The Association Between Negative Affect and Prescription Opioid Misuse in Patients With Chronic Pain

An Interview with Marc O. Martel, PhD

Dr. Martel holds a PhD in Clinical Psychology from McGill University and is currently a postdoctoral fellow in the Department of Anesthesiology & Pain Medicine at Harvard Medical School/Brigham and Women’s Hospital. Over the past few years, he has authored and co-authored several peer-reviewed articles addressing the biopsychosocial aspects of chronic pain and disability. His current lines of research primarily focus on the biopsychosocial determinants of prescription drug misuse among patients with chronic pain.

Elsbeth McSorley: 

What made you interested in conducting this study?

Marc O. Martel, PhD: Over the past decade, considerable research has shown that chronic pain patients experiencing high levels of negative affect (NA), such as anxiety and depression, are at increased risk for prescription opioid misuse. Prescription opioid misuse, which broadly refers to the use of opioids in a manner other than how they are prescribed, has become a major concern for clinicians involved in the treatment of pain.


EM: What was the primary objective of this study?

MOM: This study examined the factors that underlie the association between NA and prescription opioid misuse among patients with chronic pain. The primary purpose of the study was to examine the potential role of pain intensity and opioid craving as mediators of the association between NA and prescription opioid misuse among patients with chronic pain.

EM: How did you conduct the study?

MOM: A sample of chronic pain patients from Brigham and Women’s Hospital being prescribed opioid medication completed the Current Opioid Misuse Measure (COMM)®, an opioid risk assessment tool which identifies whether a patient, currently on long-term opioid therapy, may be misusing opioid medications. Patients also completed self-report measures of pain intensity, NA, and opioid craving. A bootstrapped multiple mediation analysis was used to examine the mediating role of pain intensity and opioid craving in the association between NA and opioid misuse.


EM: Why did you choose to use the COMM, and what purpose did it serve in this study?

MOM: We decided to use the COMM because it’s a well-validated, reliable, scientifically accepted tool designed to identify patients who are currently misusing their prescribed opioid medication. The COMM has been shown to have good predictive validity, with significant correlations between COMM scores and other indices of prescription opioid misuse.

For purposes of the present study, only the COMM items that were designed to directly assess prescription opioid misuse were included in the analyses. The COMM items that assessed emotional/psychiatric issues associated with opioid misuse were excluded from the analyses given the potential overlap between these items and measures of NA. Removing these items allowed us to ensure that the association between NA and opioid misuse was not artificially inflated because of over- lapping item content.


EM: What were the study’s results?

MOM: In our study, higher levels of NA were associated with higher scores on the COMM. This finding corroborates those of previous studies that have examined the association between measures of NA and prescription opioid misuse.

A significant positive correlation was also found between NA and self-reports of opioid craving. Patients with high levels of NA reported higher levels of opioid craving, which is consistent with the results of a recent study showing that higher levels of anxiety and depressive symptoms were associated with higher levels of opioid craving. Additionally, results showed that higher levels of opioid craving were associated with increased rates of opioid misuse. This suggests that higher levels of NA may enhance opioid craving, which in turn may lead to an increased likelihood of prescription opioid misuse. This was supported “statistically” by the results from bootstrapped mediation analysis.


EM: In your opinion, what are the clinical implications of this study, both from a treatment perspective, and an opioid risk management perspective?

MOM: Clinicians should place more focus on patients’ emotional/psychiatric issues besides pain management to help patients with opioid cravings. If clinicians are able to reduce NA, this might reduce opioid craving and, in turn, rates of opioid misuse. Study results also suggest that it’s a good idea for clinicians to routinely assess psychological function, anxiety and depression. The study’s results also highlight the importance of monitoring high-risk patients with tools like the COMM and the Screener and Opioid Assessment for Patients with Pain (SOAPP®), which facilitates assessment and planning for chronic pain patients being considered for long-term opioid treatment. Implementing these tools in the clinician setting would be extremely helpful for assessing a patient’s likelihood of opioid misuse.


EM: What future studies would you like to see done on this topic?

MOM: I think we need to better understand opioid craving. Craving has a long history in the broader substance use literature, but it’s a relatively new concept in the chronic pain literature. It would be nice to learn more about the experience of opioid craving among patients with chronic pain, as it occurs in real-life contexts. For instance, I’d like to better understand the frequency and intensity of craving in chronic pain patients and also assess these craving experiences when patients are in their natural environment, like at work or at home.


EM: What else are you currently working on or plan to work on in the future?

MOM: I had another study about prescription opioid misuse published in Drug and Alcohol Dependence called “Catastrophic thinking and increased risk for prescription opioid misuse in patients with chronic pain.” I have written many manuscripts and grant proposals in the area of craving and opioid misuse that I’m waiting to hear back on and find out if they’re accepted and funded. I’m also very interested in developing a validated scale to better assess opioid craving in patients with chronic pain.