Emotion dysregulation as a transdiagnostic mechanism of opioid misuse and suicidality among chronic pain patients

Emotion dysregulation as a transdiagnostic mechanism of opioid misuse and suicidality among... Background: Chronic pain is a prevalent condition that causes functional impairment and emotional suffering. To allay pain-induced suffering, opioids are often prescribed for chronic pain management. Yet, chronic pain patients on opioid therapy are at heightened risk for opioid misuse—behaviors that can lead to addiction and overdose. Relatedly, chronic pain patients are at elevated risk for suicidal ideation and suicidal behaviors. Main body: Opioid misuse and suicidality are maladaptive processes aimed at alleviating the negative emotional hyperreactivity, hedonic hyporeactivity, and emotion dysregulation experienced by chronic pain patients on opioid therapy. In this review, we explore the role of emotion dysregulation in chronic pain. We then describe why emotionally dysregulated chronic pain patients are vulnerable to opioid misuse and suicidality in response to these negative affective states. Conclusion: Emotion dysregulation is an important and malleable treatment target with the potential to reduce or prevent opioid misuse and suicidality among opioid-treated chronic pain patients. Keywords: Anhedonia, Chronic pain, Emotion dysregulation, Opioid misuse, Reinforcement, Suicidality Background clinical presentation of opioid-treated chronic pain Approximately 100 million Americans suffer from patients is often complicated by comorbid psychiatric chronic pain, a condition compounded by maladaptive distress, substance use disorders, and suicidality [5–7]— cognitive and emotional processes that often cooccur so-called “epidemics of despair” that account for rising with protracted and severe physical suffering [1]. Opioid mortality rates in the U.S. [8]—in part through intentional therapy continues to be the primary medical treatment opioid overdose. Yet, biobehavioral mechanistic models for chronic pain despite associated risks, including opi- linking chronic pain to opioid misuse and suicidal be- oid misuse, addiction, and overdose [2], as well as dele- havior are lacking. terious neuropsychopharmacologic effects of prolonged In this conceptual review, we posit that the transdiag- opioid exposure, including dysregulation in brain circuits nostic process of emotion dysregulation is central to un- undergirding reward processing, stress reactivity, and derstanding why opioid-treated chronic pain patients the proactive regulation of emotions [3, 4]. Given the engage in opioid misuse and suicidal behaviors. Al- magnitude of the current opioid crisis in the U.S., there though emotion dysregulation may result in multiple is an urgent need to understand the psychological fac- forms of maladaptive behavior, here we focus on opioid tors that drive individuals with chronic pain to misuse misuse and suicidality as sequelae of chronic pain due to their prescribed opioid medications. Furthermore, the their high prevalence and significant public health im- pact. Recent meta-analyses suggest that 25% of chronic pain patients engage in opioid-misusing behaviors like * Correspondence: eric.garland@socwk.utah.edu opioid dose escalation or self-medicating negative University of Utah College of Social Work, 395 South 1500 East, Salt Lake City, UT 84112, USA affective states with opioids [9]. As will be discussed Center on Mindfulness and Integrative Health Intervention Development, later, opioid misuse is associated with adverse conse- 395 South 1500 East, Salt Lake City, UT 84112, USA quences such as increased sensitivity to pain and stress, Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Riquino et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:11 Page 2 of 9 decreased sensitivity to natural rewards, functional im- In this review, we posit that emotion dysregulation is pairments, and overdose risk [10–12]. Similarly, suicidal- the process that links these situational appraisals to ity, which encompasses both suicidal ideation and maladaptive behaviors, including opioid misuse and sui- behaviors, is especially common among individuals with cidality (see Fig. 1 for a depiction of this process). Emo- chronic pain. Chronic pain patients have nearly two tion dysregulation is marked by difficulties with the times the risk of death by suicide and are two to three emotion-generative process and/or emotion regulation times more likely than individuals without chronic pain failures—i.e., not effectively employing adaptive emotion to report suicidal ideation or make suicide attempts [13]. regulation strategies when it would be appropriate to do Drug overdose is the most commonly reported means of so [18]. The decreased hedonic capacity [19] and height- attempting suicide among chronic pain patients [14]. ened stress sensitization [20] associated with chronic Given high rates of suicidal ideation and suicide at- pain and long-term opioid therapy indicate difficulties in tempts among chronic pain patients, and the ready pres- the emotion-generative process. Emotion-generation diffi- ence of lethal means via opioid prescription, risk of culties may result in persistent negative affect that con- death by suicide warrants particular attention among tributes to emotion dysregulation [18], and thus, these opioid-treated chronic pain patients—a population difficulties are relevant to the development and mainten- already at increased mortality risk [15, 16]. ance of opioid misuse and suicidality. Relying on mal- The primary aim of this review is to explore interrela- adaptive coping strategies to regulate negative cognitions tionships of emotion dysregulation and opioid-treated and affect (like misuse of opioids to self-medicate dys- chronic pain, and in particular, to propose how these phoric emotional states or attempting suicide to escape factors give rise to opioid misuse and suicidality. To from emotional suffering) would be considered emotion this end, we first describe emotion dysregulation regulation failures. Additionally, reappraisal and sup- among opioid-treated chronic pain patients. We then pression, classic forms of emotion regulation, may go explore the role of emotion dysregulation as a trans- awry in response to chronic pain [21]—a subject we will diagnostic process underlying the development and address in our discussion of factors contributing to emo- maintenance of opioid misuse and suicidality in this tion dysregulation among opioid-treated chronic pain high-risk population. Finally, we conclude by consider- patients. ing how psychological interventions designed to en- hance affect regulation might address the emotion Difficulties with the emotion-generative process dysregulatory processes subserving opioid misuse and In their review of the roles of emotion and emotion suicidality among chronic pain patients receiving long-term regulation in psychopathology, Gross and Jazaieri (2014) opioid treatment. outlined areas where individuals might experience emotion-related difficulties, e.g., emotion intensity and emotion duration [18]. These difficulties with the Emotion, appraisal, and emotion dysregulation in emotion-generative process are relevant to chronic pain chronic pain patients given the high levels of psychiatric comorbidi- The cognitive-motivational-relational theory of emotion ties present in this population. Hyperreactivity or hypor- asserts that emotions arise in response to a cognitive ap- eactivity, i.e., exhibiting too large or too small an praisal of the meaning or significance of a particular emotional response to a given situation, are indicative of stimulus context [17]. In other words, the relational problematic emotional intensity [22]. Among chronic meaning one derives through the process of appraisal in pain patients, distressing situations may elicit negative response to a given situation determines whether one emotional hyperreactivity [20], whereas rewarding situa- experiences sadness, happiness, or some other emo- tions may result in blunted positive emotional