Abstract
Rationale
Prescription opioid misuse and high-dose opioid use may result in allostatic dysregulation of hedonic brain circuitry, leading to reduced emotion regulation capacity. In particular, opioid misuse may blunt the ability to experience and upregulate positive affect from natural rewards.
Objectives
The purpose of this study was to examine associations between opioid use/misuse and autonomic indices of emotion regulation capability in a sample of chronic pain patients receiving prescription opioid pharmacotherapy.
Methods
Chronic pain patients taking long-term opioid analgesics (N = 40) completed an emotion regulation task while heart rate variability (HRV) was recorded, and also completed self-report measures of opioid misuse, craving, pain severity, and emotional distress. Based on a validated cut-point on the Current Opioid Misuse Measure, participants were grouped as opioid misusers or non-misusers. Opioid misuse status and morphine equivalent daily dose (MEDD) were examined as predictors of HRV and self-reports of emotion regulation.
Results
Opioid misusers exhibited significantly less HRV during positive and negative emotion regulation, and significantly less positive effect, than non-misusers, after controlling for confounders including pain severity and emotional distress. MEDD was inversely associated with positive emotion regulation efficacy.
Conclusion
Findings implicate the presence of reward processing deficits among chronic pain patients with opioid-misusing behaviors, and opioid dosage was associated with deficient emotion regulation, suggesting the presence of compromised top-down cognitive control over bottom-up hedonic processes. Emotion regulation among opioid misusers may represent an important treatment target.
Similar content being viewed by others
References
Antony MM, Bieling PJ, Cox BJ et al (1998) Psychometric properties of the 42-item and 21-item versions of the depression anxiety stress scales in clinical groups and a community sample. Psychol Assess 10:176–181. doi:10.1037/1040-3590.10.2.176
Appelhans BM, Luecken LJ (2006) Heart rate variability as an index of regulated emotional responding. Rev Gen Psychol 10:229–240
Berntson GG, Bigger JT Jr, Eckberg DL et al (1997) Heart rate variability: origins, methods, and interpretive caveats. Psychophysiology 34:623–648
Borsook D, Linnman C, Faria V et al (2016) Reward deficiency and anti-reward in pain chronification. Neurosci Biobehav Rev 68:282–297. doi:10.1016/j.neubiorev.2016.05.033
Braams BR, Blechert J, Boden MT, Gross JJ (2012) The effects of acceptance and suppression on anticipation and receipt of painful stimulation. J Behav Ther Exp Psychiatry 43:1014–1018. doi:10.1016/j.jbtep.2012.04.001
Bunce SC, Harris JD, Bixler EO et al (2015) Possible evidence for re-regulation of hpa axis and brain reward systems over time in treatment in prescription opioid-dependent patients. J Addict Med 9:53–60. doi:10.1097/ADM.0000000000000087
Burns JW (2006) The role of attentional strategies in moderating links between acute pain induction and subsequent psychological stress: evidence for symptom-specific reactivity among patients with chronic pain versus healthy nonpatients. Emotion 6:180–192. doi:10.1037/1528-3542.6.2.180
Burns JW, Quartana PJ, Gilliam W et al (2011) Suppression of anger and subsequent pain intensity and behavior among chronic low back pain patients: the role of symptom-specific physiological reactivity. J Behav Med 35:103–114. doi:10.1007/s10865-011-9347-3
Burr RL (2007) Interpretation of normalized spectral heart rate variability indices in sleep research: a critical review. Sleep 30:913–919
