Figure 1. Conceptual model depicting positive affective/reward-related processes to be targeted by psychosocial interventions for chronic pain and opioid misuse.

Chronic pain and chronic opioid use/misuse amplify one another through reward/antireward processes kindled by opioid-induced neuroplasticity in cortio-limbic-striatal circuitry. Psychosocial interventions may leverage positive affective/reward-related processes to ameliorate chronic pain and opioid misuse. Standard CBT techniques are well-suited to interrupt the habit loop of attentional bias and hypervigilance towards pain, reducing biased pain appraisals (e.g., pain catastrophizing) and thereby decreasing negative affect and maladaptive coping behaviors (e.g., avoidance). Mindfulness techniques can then be used to decenter from dysfunctional pain-related cognitive processing and re-orient attention from pain sensations and catastrophic appraisals to focus on three therapeutic targets: positive external stimuli, positive internal stimuli, or self-schemas. Focused attention and meta-awareness facilitates the practice of savoring natural rewards, involving attending the pleasant exteroceptive (i.e., perceptual) features of a naturally rewarding stimulus while cultivating meta-awareness of the positive emotions and pleasant interoceptive sensations occasioned by that stimulus. Through focused attention and meta-awareness, one may notice and generate pleasant internal states (e.g., positive affect and pleasurable sensations) in spite of painful sensations. This process may be accomplished by fine-grained interoceptive awareness to delimit pain and increase appreciation of pleasure, as well as the use of imagination to superimpose pleasure on body sites proximal and distal to the painful body part. Finally, meta-awareness and acceptance may disrupt biased appraisals and allow one to integrate a widened array of pleasant, neutral, and painful life experiences within the broadened scope of attention, thereby attenuating default model processing and fueling adaptive reappraisals of pain-laden self-schemas. This process ultimately results in cultivating meaning and self-transcendence in the face of adversity. By virtue of their effects on corticostriatal circuitry function, these three processes in turn shift the motivation-decision balance to disengage from pain and engage salient life goals, resulting in enhanced reward and reduced pain experience. Ultimately, this process may reduce the drive towards opioid dose escalation and opioid misuse.