re- tion. From this perspective, appraisals drive emotions sponses—i.e., hedonic hyporeactivity [19]. Just as the and thereby shape emotion regulatory attempts [17]. experience of pain may modulate emotional intensity With respect to chronic pain, when patients experi- [23], pain may also affect the duration of emotional ex- ence an aggravation in the symptomatic expression of perience. As the experience of pain transitions from an their underlying painful condition or encounter an acute to a chronic condition, negative affective reactions emotionally-distressing situation, they may respond in may become more common and long-lasting due to in- maladaptive ways depending on how they appraise the creasingly catastrophic appraisals of pain [24]. situation. For example, appraisals of situational help- In the context of recurrent negative emotionality and lessness, hopelessness, or feelings of interpersonal hedonic hyporeactivity, individuals may become hyper- burdensomeness may drive opioid misuse as a coping vigilant for perturbations to their normative physio- strategy or thoughts of suicide as a way to escape the logical state and negatively appraise their bodily situation. condition as problematic. For chronic pain patients, Riquino et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:11 Page 3 of 9 sensations that do not signal harm [25]. These negative interpretations can lead to a cascade of negative emo- Opioid use Chronic pain tions or catastrophic thinking that interferes with indi- viduals’ ability to regulate emotional distress. Given evidence for interoceptive deficits among individuals with chronic pain [26, 27], chronic pain patients may Emotion dysregulation struggle with differentiating pain sensations from the autonomic, visceral, and musculoskeletal changes evoked by negative emotions. The tendency to label pain as “awful,”“horrible,” or with other emotionally-laden de- scriptors suggests pain can become conflated with the Negative Negative cognitions & affect cognitions & affect emotional distress it creates [28]. Because interoceptive awareness facilitates emotion regulation [29], chronic pain patients with interoceptive deficits may be less able to discriminate pain from the physical sequelae of nega- Opioid craving Suicidal ideation tive emotions, and therefore are less inclined (or able) to engage in proactive emotion regulation attempts. Suicidal behaviors (e.g., preparatory Opioid misuse Factors contributing to emotion dysregulation behaviors) When chronic pain patients do attempt to regulate their emotions, ineffective strategies or skills deficits may im- pede their ability to experience emotional relief. For ex- Reinforcement Reinforcement (decreased negative (decreased negative ample, in response to negative appraisals, suppression affect or increased affect or increased positive affect) positive affect) may be employed in an attempt to regulate negative emotional responses. However, suppression of unwanted thoughts and emotions paradoxically leads to more in- Fig. 1 This model highlights the links between emotion dysregulation, opioid misuse, and suicide risk among chronic pain patients as outlined tense emotional reactions as cognitive resources become in this review. The recurrent experience of pain and long-term opioid exhausted [21]. Additionally, thought suppression is as- exposure may drive emotion dysregulation in the form of negative sociated with greater pain severity, pain interference, emotional hyperreactivity and hedonic hyporeactivity, as well as deficits and depressive symptoms among chronic pain patients in the ability to proactively regulate emotions. Chronic pain patients with trauma histories [30], and increased opioid craving prescribed long-term opioids who experience emotion dysregulation may respond with risky or maladaptive behaviors through a process of among chronic pain patients with depressive symptoms negative cognitions and affect. Specifically, as chronic pain patients [31]. Rather than engaging in suppression, individuals become caught up in negative thoughts and feelings about their pain may attempt to regulate their emotions through re- (e.g., pain catastrophizing), they may experience craving for opioids as a appraisal, a cognitive emotion regulation strategy fo- way to relieve those negative thoughts and feelings or thoughts of cused on decreasing negative affect by reinterpreting suicide as a way of escaping their present experiences. If they engage in opioid-misusing behaviors and experience either relief from negative situations in more adaptive ways [32]. However, studies affect or increased positive affect, they become more likely to engage in suggest that both chronic pain and opioid use interfere those behaviors as ways to manage distress through a process of with reappraisal processes and decrease reappraisal effi- reinforcement. Relatedly, suicidal behaviors, such as planning or cacy [33, 34]. From a neurobiological perspective, emo- preparatory behaviors, may result in relief from negative affect or tion regulation failures may result from inefficient increased positive affect when chronic pain patients feel like they have the means to escape their pain and distress. For example, top-down prefrontal modulation of bottom-up limbic hoarding medications, an indication of opioid misuse, can also be activation—a pattern of neural dysfunction that has been considered a preparatory behavior given the primary method of observed among chronic pain patients [35]. When sup- suicide planning endorsed by chronic pain patients is medication pression or reappraisal efforts fail, opioid-treated pain overdose. These links likely represent recursive processes, e.g., just patients may turn to problematic emotion regulation as chronic pain and opioid use lead to emotion dysregulation, so does emotion dysregulation likely contribute to increased pain and strategies (i.e., opioid misuse or suicidal behavior) as opioid use. Similarly, although opioid misuse and suicidal behaviors may means of experiencing relief from their negative cogni- be employed in response to emotion dysregulation, they ultimately may tions and affect. lead to more frequent instances of emotion dysregulation Emotion dysregulation as a transdiagnostic momentary fluctuations in pain or other somatic states process in chronic pain may be misinterpreted as dangerous or an indication of Mental health professionals have traditionally relied on damage to the body rather than benign physiological categorical descriptions to classify psychiatric disorders, Riquino et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:11 Page 4 of 9 in contrast to a newer transdiagnostic perspective that especially in the absence of other available adaptive coping eschews discrete taxonomies to consider underlying and strategies [9, 13]. Insofar as skill and self-efficacy are ne- universal processes undergirding impaired functioning cessary for effective implementation of emotion regulation [36]. A transdiagnostic approach may more effectively strategies [18], psychotherapeutic interventions that pro- characterize the maladaptive psychological conditions vide affect regulation training may prevent opioid misuse that commonly cooccur with chronic pain [37, 38]. For and suicidal behavior in the context of chronic pain. As example, chronic pain patients are at increased risk for such, we conclude with a discussion of promising be- comorbid psychiatric disorders, including depression, havioral treatment approaches to remediate emotion trauma, and substance use disorders. Indeed, it has been dysregulation among chronic pain patients [49, 50]. estimated that up to 85% of chronic pain patients experi- ence severe depression [39, 40], between 10 and 50% re- Maladaptive responses to emotion dysregulation port a history of trauma [41], and 16% exhibit substance Opioid misuse among opioid-treated chronic pain use disorders above and beyond misuse of prescription patients opioids [7]. Although these psychiatric comorbidities Despite increasing recognition of the public health risks of have