Butler EA, Wilhelm FH, Gross JJ (2006) Respiratory sinus arrhythmia, emotion, and emotion regulation during social interaction. Psychophysiology 43:612–622
Butler SF, Budman SH, Fernandez KC et al (2007) Development and validation of the current opioid misuse measure. Pain 130:144–156
Chou R, Fanciullo GJ, Fine PG et al (2009) Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 10:113–130
Cleeland CS (1994) Brief pain inventory–short form (BPI–SF). Houston, TX
Culbertson C, Nicolas S, Zaharovits I et al (2010) Methamphetamine craving induced in an online virtual reality environment. Pharmacol Biochem Behav 96:454–460. doi:10.1016/j.pbb.2010.07.005
Di Simplicio M, Costoloni G, Western D, et al. (2011) Decreased heart rate variability during emotion regulation in subjects at risk for psychopathology. Psychol Med 1–9. doi: 10.1017/S0033291711002479
Di Simplicio M, Costoloni G, Western D et al (2012) Decreased heart rate variability during emotion regulation in subjects at risk for psychopathology. Psychol Med 42:1775–1783. doi:10.1017/S0033291711002479
Edwards RR, Dolman AJ, Michna E, et al. (2016) Changes in pain sensitivity and pain modulation during oral opioid treatment: the impact of negative affect. Pain Med pnw010. doi: 10.1093/pm/pnw010
Elman I, Borsook D (2016) Common brain mechanisms of chronic pain and addiction. Neuron 89:11–36
Erblich J, Bovbjerg DH, Sloan RP (2011) Exposure to smoking cues: cardiovascular and autonomic effects. Addict Behav 36:737–742. doi:10.1016/j.addbeh.2011.02.011
Felder JN, Smoski MJ, Kozink RV et al (2012) Neural mechanisms of subclinical depressive symptoms in women: a pilot functional brain imaging study. BMC Psychiatry 12:152
Finan PH, Garland EL (2015) The role of positive affect in pain and its treatment. Clin J Pain 31:177–187
Garland EL (2016) Restructuring reward processing with mindfulness-oriented recovery enhancement: novel therapeutic mechanisms to remediate hedonic dysregulation in addiction, stress, and pain. Ann N Y Acad Sci 1373:25–37. doi:10.1111/nyas.13034
Garland EL, Carter K, Ropes K, Howard MO (2012a) Thought suppression, impaired regulation of urges, and addiction-Stroop predict affect-modulated cue-reactivity among alcohol dependent adults. Biol Psychol 89:87–93
Garland EL, Franken IH, Howard MO (2012b) Cue-elicited heart rate variability and attentional bias predict alcohol relapse following treatment. Psychopharmacology 222:17–26
Garland EL, Froeliger B, Howard MO (2015a) Allostatic dysregulation of natural reward processing in prescription opioid misuse: autonomic and attentional evidence. Biol Psychol 105:124–129. doi:10.1016/j.biopsycho.2015.01.005
Garland EL, Froeliger B, Howard MO (2014a) Effects of mindfulness-oriented recovery enhancement on reward responsiveness and opioid cue-reactivity. Psychopharmacology 231:3229–3238. doi:10.1007/s00213-014-3504-7
Garland EL, Froeliger B, Howard MO (2014b) Neurophysiological evidence for remediation of reward processing deficits in chronic pain and opioid misuse following treatment with mindfulness-oriented recovery enhancement: exploratory ERP findings from a pilot RCT. J Behav Med 38:327–336. doi:10.1007/s10865-014-9607-0
Garland EL, Froeliger B, Zeidan F et al (2013) The downward spiral of chronic pain, prescription opioid misuse, and addiction: cognitive, affective, and neuropsychopharmacologic pathways. Neurosci Biobehav Rev 37:2597–2607. doi:10.1016/j.neubiorev.2013.08.006
Garland EL, Hanley AW, Thomas EA et al (2015b) Low dispositional mindfulness predicts self-medication of negative emotion with prescription opioids. J Addict Med 9:61–67
Garland EL, Hanley AW, Thomas EA, et al. (2014c) Low dispositional mindfulness predicts self-medication of negative emotion with prescription opioids.
