The Positivity Effect: The Role of Resilience in Battling the Current Opioid Epidemic

“Nothing is either good or bad, but thinking makes it so.”

                                                                                                   -William Shakespeare

 

According to the National Center for Complementary and Integrative Health (NCCIH), nearly 100 million American adults report suffering from chronic or severe pain [1]. Additionally, pain is a condition that disables more Americans in the US than heart disease, cancer and diabetes combined [2-5]. The most recent definition of chronic pain is as follows, “a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive, and social components” [6]. In accordance with the high prevalence of chronic pain, reports from the Centers for Disease Control concluded that the most commonly prescribed class of medication in the US are opioid analgesics despite a lack of evidence supporting their efficacy in treating chronic pain [7,8].  On the contrary, there is evidence to suggest prolonged opioid use leads to heightened pain sensitivity contributing to a toxic feedback loop [9].  A significant contributor to the current opioid epidemic is divergence from physician-prescribed opioids. In light of this, a more concerted effort has been made to investigate alternative treatments that require minimal opioid involvement for the management of chronic pain. Some strategies target altering prescriber practices of healthcare professionals to mitigate risks of overprescribing while enabling proper management of pain [10]. More recently, evidence has emerged supporting the efficacy of treatment strategies involving psychotherapeutic and mind-body approaches to enhance an individual’s ability to manage chronic pain as an alternative to long-term opioid use.

 

  Excerpt from a 1987  New York Times  interview with world renowned psychoneuroendocrinologist, Robert Ader. Psychotherapeutic methods that target the psychological component of chronic pain and other psychosomatic disorders are no longer new. The availability of current technologies that allow for evaluation of potential mechanisms of impact enables us to better understand and responsibly implement them in patient care practices  [ 11 ].

Excerpt from a 1987 New York Times interview with world renowned psychoneuroendocrinologist, Robert Ader. Psychotherapeutic methods that target the psychological component of chronic pain and other psychosomatic disorders are no longer new. The availability of current technologies that allow for evaluation of potential mechanisms of impact enables us to better understand and responsibly implement them in patient care practices [11].

 

Mind-body strategies have been highlighted due to empirical evidence supporting their use as a valuable alternative to opioids for treatment of chronic pain. These are strategies designed to change the way patients interact their pain based on scientific observations of the mind affecting body physiology and promoting health [12-15]. One subgroup of mind-body interventions, and the main subject of this article are Resilience Oriented Interventions (ROIs) for the management of chronic pain. This interest is due to their accessibility and thus increased likelihood of engagement by individuals suffering from chronic pain, as care provided by a mental health professional is not required. Resilience in the context of chronic pain, as modeled by Sturgeon & Zautra, is a process through which adaptation to aversive stimuli is promoted by reorienting an individual’s approach to their pain [16]. Resilience promoting strategies target the psychological and emotional components of chronic pain to, over time, alter pain perception such that the patient experiences reductions in feelings of helplessness and improvements in pain intensity, pain control, life satisfaction and overall well-being [16]. There are both negative and positive psychological and emotional components involved in chronic pain. The role of negative mechanisms in pain is well cited and includes catastrophizing or the tendency to feel more helpless about a painful experience, avoidance, and withdrawal which can lead to affective comorbidities such as depression, anxiety and long-term disability. Positive mechanisms are the target of ROIs that aim to promote adaptation to adversity, which in the context of this article is chronic pain.  Although people generally naturally exhibit resilience in many different contexts, it is unlikely an individual will be resilient to all adverse circumstances or stimuli. Thus, identification of therapeutic tools to reduce maladaptation to adversity that are easily accessible and can be employed at any time to foster resilience become of clinical value.

 

 Illustration of brain regions which are potential targets of Resilience Oriented Strategies. The  anterior cingulate cortex  is associated with pain and negative emotions. It encodes affective information preferentially over sensory information. The  prefrontal cortex  is considered the main driver in blocking responses to painful stimuli while the  striatum  and  amygdala  play significant roles in learning and predicting aversive stimuli. The  insula  and  posterior cingulate cortex/precuneus  are involved in processing self referential information." 