been traditionally studied as separate nosological opioid analgesic pharmacotherapy [2], a dearth of access- entities with distinct etiologies, emerging research sug- ible, alternative treatments has led to an over-reliance on gests that they share common transdiagnostic processes opioids and adverse consequences for chronic pain pa- that may explain their association with chronic pain. tients [51]. These consequences include misuse of medi- Emotion dysregulation is one such transdiagnostic cation (e.g., unauthorized dose escalation) as a way to process that subserves the development and mainten- escape from pain, manage mood, and relieve stress— ance of disrupted functioning and maladaptive behaviors behaviors that are maintained through a process of across an array of physical and mental health conditions negative reinforcement. Chronic pain is an ever-present, [42, 43]. Emotion dysregulation may be antecedent and aversive experience. Research supports that relief of on- consequent to chronic pain. For instance, individuals going pain increases dopamine transmission and negative with a trait-like propensity towards emotion dysregula- reinforcement of the behavior (e.g., [50, 51]). When a tion may be at greater risk for developing chronic pain chronic pain patient relieves pain with opioids, taking following an acute injury. However, as pain progresses medication is negatively reinforced [52, 53]. Over time, from an acute to chronic condition, many individuals some patients will begin to take their medication more develop an attentional bias to pain-related information frequently or in higher doses to experience less pain or such that their attention becomes preferentially allocated greater relief for longer periods of time. Neuropharmaco- to sensations of pain and environmental stimuli associ- logical studies demonstrate that opioids bind to ated with pain episodes [44, 45]. Over time, the experi- mu-opioid receptors in brain regions subserving pain per- ence of pain coupled with this attentional bias can result ception, emotional experience, and reward (i.e., pleasure in pain catastrophizing [46] and persistent negative cog- and well-being) [54]. Opioidergic activation of reward cir- nitions, e.g., “This pain will never end” or “This is the cuitry, including the ventral tegmental area and nucleus worst pain I have ever felt.” When pain sensations are accumbens, results in feelings of euphoria [55]. Conse- interpreted through the lens of catastrophic cognitive quently, chronic pain patients begin to associate appraisals, chronic pain patients may experience dysreg- opioid-related cues (e.g., the sight of a pill bottle) with that ulated emotions, manifested by decreased distress toler- euphoria [56], leading to an attentional bias toward opioid ance [47] and heightened stress reactivity [20]. In turn, cues [57] and the subjective experience of craving [58]ir- the consequent deficits in positive affect and surfeits in respective of the need to obtain pain relief. This process of negative affect result in heightened pain sensitivity [48], conditioning may drive opioid dose escalation and result which thereby exacerbates and prolongs chronic pain. in opioid use that increases risk of overdose [54]. The escalation over time of this downward spiral of pain Moreover, chronic opioid use and misuse may result sensations, biased attention to pain cues, pain catastro- in allostatic changes to limbic and striatal brain circuitry phizing, and dysregulated emotions may drive chronic leading to a persistent and escalating hedonic deficit pain patients to misuse opioids [4] or attempt suicide as characterized by increased sensitivity to stress and pain ways of responding to their overwhelming distress. coupled with decreased sensitization to natural rewards For the remainder of this review, we focus on opioid [4, 59, 60]. As a result of this allostatic process, misuse and suicidality—two maladaptive processes that opioid-misusing chronic pain patients evince blunted are especially prevalent and pernicious among individ- autonomic responses during processing of natural re- uals with chronic pain. Chronic pain patients prescribed wards and while attempting to regulate negative emo- opioid therapy may turn to opioid misuse and suicidality tions through reappraisal [61]. Indeed, opioid-misusing in response to instances of emotion dysregulation, chronic pain patients report less use of reappraisal than Riquino et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:11 Page 5 of 9 pain patients who take opioids as prescribed, and these experience suicidality with increasing frequency and in- deficits in reappraisal use predict heightened affective tensity due to physical pain and emotional distress. Sui- distress and opioid craving (Garland EL, Hanley AW, cidality is negatively reinforced insofar as suicidal ideation Bedford C, Zubieta JK, Howard MO, Nakamura Y, and suicidal behaviors (e.g., preparatory behaviors) may Donaldson GW, Froeliger, B. Reappraisal deficits among relieve negative cognitions and affect [70, 71]—in other prescription opioid misusing chronic pain patients, sub- words, as individuals consider suicide as a way of es- mitted). This opioid-induced emotion dysregulation may caping pain or hoard their opioids in preparation of exacerbate pre-existing affective disorders that antedate attempting suicide, they may experience relief from chronic pain and initiation of opioid analgesic use [62, thoughts of burdensomeness or feelings of hopelessness 63]. Thus, individuals who are vulnerable to negative nowthattheyhavedeterminedawaytoend theirsuf- affect may be more likely to misuse medication to offset fering. These suicidal thoughts and behaviors may pro- dysphoria, which may exacerbate negative mood via allo- duce positive affect, such as feelings of calm or static neuroadaptations to brain circuits involved in emo- acceptance of death. The dangerous escalation and tion regulation. Relatedly, through processes of positive cooccurrence of opioid misuse and suicidality may re- and negative reinforcement, individuals become more sult in death by overdose or suicide if left untreated. likely to continue engaging in opioid misuse as an emo- tion regulatory (i.e., coping) mechanism; the euphorigenic Psychotherapeutic mechanisms addressing neuropsychopharmacological effects of opioids may tem- emotion dysregulation porarily increase positive affect and decrease negative A growing body of literature has illustrated the effective- affect, propelling the cycle of escalating opioid misuse to- ness of psychosocial interventions to address chronic ward opioid addiction [4]. pain. For example, a recent systematic review of ran- domized controlled trials (RCTs) of mindfulness-based Suicidality among opioid-treated chronic pain patients interventions (MBIs) for chronic pain demonstrated sig- Although the mechanisms linking suicidality to chronic nificant improvements in pain, depression symptoms, pain are still being explored, consistent evidence has and quality of life [50]. Similarly, cognitive-behavior demonstrated that chronic pain patients are at height- therapy (CBT) has been extensively researched as a ened risk for experiencing suicidal thoughts and exhibit- treatment for chronic pain, and has demonstrated effi- ing life-threatening behaviors [13, 64, 65]. The link cacy for reducing pain-related interference by restructur- between chronic pain and suicidality may, in part, be ex- ing the cognitive distortions that arise in response to plained by emotion dysregulation. For example, suicidal- pain, as well as by increasing activity scheduling and ity is often preceded by persistent negative affect and pacing [72]. Though both MBIs and CBT can reduce anhedonia [66–69], two characteristics that often de- negative emotional hyperreactivity [50, 72], neither velop in response to pain. Specifically, as individuals ex- MBIs nor CBT are specifically focused on remediating perience repeated instances of heightened negative affect hedonic hyporeactivity undergirding opioid misuse and because of pain and