Green TC, Black R, Grimes Serrano JM et al (2011) Typologies of prescription opioid use in a large sample of adults assessed for substance abuse treatment. PLoS One 6:e27244. doi:10.1371/journal.pone.0027244
Hampton AJ, Hadjistavropoulos T, Gagnon MM et al (2015) The effects of emotion regulation strategies on the pain experience: a structured laboratory investigation. Pain 156:868–879
Huhn A, Meyer R, Harris J et al (2016) Evidence of anhedonia and differential reward processing in prefrontal cortex among post-withdrawal patients with prescription opiate dependence. Brain Res Bull. doi:10.1016/j.brainresbull.2015.12.004
Inagaki H, Kuwahara M, Tsubone H (2005) Changes in autonomic control of heart associated with classical appetitive conditioning in rats. Exp Anim 54:61–69
Ingjaldsson JT, Laberg JC, Thayer JF (2003) Reduced heart rate variability in chronic alcohol abuse: relationship with negative mood, chronic thought suppression, and compulsive drinking. Biol Psychiatry 54:1427–1436
Jackson DC, Malmstadt JR, Larson CL, Davidson RJ (2000) Suppression and enhancement of emotional responses to unpleasant pictures. Psychophysiology 37:515–522
Khantzian EJ (1997) The self-medication hypothesis of substance use disorders: a reconsideration and recent applications. Harv Rev Psychiatry 4:231–244
Kim SH, Hamann S (2007) Neural correlates of positive and negative emotion regulation. J Cogn Neurosci 19:776–798
Kohl A, Rief W, Glombiewski JA (2013) Acceptance, cognitive restructuring, and distraction as coping strategies for acute pain. J Pain 14:305–315. doi:10.1016/j.jpain.2012.12.005
Kok BE, Coffey KA, Cohn MA et al (2013) How positive emotions build physical health perceived positive social connections account for the upward spiral between positive emotions and vagal tone. Psychol Sci 24:1123–1132
Koob GF, Le Moal M (2001) Drug addiction, dysregulation of reward, and allostasis. Neuropsychopharmacology 24:97–129
Koob GF, Le Moal M (2008) Addiction and the brain antireward system. Annu Rev Psychol 59:29–53
Lang P, Bradley M, Cuthbert B (1997) International affective picture system (IAPS): technical manual and affective ratings
Lapate RC, Lee H, Salomons TV et al (2011) Amygdalar function reflects common individual differences in emotion and pain regulation success. J Cogn Neurosci 24:148–158. doi:10.1162/jocn_a_00125
Lubman DI, Yucel M, Kettle JW et al (2009) Responsiveness to drug cues and natural rewards in opiate addiction: associations with later heroin use. Arch Gen Psychiatry 66:205–212
Malliani A, Lombardi F, Pagani M (1994) Power spectrum analysis of heart rate variability: a tool to explore neural regulatory mechanisms. Br Heart J 71:1–2
Martel MO, Dolman AJ, Edwards RR et al (2014) The association between negative affect and prescription opioid misuse in patients with chronic pain: the mediating role of opioid craving. J Pain 15:90–100
Martins SS, Fenton MC, Keyes KM et al (2012) Mood and anxiety disorders and their association with non-medical prescription opioid use and prescription opioid-use disorder: longitudinal evidence from the National Epidemiologic study on alcohol and related conditions. Psychol Med 42:1261–1272
Ochsner KN, Bunge SA, Gross JJ, Gabrieli JDE (2002) Rethinking feelings: an fMRI study of the cognitive regulation of emotion. J Cogn Neurosci 14:1215–1229
Preacher KJ, Hayes AF (2008) Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Methods 40:879–891
Quartana PJ, Bounds S, Yoon KL et al (2010) Anger suppression predicts pain, emotional, and cardiovascular responses to the cold pressor. Ann Behav Med 39:211–221. doi:10.1007/s12160-010-9182-8
Quintana DS, McGregor IS, Guastella AJ et al (2013) A meta-analysis on the impact of alcohol dependence on short-term resting-state heart rate variability: implications for cardiovascular risk. Alcohol Clin Exp Res 37:E23–E29
