Figure 1.

The Downward Spiral of Chronic Pain and Opioid Addiction.

In brief, the problem of co-occurring chronic pain and opioid addiction involves a cycle of behavioral escalation in which nociception triggers pain hypervigilance and catastrophizing, amplifying pain with emotional anguish. Among affectively dysregulated individuals, recurrent self-administration of opioids in response to pain and negative emotions results in associative learning processes that bias attention towards opioid-related cues (e.g., a sight of a pill bottle), strengthening the automatic habit of opioid use despite tolerance to opioid analgesia. Chronic pain and prolonged opioid misuse causes allostatic changes to stress and reward circuitry in the brain, increasing sensitivity to pain and decreasing the pleasure derived from healthful objects and events. As functional connectivity between the default mode network and other neural circuits changes over time, the sense of self may become entwined with pain-laden narratives and entrapped by a compulsive drive for relief. This downward spiral may ultimately result in mindless, uncontrolled opioid use and addiction.