stress (i.e., negative emotional hy- suicidality among chronic pain patients—akeyrisk perreactivity), they may experience a concomitant blunt- mechanism thought to perpetuate the downward spiral ing of hedonic capacity—the ability to experience of behavioral escalation articulated above. In contrast, pleasure from naturally rewarding objects and events in Mindfulness-Oriented Recovery Enhancement (MORE) the social environment [19]. This deficit in hedonic cap- is a novel intervention that combines principles of acity may be exacerbated by the neuropsychopharmacolo- mindfulness, CBT, and positive psychology to target he- gic effects of chronic opioid use, as articulated above. In the donic dysregulation in addiction, affective disorders, absence of healthy hedonic tone (i.e., hedonic hyporeac- and chronic pain through training in mindfulness, re- tivity), chronic pain patients may respond to distressing appraisal, and savoring skills [73, 74]. Completed and situations with suicidal ideation, e.g., thoughts of escap- ongoing RCTs are demonstrating positive effects of this ing the resultant negative cognitive-affective states. In intervention on treating pain symptoms and opioid support of this, our team recently published a study on misuse among chronic pain patients prescribed opioid the association between suicidal ideation and prescrip- therapy [75]. From a mechanistic perspective, the three tion opioid craving and cue-reactivity [69]. Among a primary components of MORE may be especially effica- sample of 115 chronic pain patients, we found that sui- cious means of remediating the emotion dysregulation cidal ideation predicted opioid cue-reactivity, as mea- that impels both opioid misuse and suicidality among sured by heart rate variability while completing a chronic pain patients. dot-probe task, via self-medication urges. Just as opioid Mindfulness can be conceptualized as a practice,a misuse is strengthened through processes of negative state, and a trait [76]. The state of mindfulness is char- and positive reinforcement, chronic pain patients may acterized by a nonreactive, metacognitive awareness and Riquino et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:11 Page 6 of 9 acceptance of present moment thoughts, emotions, and to the restructuring reward hypothesis [74], savoring may sensations [77]. Mindfulness practices include mindful counter hedonic hyporeactivity underlying opioid misuse breathing, body scan meditations, and the informal prac- by shifting valuation of drug-related rewards back to valu- tice of mindfulness during everyday tasks and activities. ation of natural rewards. A number of studies have pro- As one evokes the state of mindfulness through these vided support for the restructuring reward hypothesis by practices, one begins to develop the trait of mindfulness, demonstrating effects of MORE on autonomic [95, 96], or dispositional mindfulness [78]. With respect to the electrocortical [97], and neural functional [98] measures focus of this article, trait mindfulness is positively associ- of reward processing that were in turn correlated with re- ated with psychological well-being [79] and negatively ductions in drug craving and use/misuse. Moreover, in- associated with self-medication of negative emotions creasing positive affect has analgesic effects [99], and in with opioids among a sample of chronic pain patients that regard, increasing brain reward responses through [80]. Mindfulness practice appears to strengthen the mindfulness and other behavioral manipulations has been function and structure of prefrontally-mediated cognitive associated with decreased pain [100, 101]. control networks [80–83], including those associated MORE shares common transtherapeutic processes with emotion regulation, which in turn promotes with other MBIs and CBT approaches; however, the top-down regulation of bottom-up emotional impulses unique integration of its three components may be espe- [83, 84]. Moreover, mindfulness alleviates pain by facili- cially effective for addressing emotion dysregulation tating a shift from affective to sensory processing of pain among chronic pain patients. To be clear, whether or sensations [75, 85] and reducing thalamic amplification not they are combined in an integrative treatment pack- of nociceptive input via prefrontal cognitive control age like MORE, therapeutic techniques involving mind- mechanisms [86, 87]. In these ways, mindfulness training fulness, reappraisal, and savoring can successfully treat can promote emotion regulation, reduce pain, and pre- the difficulties in emotion-generation and emotion regu- vent maladaptive coping behaviors. lation failures associated with maladaptive pain coping. Reappraisal is an adaptive emotion regulation skill that Moreover, new affect regulation interventions and those can interrupt intense or persistent negative emotions that have demonstrated success in reducing suicidal [88]. Recent neuroscientific research demonstrates that ideation and substance misuse outside the context of it may also activate brain reward circuitry in ways con- chronic pain might be translated and tailored to address sistent with positive emotion regulation [89]. Specifically, the unique clinical features of comorbid pain, suicidality, as individuals examine irrational or unhelpful cognitions and opioid misuse. that arise in response to distressing situations and recognize how those perceptions influence their emo- Conclusion tional experiences, they can dispute those negative cog- Cognitive, affective, and physiological antecedents and nitions through the process of reappraisal and thereby consequences of pain render chronic pain patients pre- experience consequent decreases in negative affect and scribed long-term opioid pharmacotherapy vulnerable to increases in positive affect. Further, cognitive regulation opioid misuse and suicidality—two hazardous behaviors strategies like reappraisal have been shown to be an es- with significant mortality risk. Established bidirectional pecially potent means of decreasing pain intensity, in relationships between pain, opioid use, and affective dis- part though cortical modulation of pain and concomi- tress underscore the potential role of emotion dysregula- tant emotional reactivity [90, 91]. According to recent tion in the development and maintenance of opioid theorizing, reappraisal may also be strengthened by misuse and suicidality among chronic pain patients. As mindfulness practice [92]—a claim supported by empir- such, emotion dysregulation represents an important ical evidence [93, 94]. MORE capitalizes on the synergy transdiagnostic treatment target for future prevention of mindfulness and reappraisal to strengthen emotion and intervention approaches designed to reduce lethal regulation capacity. and life-threatening behaviors among opioid-treated The final component of MORE, savoring, targets he- chronic pain patients. donic hyporeactivity resulting from chronic pain and long-term exposure to opioids [60]. Savoring is an emo- tion regulation strategy in which the individual mindfully Abbreviations attends to features (e.g., the sight, sound, scent, and feel) CBT: Cognitive-Behavior Therapy; MBI: Mindfulness-Based Intervention; of naturally-rewarding stimuli (e.g., beauty of the natural MORE: Mindfulness-Oriented Recovery Enhancement world, affiliative rewards, pleasurable physical sensations) while metacognitively monitoring and appreciating pleas- Funding ant emotions and higher-order affective meaning arising ELG was supported by grants NIDA-R01DA042033 and NCCIH-R61AT009296 during the preparation of this manuscript. from the encounter with the pleasant stimulus. According Riquino et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:11 Page 7 of 9 Authors’ contributions 18. Gross JJ, Jazaieri H. Emotion, emotion regulation, and psychopathology: an MRR developed the conceptual framework and conducted the literature affective science perspective. 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Emotion dysregulation as a transdiagnostic mechanism of opioid misuse and suicidality among chronic pain patients