Rajan I, Murthy PJ, Ramakrishnan AG et al (1998) Heart rate variability as an index of cue reactivity in alcoholics. Biol Psychiatry 43:544–546
Salomons TV, Nusslock R, Detloff A et al (2014) Neural emotion regulation circuitry underlying anxiolytic effects of perceived control over pain. J Cogn Neurosci 27:222–233. doi:10.1162/jocn_a_00702
Segerstrom SC, Nes LS (2007) Heart rate variability reflects self-regulatory strength, effort, and fatigue. Psychol Sci 18:275–281
Shurman J, Koob GF, Gutstein HB (2010) Opioids, pain, the brain, and hyperkatifeia: a framework for the rational use of opioids for pain. Pain Med Malden Mass 11:1092–1098. doi:10.1111/j.1526-4637.2010.00881.x
Stockhorst U, Huenig A, Ziegler D, Scherbaum WA (2011) Unconditioned and conditioned effects of intravenous insulin and glucose on heart rate variability in healthy men. Physiol Behav 103:31–38
Tang Y-Y, Posner MI, Rothbart MK, Volkow ND (2015) Circuitry of self-control and its role in reducing addiction. Trends Cogn Sci 19:439–444. doi:10.1016/j.tics.2015.06.007
Thayer JF, Åhs F, Fredrikson M et al (2012) A and neuroimaging studies: implications for heart rate variability meta-analysis of heart rate variability as a marker of stress and health. Neurosci Biobehav Rev 36:747–756. doi:10.1016/j.neubiorev.2011.11.009
Thayer JF, Lane RD (2000) A model of neurovisceral integration in emotion regulation and dysregulation. J Affect Disord 61:201–216
Thayer JF, Lane RD (2009) Claude Bernard and the heart-brain connection: further elaboration of a model of neurovisceral integration. Neurosci Biobehav Rev 33:81–88
Udo T, Weinberger AH, Grilo CM, et al. (2013) Heightened vagal activity during high-calorie food presentation in obese compared with non-obese individuals—results of a pilot study
Volkow ND, Koob GF, McLellan AT (2016) Neurobiologic advances from the brain disease model of addiction. N Engl J Med 374:363–371. doi:10.1056/NEJMra1511480
Vowles KE, McEntee ML, Julnes PS et al (2015) Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain 156:569–576. doi:10.1097/01.j.pain.0000460357.01998.f1
Wasan AD, Butler SF, Budman SH et al (2009) Does report of craving opioid medication predict aberrant drug behavior among chronic pain patients? Clin J Pain 25:193–198
Wasan AD, Michna E, Edwards RR et al (2015) Psychiatric comorbidity is associated prospectively with diminished opioid analgesia and increased opioid misuse in patients with chronic low back pain. Anesthesiology 123:861–872. doi:10.1097/ALN.0000000000000768
Williams DP, Cash C, Rankin C et al (2015) Resting heart rate variability predicts self-reported difficulties in emotion regulation: a focus on different facets of emotion regulation. Emot Sci 6:261. doi:10.3389/fpsyg.2015.00261
Younger JW, Chu LF, D’Arcy NT et al (2011) Prescription opioid analgesics rapidly change the human brain. Pain 152:1803–1810. doi:10.1016/j.pain.2011.03.028
Acknowledgments
This work was supported by grant numbers R34DA037005 and R01DA042033 from the National Institutes of Health awarded to E.L.G. and a grant from the Fahs Beck Fund for Research and Experimentation, also awarded to E.L.G.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Ethics statement
All procedures complied with standards propounded in the Helsinki Declaration of 1975.
Conflict of interest
The authors declare that they have no conflicts of interest.
Rights and permissions
About this article
Cite this article
Garland, E.L., Bryan, C.J., Nakamura, Y. et al. Deficits in autonomic indices of emotion regulation and reward processing associated with prescription opioid use and misuse. Psychopharmacology 234, 621–629 (2017). https://doi.org/10.1007/s00213-016-4494-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00213-016-4494-4