Clinical Implications

While some psychologists specialize in treating individuals experiencing chronic pain, many individuals with chronic pain may not have access to or seek specialized care and some may be presenting for care for a variety of other reasons. As the problems of opioid use and misuse grow, psychologists will likely want to become more familiar with the latest literature in this growing area in order to know when to seek additional assessment, refer for specialty care, or modify planned interventions when treating those experiencing chronic pain and using opioids.

Psychological treatments (existing and emerging) can help reduce and manage the experience of chronic pain. Identifying individual factors, such as volatility of pain and current coping strategies (or lack thereof), that may make someone more likely to begin misusing prescribed opioids could be an important initial step for psychologists to then know when to intervene to potentially reduce the occurrence of opioid addiction among patients already receiving psychological care for pain and other reasons.