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Abstract

Background: Chronic pain is a prevalent condition that causes functional impairment and emotional suffering. To allay pain-induced suffering, opioids are often prescribed for chronic pain management. Yet, chronic pain patients on opioid therapy are at heightened risk for opioid misuse—behaviors that can lead to addiction and overdose. Relatedly, chronic pain patients are at elevated risk for suicidal ideation and suicidal behaviors. Main body: Opioid misuse and suicidality are maladaptive processes aimed at alleviating the negative emotional hyperreactivity, hedonic hyporeactivity, and emotion dysregulation experienced by chronic pain patients on opioid therapy. In this review, we explore the role of emotion dysregulation in chronic pain. We then describe why emotionally dysregulated chronic pain patients are vulnerable to opioid misuse and suicidality in response to these negative affective states. Conclusion: Emotion dysregulation is an important and malleable treatment target with the potential to reduce or prevent opioid misuse and suicidality among opioid-treated chronic pain patients. Keywords: Anhedonia, Chronic pain, Emotion dysregulation, Opioid misuse, Reinforcement, Suicidality Background clinical presentation of opioid-treated chronic pain Approximately 100 million Americans suffer from patients is often complicated by comorbid psychiatric chronic pain, a condition compounded by maladaptive distress, substance use disorders, and suicidality [5–7]— cognitive and emotional processes that often cooccur so-called “epidemics of despair” that account for rising with protracted and severe physical suffering [1]. Opioid mortality rates in the U.S. [8]—in part through intentional therapy continues to be the primary medical treatment opioid overdose. Yet, biobehavioral mechanistic models for chronic pain despite associated risks, including opi- linking chronic pain to opioid misuse and suicidal be- oid misuse, addiction, and overdose [2], as well as dele- havior are lacking. terious neuropsychopharmacologic effects of prolonged In this conceptual review, we posit that the transdiag- opioid exposure, including dysregulation in brain circuits nostic process of emotion dysregulation is central to un- undergirding reward processing, stress reactivity, and derstanding why opioid-treated chronic pain patients the proactive regulation of emotions [3, 4]. Given the engage in opioid misuse and suicidal behaviors. Al- magnitude of the current opioid crisis in the U.S., there though emotion dysregulation may result in multiple is an urgent need to understand the psychological fac- forms of maladaptive behavior, here we focus on opioid tors that drive individuals with chronic pain to misuse misuse and suicidality as sequelae of chronic pain due to their prescribed opioid medications. Furthermore, the their high prevalence and significant public health im- pact. Recent meta-analyses suggest that 25% of chronic pain patients engage in opioid-misusing behaviors like * Correspondence: eric.garland@socwk.utah.edu opioid dose escalation or self-medicating negative University of Utah College of Social Work, 395 South 1500 East, Salt Lake City, UT 84112, USA affective states with opioids [9]. As will be discussed Center on Mindfulness and Integrative Health Intervention Development, later, opioid misuse is associated with adverse conse- 395 South 1500 East, Salt Lake City, UT 84112, USA quences such as increased sensitivity to pain and stress, Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Riquino et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:11 Page 2 of 9 decreased sensitivity to natural rewards, functional im- In this review, we posit that emotion dysregulation is pairments, and overdose risk [10–12]. Similarly, suicidal- the process that links these situational appraisals to ity, which encompasses both suicidal ideation and maladaptive behaviors, including opioid misuse and sui- behaviors, is especially common among individuals with cidality (see Fig. 1 for a depiction of this process). Emo- chronic pain. Chronic pain patients have nearly two tion dysregulation is marked by difficulties with the times the risk of death by suicide and are two to three emotion-generative process and/or emotion regulation times more likely than individuals without chronic pain failures—i.e., not effectively employing adaptive emotion to report suicidal ideation or make suicide attempts [13]. regulation strategies when it would be appropriate to do Drug overdose is the most commonly reported means of so [18]. The decreased hedonic capacity [19] and height- attempting suicide among chronic pain patients [14]. ened stress sensitization [20] associated with chronic Given high rates of suicidal ideation and suicide at- pain and long-term opioid therapy indicate difficulties in tempts among chronic pain patients, and the ready pres- the emotion-generative process. Emotion-generation diffi- ence of lethal means via opioid prescription, risk of culties may result in persistent negative affect that con- death by suicide warrants particular attention among tributes to emotion dysregulation [18], and thus, these opioid-treated chronic pain patients—a population difficulties are relevant to the development and mainten- already at increased mortality risk [15, 16]. ance of opioid misuse and suicidality. Relying on mal- The primary aim of this review is to explore interrela- adaptive coping strategies to regulate negative cognitions tionships of emotion dysregulation and opioid-treated and affect (like misuse of opioids to self-medicate dys- chronic pain, and in particular, to propose how these phoric emotional states or attempting suicide to escape factors give rise to opioid misuse and suicidality. To from emotional suffering) would be considered emotion this end, we first describe emotion dysregulation regulation failures. Additionally, reappraisal and sup- among opioid-treated chronic pain patients. We then pression, classic forms of emotion regulation, may go explore the role of emotion dysregulation as a trans- awry in response to chronic pain [21]—a subject we will diagnostic process underlying the development and address in our discussion of factors contributing to emo- maintenance of opioid misuse and suicidality in this tion dysregulation among opioid-treated chronic pain high-risk population. Finally, we conclude by consider- patients. ing how psychological interventions designed to en- hance affect regulation might address the emotion Difficulties with the emotion-generative process dysregulatory processes subserving opioid misuse and In their review of the roles of emotion and emotion suicidality among chronic pain patients receiving long-term regulation in psychopathology, Gross and Jazaieri (2014) opioid treatment. outlined areas where individuals might experience emotion-related difficulties, e.g., emotion intensity and emotion duration [18]. These difficulties with the Emotion, appraisal, and emotion dysregulation in emotion-generative process are relevant to chronic pain chronic pain patients given the high levels of psychiatric comorbidi- The cognitive-motivational-relational theory of emotion ties present in this population. Hyperreactivity or hypor- asserts that emotions arise in response to a cognitive ap- eactivity, i.e., exhibiting too large or too small an praisal of the meaning or significance of a particular emotional response to a given situation, are indicative of stimulus context [17]. In other words, the relational problematic emotional intensity [22]. Among chronic meaning one derives through the process of appraisal in pain patients, distressing situations may elicit negative response to a given situation determines whether one emotional hyperreactivity [20], whereas rewarding situa- experiences sadness, happiness, or some other emo- tions may result in blunted positive emotional re- tion. From this perspective, appraisals drive emotions sponses—i.e., hedonic hyporeactivity [19]. Just as the and thereby shape emotion regulatory attempts [17]. experience of pain may modulate emotional intensity With respect to chronic pain, when patients experi- [23], pain may also affect the duration of emotional ex- ence an aggravation in the symptomatic expression of perience. As the experience of pain transitions from an their underlying painful condition or encounter an acute to a chronic condition, negative affective reactions emotionally-distressing situation, they may respond in may become more common and long-lasting due to in- maladaptive ways depending on how they appraise the creasingly catastrophic appraisals of pain [24]. situation. For example, appraisals of situational help- In the context of recurrent negative emotionality and lessness, hopelessness, or feelings of interpersonal hedonic hyporeactivity, individuals may become hyper- burdensomeness may drive opioid misuse as a coping vigilant for perturbations to their normative physio- strategy or thoughts of suicide as a way to escape the logical state and negatively appraise their bodily situation. condition as problematic. For chronic pain patients, Riquino et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:11 Page 3 of 9 sensations that do not signal harm [25]. These negative interpretations can lead to a cascade of negative emo- Opioid use Chronic pain tions or catastrophic thinking that interferes with indi- viduals’ ability to regulate emotional distress. Given evidence for interoceptive deficits among individuals with chronic pain [26, 27], chronic pain patients may Emotion dysregulation struggle with differentiating pain sensations from the autonomic, visceral, and musculoskeletal changes evoked by negative emotions. The tendency to label pain as “awful,”“horrible,” or with other emotionally-laden de- scriptors suggests pain can become conflated with the Negative Negative cognitions & affect cognitions & affect emotional distress it creates [28]. Because interoceptive awareness facilitates emotion regulation [29], chronic pain patients with interoceptive deficits may be less able to discriminate pain from the physical sequelae of nega- Opioid craving Suicidal ideation tive emotions, and therefore are less inclined (or able) to engage in proactive emotion regulation attempts. Suicidal behaviors (e.g., preparatory Opioid misuse Factors contributing to emotion dysregulation behaviors) When chronic pain patients do attempt to regulate their emotions, ineffective strategies or skills deficits may im- pede their ability to experience emotional relief. For ex- Reinforcement Reinforcement (decreased negative (decreased negative ample, in response to negative appraisals, suppression affect or increased affect or increased positive affect) positive affect) may be employed in an attempt to regulate negative emotional responses. However, suppression of unwanted thoughts and emotions paradoxically leads to more in- Fig. 1 This model highlights the links between emotion dysregulation, opioid misuse, and suicide risk among chronic pain patients as outlined tense emotional reactions as cognitive resources become in this review. The recurrent experience of pain and long-term opioid exhausted [21]. Additionally, thought suppression is as- exposure may drive emotion dysregulation in the form of negative sociated with greater pain severity, pain interference, emotional hyperreactivity and hedonic hyporeactivity, as well as deficits and depressive symptoms among chronic pain patients in the ability to proactively regulate emotions. Chronic pain patients with trauma histories [30], and increased opioid craving prescribed long-term opioids who experience emotion dysregulation may respond with risky or maladaptive behaviors through a process of among chronic pain patients with depressive symptoms negative cognitions and affect. Specifically, as chronic pain patients [31]. Rather than engaging in suppression, individuals become caught up in negative thoughts and feelings about their pain may attempt to regulate their emotions through re- (e.g., pain catastrophizing), they may experience craving for opioids as a appraisal, a cognitive emotion regulation strategy fo- way to relieve those negative thoughts and feelings or thoughts of cused on decreasing negative affect by reinterpreting suicide as a way of escaping their present experiences. If they engage in opioid-misusing behaviors and experience either relief from negative situations in more adaptive ways [32]. However, studies affect or increased positive affect, they become more likely to engage in suggest that both chronic pain and opioid use interfere those behaviors as ways to manage distress through a process of with reappraisal processes and decrease reappraisal effi- reinforcement. Relatedly, suicidal behaviors, such as planning or cacy [33, 34]. From a neurobiological perspective, emo- preparatory behaviors, may result in relief from negative affect or tion regulation failures may result from inefficient increased positive affect when chronic pain patients feel like they have the means to escape their pain and distress. For example, top-down prefrontal modulation of bottom-up limbic hoarding medications, an indication of opioid misuse, can also be activation—a pattern of neural dysfunction that has been considered a preparatory behavior given the primary method of observed among chronic pain patients [35]. When sup- suicide planning endorsed by chronic pain patients is medication pression or reappraisal efforts fail, opioid-treated pain overdose. These links likely represent recursive processes, e.g., just patients may turn to problematic emotion regulation as chronic pain and opioid use lead to emotion dysregulation, so does emotion dysregulation likely contribute to increased pain and strategies (i.e., opioid misuse or suicidal behavior) as opioid use. Similarly, although opioid misuse and suicidal behaviors may means of experiencing relief from their negative cogni- be employed in response to emotion dysregulation, they ultimately may tions and affect. lead to more frequent instances of emotion dysregulation Emotion dysregulation as a transdiagnostic momentary fluctuations in pain or other somatic states process in chronic pain may be misinterpreted as dangerous or an indication of Mental health professionals have traditionally relied on damage to the body rather than benign physiological categorical descriptions to classify psychiatric disorders, Riquino et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:11 Page 4 of 9 in contrast to a newer transdiagnostic perspective that especially in the absence of other available adaptive coping eschews discrete taxonomies to consider underlying and strategies [9, 13]. Insofar as skill and self-efficacy are ne- universal processes undergirding impaired functioning cessary for effective implementation of emotion regulation [36]. A transdiagnostic approach may more effectively strategies [18], psychotherapeutic interventions that pro- characterize the maladaptive psychological conditions vide affect regulation training may prevent opioid misuse that commonly cooccur with chronic pain [37, 38]. For and suicidal behavior in the context of chronic pain. As example, chronic pain patients are at increased risk for such, we conclude with a discussion of promising be- comorbid psychiatric disorders, including depression, havioral treatment approaches to remediate emotion trauma, and substance use disorders. Indeed, it has been dysregulation among chronic pain patients [49, 50]. estimated that up to 85% of chronic pain patients experi- ence severe depression [39, 40], between 10 and 50% re- Maladaptive responses to emotion dysregulation port a history of trauma [41], and 16% exhibit substance Opioid misuse among opioid-treated chronic pain use disorders above and beyond misuse of prescription patients opioids [7]. Although these psychiatric comorbidities Despite increasing recognition of the public health risks of have been traditionally studied as separate nosological opioid analgesic pharmacotherapy [2], a dearth