Illustration of brain regions which are potential targets of Resilience Oriented Strategies. The anterior cingulate cortex is associated with pain and negative emotions. It encodes affective information preferentially over sensory information. The prefrontal cortex is considered the main driver in blocking responses to painful stimuli while the striatum and amygdala play significant roles in learning and predicting aversive stimuli. The insula and posterior cingulate cortex/precuneus are involved in processing self referential information." 

Promotion of positive psychological states to manage chronic conditions through fostering resilience is a relatively new area of research, especially in the context of chronic pain. Studies employing the use of Positive Activity Interventions (PAIs) are amongst a group of mind-body therapies which aim to improve pain outcomes and life satisfaction by modulating how the individual thinks about themselves, others, and their environment when faced with aversive stimuli such as chronic pain [17]. PAIs are strategies designed from cognitions observed in emotionally resilient people which seek to provide an individual with cognitive and behavioral resources to enhance their own resilience [12]. In a 2016 study from the University Of Washington Department Of Rehabilitation Medicine, 96 participants with various chronic pain conditions were placed in either an untreated group or an 8-week PAI through an online diagnostic tool that matched each participant with an individually identified regimen of PAIs, four in total. This tailored method drew from PAIs such as Acts of Kindness, Gratitude, Savoring, Flow, Optimism, Relationships/social support, and Forgiveness to tailor the positive activities to those the participant would be most likely to enjoy and consistently engage in. The results of this study showed that 74% of participants indicated persistence in engagement throughout the eight weeks and those within the intervention group showed improvements in pain control, catastrophizing, intensity, pain interference, positive affect, depression, and life satisfaction. They also observed a dose effect in which participants who devoted more time engaging in the PAIs exhibited greater benefit than those who devoted less. In addition to this, a number of these positive effects persisted for two and a half months following the cessation of the study—a favorable outcome when compared to the nearly immediate loss of analgesic effects following cessation of opioid use [9, 18]. A major advantage of mind-body interventions is in their ability to be designed through mediums such as apps and online resources that patients and clinicians have access to without frequent visits to the clinic. Research continues to emerge in demonstrating a link between how one processes their experiences and subsequent inflammatory states—this link is thought to be the mechanism through which psychological activities driven by the mind such as PAIs exact physiological changes in the body.

 

 A painful experience can be considered an integration of information related to the stimuli itself – nocioception - and to an individual’s perception of that stimuli. These are referred to as “bottom up” and “top down” processing of pain where “bottom up” is initiated with sensory input, and “top down” begins with prior experience and knowledge associated with that stimulus. The role of negative emotions in “top down” processing is well documented in experiencing pain, but research demonstrating mechanisms through which positive affect attenuates pain is an emerging field of study. Resilience Oriented Strategies target “top down” processing to modulate attention paid to nocioceptive stimuli and to reduce perceived severity of the experience. Image credit:  Alex Sercel  with images licensed under  CC BY-NC-SA 4.0 .

A painful experience can be considered an integration of information related to the stimuli itself – nocioception - and to an individual’s perception of that stimuli. These are referred to as “bottom up” and “top down” processing of pain where “bottom up” is initiated with sensory input, and “top down” begins with prior experience and knowledge associated with that stimulus. The role of negative emotions in “top down” processing is well documented in experiencing pain, but research demonstrating mechanisms through which positive affect attenuates pain is an emerging field of study. Resilience Oriented Strategies target “top down” processing to modulate attention paid to nocioceptive stimuli and to reduce perceived severity of the experience. Image credit: Alex Sercel with images licensed under CC BY-NC-SA 4.0.