of access- entities with distinct etiologies, emerging research sug- ible, alternative treatments has led to an over-reliance on gests that they share common transdiagnostic processes opioids and adverse consequences for chronic pain pa- that may explain their association with chronic pain. tients [51]. These consequences include misuse of medi- Emotion dysregulation is one such transdiagnostic cation (e.g., unauthorized dose escalation) as a way to process that subserves the development and mainten- escape from pain, manage mood, and relieve stress— ance of disrupted functioning and maladaptive behaviors behaviors that are maintained through a process of across an array of physical and mental health conditions negative reinforcement. Chronic pain is an ever-present, [42, 43]. Emotion dysregulation may be antecedent and aversive experience. Research supports that relief of on- consequent to chronic pain. For instance, individuals going pain increases dopamine transmission and negative with a trait-like propensity towards emotion dysregula- reinforcement of the behavior (e.g., [50, 51]). When a tion may be at greater risk for developing chronic pain chronic pain patient relieves pain with opioids, taking following an acute injury. However, as pain progresses medication is negatively reinforced [52, 53]. Over time, from an acute to chronic condition, many individuals some patients will begin to take their medication more develop an attentional bias to pain-related information frequently or in higher doses to experience less pain or such that their attention becomes preferentially allocated greater relief for longer periods of time. Neuropharmaco- to sensations of pain and environmental stimuli associ- logical studies demonstrate that opioids bind to ated with pain episodes [44, 45]. Over time, the experi- mu-opioid receptors in brain regions subserving pain per- ence of pain coupled with this attentional bias can result ception, emotional experience, and reward (i.e., pleasure in pain catastrophizing [46] and persistent negative cog- and well-being) [54]. Opioidergic activation of reward cir- nitions, e.g., “This pain will never end” or “This is the cuitry, including the ventral tegmental area and nucleus worst pain I have ever felt.” When pain sensations are accumbens, results in feelings of euphoria [55]. Conse- interpreted through the lens of catastrophic cognitive quently, chronic pain patients begin to associate appraisals, chronic pain patients may experience dysreg- opioid-related cues (e.g., the sight of a pill bottle) with that ulated emotions, manifested by decreased distress toler- euphoria [56], leading to an attentional bias toward opioid ance [47] and heightened stress reactivity [20]. In turn, cues [57] and the subjective experience of craving [58]ir- the consequent deficits in positive affect and surfeits in respective of the need to obtain pain relief. This process of negative affect result in heightened pain sensitivity [48], conditioning may drive opioid dose escalation and result which thereby exacerbates and prolongs chronic pain. in opioid use that increases risk of overdose [54]. The escalation over time of this downward spiral of pain Moreover, chronic opioid use and misuse may result sensations, biased attention to pain cues, pain catastro- in allostatic changes to limbic and striatal brain circuitry phizing, and dysregulated emotions may drive chronic leading to a persistent and escalating hedonic deficit pain patients to misuse opioids [4] or attempt suicide as characterized by increased sensitivity to stress and pain ways of responding to their overwhelming distress. coupled with decreased sensitization to natural rewards For the remainder of this review, we focus on opioid [4, 59, 60]. As a result of this allostatic process, misuse and suicidality—two maladaptive processes that opioid-misusing chronic pain patients evince blunted are especially prevalent and pernicious among individ- autonomic responses during processing of natural re- uals with chronic pain. Chronic pain patients prescribed wards and while attempting to regulate negative emo- opioid therapy may turn to opioid misuse and suicidality tions through reappraisal [61]. Indeed, opioid-misusing in response to instances of emotion dysregulation, chronic pain patients report less use of reappraisal than Riquino et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:11 Page 5 of 9 pain patients who take opioids as prescribed, and these experience suicidality with increasing frequency and in- deficits in reappraisal use predict heightened affective tensity due to physical pain and emotional distress. Sui- distress and opioid craving (Garland EL, Hanley AW, cidality is negatively reinforced insofar as suicidal ideation Bedford C, Zubieta JK, Howard MO, Nakamura Y, and suicidal behaviors (e.g., preparatory behaviors) may Donaldson GW, Froeliger, B. Reappraisal deficits among relieve negative cognitions and affect [70, 71]—in other prescription opioid misusing chronic pain patients, sub- words, as individuals consider suicide as a way of es- mitted). This opioid-induced emotion dysregulation may caping pain or hoard their opioids in preparation of exacerbate pre-existing affective disorders that antedate attempting suicide, they may experience relief from chronic pain and initiation of opioid analgesic use [62, thoughts of burdensomeness or feelings of hopelessness 63]. Thus, individuals who are vulnerable to negative nowthattheyhavedeterminedawaytoend theirsuf- affect may be more likely to misuse medication to offset fering. These suicidal thoughts and behaviors may pro- dysphoria, which may exacerbate negative mood via allo- duce positive affect, such as feelings of calm or static neuroadaptations to brain circuits involved in emo- acceptance of death. The dangerous escalation and tion regulation. Relatedly, through processes of positive cooccurrence of opioid misuse and suicidality may re- and negative reinforcement, individuals become more sult in death by overdose or suicide if left untreated. likely to continue engaging in opioid misuse as an emo- tion regulatory (i.e., coping) mechanism; the euphorigenic Psychotherapeutic mechanisms addressing neuropsychopharmacological effects of opioids may tem- emotion dysregulation porarily increase positive affect and decrease negative A growing body of literature has illustrated the effective- affect, propelling the cycle of escalating opioid misuse to- ness of psychosocial interventions to address chronic ward opioid addiction [4]. pain. For example, a recent systematic review of ran- domized controlled trials (RCTs) of mindfulness-based Suicidality among opioid-treated chronic pain patients interventions (MBIs) for chronic pain demonstrated sig- Although the mechanisms linking suicidality to chronic nificant improvements in pain, depression symptoms, pain are still being explored, consistent evidence has and quality of life [50]. Similarly, cognitive-behavior demonstrated that chronic pain patients are at height- therapy (CBT) has been extensively researched as a ened risk for experiencing suicidal thoughts and exhibit- treatment for chronic pain, and has demonstrated effi- ing life-threatening behaviors [13, 64, 65]. The link cacy for reducing pain-related interference by restructur- between chronic pain and suicidality may, in part, be ex- ing the cognitive distortions that arise in response to plained by emotion dysregulation. For example, suicidal- pain, as well as by increasing activity scheduling and ity is often preceded by persistent negative affect and pacing [72]. Though both MBIs and CBT can reduce anhedonia [66–69], two characteristics that often de- negative emotional hyperreactivity [50, 72], neither velop in response to pain. Specifically, as individuals ex- MBIs nor CBT are specifically focused on remediating perience repeated instances of heightened negative affect hedonic hyporeactivity undergirding opioid misuse and because of pain and stress (i.e., negative emotional hy- suicidality among chronic pain patients—akeyrisk perreactivity), they may experience a concomitant blunt- mechanism thought to perpetuate the downward spiral ing of hedonic capacity—the ability to experience of behavioral escalation articulated above. In contrast, pleasure from naturally rewarding objects and events in Mindfulness-Oriented Recovery Enhancement (MORE) the social environment [19]. This deficit in hedonic cap- is a novel intervention that combines principles of acity may be exacerbated by the neuropsychopharmacolo- mindfulness, CBT, and positive psychology to target he- gic effects of chronic opioid use, as articulated above. In the donic dysregulation in addiction, affective disorders, absence of healthy hedonic tone (i.e., hedonic hyporeac- and chronic pain through training in mindfulness, re- tivity), chronic pain patients may respond to distressing appraisal, and savoring skills [73, 74]. Completed and situations with suicidal ideation, e.g., thoughts of escap- ongoing RCTs are demonstrating positive effects of this ing the resultant negative cognitive-affective states. In intervention on treating pain symptoms and opioid support of this, our team recently published a study on misuse among chronic pain patients prescribed opioid the association between suicidal ideation and prescrip- therapy [75]. From a mechanistic perspective, the three tion opioid craving and cue-reactivity [69]. Among a primary components of MORE may be especially effica- sample of 115 chronic pain patients, we found that sui- cious means of remediating the emotion dysregulation cidal ideation predicted opioid cue-reactivity, as mea- that impels both opioid misuse and suicidality among sured by heart rate variability while completing a chronic pain patients. dot-probe task, via self-medication urges. Just as opioid Mindfulness can be conceptualized as a practice,a misuse is strengthened through processes of negative state, and a trait [76]. The state of mindfulness is char- and positive reinforcement, chronic pain patients may acterized by a nonreactive, metacognitive awareness and Riquino et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:11 Page 6 of 9 acceptance of present moment thoughts, emotions, and to the restructuring reward hypothesis [74], savoring may sensations [77]. Mindfulness practices include mindful counter hedonic hyporeactivity underlying opioid misuse breathing, body scan meditations, and the informal prac- by shifting valuation of drug-related rewards back to valu- tice of mindfulness during everyday tasks and activities. ation of natural rewards. A number of studies have pro- As one evokes the state of mindfulness through these vided support for the restructuring reward hypothesis by practices, one begins to develop the trait of mindfulness, demonstrating effects of MORE on autonomic [95, 96], or dispositional mindfulness [78]. With respect to the electrocortical [97], and neural functional [98] measures focus of this article, trait mindfulness is positively associ- of reward processing that were in turn correlated with re- ated with psychological well-being [79] and negatively ductions in drug craving and use/misuse. Moreover, in- associated with self-medication of negative emotions creasing positive affect has analgesic effects [99], and in with opioids among a sample of chronic pain patients that regard, increasing brain reward responses through [80]. Mindfulness practice appears to strengthen the mindfulness and other behavioral manipulations has been function and structure of prefrontally-mediated cognitive associated with decreased pain [100, 101]. control networks [80–83], including those associated MORE shares common transtherapeutic processes with emotion regulation, which in turn promotes with other MBIs and CBT approaches; however, the top-down regulation of bottom-up emotional impulses unique integration of its three components may be espe- [83, 84]. Moreover, mindfulness alleviates pain by facili- cially effective for addressing emotion dysregulation tating a shift from affective to sensory processing of pain among chronic pain patients. To be clear, whether or sensations [75, 85] and reducing thalamic amplification not they are combined in an integrative treatment pack- of nociceptive input via prefrontal cognitive control age like MORE, therapeutic techniques involving mind- mechanisms [86, 87]. In these ways, mindfulness training fulness, reappraisal, and savoring can successfully treat can promote emotion regulation, reduce pain, and pre- the difficulties in emotion-generation and emotion regu- vent maladaptive coping behaviors. lation failures associated with maladaptive pain coping. Reappraisal is an adaptive emotion regulation skill that Moreover, new affect regulation interventions and those can interrupt intense or persistent negative emotions that have demonstrated success in reducing suicidal [88]. Recent neuroscientific research demonstrates that ideation and substance misuse outside the context of it may also activate brain reward circuitry in ways con- chronic pain might be translated and tailored to address sistent with positive emotion regulation [89]. Specifically, the unique clinical features of comorbid pain, suicidality, as individuals examine irrational or unhelpful cognitions and opioid misuse. that arise in response to distressing situations and recognize how those perceptions influence their emo- Conclusion tional experiences, they can dispute those negative cog- Cognitive, affective, and physiological antecedents and nitions through the process of reappraisal and thereby consequences of pain render chronic pain patients pre- experience consequent decreases in negative affect and scribed long-term opioid pharmacotherapy vulnerable to increases in positive affect. Further, cognitive regulation opioid misuse and suicidality—two hazardous behaviors strategies like reappraisal have been shown to be an es- with significant mortality risk. Established bidirectional pecially potent means of decreasing pain intensity, in relationships between pain, opioid use, and affective dis- part though cortical modulation of pain and concomi- tress underscore the potential role of emotion dysregula- tant emotional reactivity [90, 91]. According to recent tion in the development and maintenance of opioid theorizing, reappraisal may also be strengthened by misuse and suicidality among chronic pain patients. As mindfulness practice [92]—a claim supported by empir- such, emotion dysregulation represents an important ical evidence [93, 94]. MORE capitalizes on the synergy transdiagnostic treatment target for future prevention of mindfulness and reappraisal to strengthen emotion and intervention approaches designed to reduce lethal regulation capacity. and life-threatening behaviors among opioid-treated The final component of MORE, savoring, targets he- chronic pain patients. donic hyporeactivity resulting from chronic pain and long-term exposure to opioids [60]. Savoring is an emo- tion regulation strategy in which the individual mindfully Abbreviations attends to features (e.g., the sight, sound, scent, and feel) CBT: Cognitive-Behavior Therapy; MBI: Mindfulness-Based Intervention; of naturally-rewarding stimuli (e.g., beauty of the natural MORE: Mindfulness-Oriented Recovery Enhancement world, affiliative rewards, pleasurable physical sensations) while metacognitively monitoring and appreciating pleas- Funding ant emotions and higher-order affective meaning arising ELG was supported by grants NIDA-R01DA042033 and NCCIH-R61AT009296 during the preparation of this manuscript. from the encounter with the pleasant stimulus. According Riquino et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:11 Page 7 of 9 Authors’ contributions 18. Gross JJ, Jazaieri H. Emotion, emotion regulation, and psychopathology: an MRR developed the conceptual framework and conducted the literature affective science perspective. 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Journal

Borderline Personality Disorder and Emotion DysregulationSpringer Journals

Published: Jun 6, 2018

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