 

Implementation of practices that promote resilience in individuals coping with chronic pain serve to aid in reducing opioid exposure and thus mitigate risks of diversion and addiction. While there is little evidence to support the efficacy of opioids in treating chronic pain, recent studies support the role of the positivity effect in significantly reducing pain sensitivity and fostering well-being through psychological and biological pathways. Despite their evidenced benefit, ROIs are not a cure-all, and there remains a spectrum in efficacy of treatment highlighting the need for further research into the mechanisms of positive affect and how to effectively and sustainably modulate this mind-body interaction. Research exploring the influence and modulation of pain perception has the potential to revolutionize our methods of treating chronic pain by bolstering resilience and reducing opioid dependence.

 

 

Rockelle Guthrie

Staff Writer, Signal to Noise Magazine

PhD student, Molecular, Cellular, and Integrative Physiology Department, UCLA

 

 

References:

[1] “Chronic Pain: a Major Public Health Problem.” National Center for Complementary and Integrative Health, U.S. Department of Health and Human Services (24 Sept. 2017). nccih.nih.gov/news/multimedia/infographics/chronic-pain.

 

[2] Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press (2011).
http://books.nap.edu/openbook.php?record_id=13172&page=1.

 

[3] American Diabetes Association. 
http://www.diabetes.org/diabetes-basics/diabetes-statistics/ (22 Mar. 2018)

 

[4] Roger, V. L. et al. Heart Disease and Stroke Statistics—2011 Update: A Report From the American Heart Association. Circulation, 123, e18-e209, page 20 (2011).
http://circ.ahajournals.org/content/123/4/e18.full.pdf

 

[5] American Cancer Society medical and editorial content team, Cancer Prevalence: How Many People Have Cancer? http://www.cancer.org/docroot/CRI/content/CRI_2_6x_Cancer_Prevalence_How_Many_People_Have_Cancer.asp(2014, May 20).

 

[6] Williams, A. C. de C. & Craig, K. D. Updating the definition of pain. Pain. 157(11), 1-14 (2016). doi:10.1097/j.pain.0000000000000613.

 

[7] Centers for Disease Control and Prevention. Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999—2008. MMWR 60(43), 1487-1492 (2011).

 

[8] IMS Health, National Prescription Audit (NPATM). Cited in internal document: Preliminary Update on Opioid Pain Reliever (OPR) Prescription Rates Nationally and by State: 2010-2013.

 

[9] Dalton, C. “When Opioids Made Pain Worse.” NPR (2018, Mar. 3). www.npr.org/sections/health-shots/2018/03/03.586621236/when-opioids-make-pain-worse.

 

[10] Common elements in guidelines for prescribing opioids for chronic pain. Atlanta: Centers for Disease Control and Prevention (2015).

 

[11] Goleman, D. The Mind Over the Body. The New York Times (1987, Sep 27). https://www.nytimes.com/1987/09/27/magazine/the-mind-over-the-body.html

 

[12] Hassett, A. L. & Finan, P. H. The role of resilience in the clinical management of chronic pain. Curr Pain Headache Rep. 20, 39 (2016).

 

[13] Zautra, A. J., Johnson, L. M., Davis, M. C. Positive affect as a source of resilience for women in chronic pain. J Consult Clin Psychol 73, 212–220 (2005).

 

[14] Stone, A. A. et al.: Daily events are associated with a secretory immune response to an oral antigen in men. Health Psychol 13, 440–446 (1994).

 

[15] Cohen, S. et al. Positive emotional style predicts resistance to illness after experimental exposure to rhinovirus or influenza A virus. Psychosom Med 68, 809– 815 (2006).

 

[16] Sturgeon, J. A. & Zautra, A. J. Psychological resilience, pain catastrophizing, and positive emotions: perspectives on comprehensive modeling of individual pain adaptation. Curr Pain Headache Rep. 17(3), 317 (2013).

 

[17] Diener E. Assessing Well-Being: The Collected Works of Ed Diener. Springer, New York (2009).

 

[18] Muller, R. et al. Effects of a Tailored Positive Psychology Intervention on Well-Being and Pain in Individuals with Chronic Pain and a Physical Disability: A Feasibility Trial. Clin J Pain. 32(1), 32-44 (2016).