Measuring anger in patients experiencing chronic pain - A systematic review

The Impact of Stressful Life Events on Centralized Pain and Pain Intensity: A Combined Model Examining the Mediating Roles of Anger and Perceived Injustice Among Racially Minoritized Adults With Chronic Pain

Stressful life events are highly associated with chronic pain. Yet, research is needed to identify the psychological mechanisms that link life adversity and pain, especially studies that test comprehensive models, recruit racially diverse samples, and measure varied pain-related symptoms. This study examined the relationship between stressful life events and pain in a racially diverse sample and tested the potential mediating roles of both anger and perceived injustice. Both centralized pain symptoms and pain intensity were the outcomes. Analyses consisted of 2 cross-sectional, mediation models among 673 adults with self-reported chronic pain who were racially diverse (Black: n = 258, Latine: n = 254, Asian American: n = 161). The results indicated a positive relationship between stressful life events and centralized pain symptoms (b = 2.53, P < .001) and pain intensity (b = .20, P < .001). In parallel mediation analyses, anger (b = .91, 95% CI = .67, 1.17) and perceived injustice (b = .86, 95% CI = .64, 1.11) acted as partial mediators on centralized pain symptoms. Also, anger (b = .05, 95% CI = .03, .08) and perceived injustice (b = .11, 95% CI = .08, .14) acted as full mediators on pain intensity. The combined psychosocial variables accounted for 51% of centralized pain symptoms and 26% of pain intensity. The findings suggest that psychosocial factors are significantly associated with pain outcomes. Future research is needed to investigate exposure to adversity in life, anger, and perceived injustice together as psychosocial mechanisms of pain symptoms. PERSPECTIVE: Among racially minoritized adults with chronic pain, this article presents empirical evidence that stressful life events, anger, and perceived injustice are associated with centralized pain symptoms and pain intensity. This could guide psychological intervention to focus on anger and perceived injustice, especially when addressing centralized pain.

Perceived Injustice and Anger in Fibromyalgia With and Without Comorbid Mental Health Conditions: A Hebrew Validation of the Injustice Experience Questionnaire

OBJECTIVES

Perceived injustice (PI), assessed by the Injustice Experience Questionnaire (IEQ), is an important trigger of anger. Both PI and anger are associated with adverse chronic pain outcomes, and with comorbid mental health severity. We aimed examined the roles of PI and anger in mediating pain across Fibromyalgia patients, with and without comorbid anxiety/depression (FM+A/D, FM-A/D, respectively), as well as rheumatoid arthritis (RA), and pain-free controls (PFC). We hypothesized the highest levels of PI, anger, and pain in FM+A/D patients, followed by FM-A/D, RA, and PFC, thus also validating a Hebrew version of the IEQ.

METHODS

We translated the IEQ using the forward-backward method and collected data online. Based on self-reported anxiety/depression, the sample comprised 66 FM+A/D patients, 64 FM-A/D, 34 RA, and 32 PFCs. Assessments included the IEQ, state and trait anger, pain intensity, anxiety, depression, and pain catastrophizing. The structure and reliability of the Hebrew IEQ were examined using factor analysis and Cronbach alpha. Bootstrapped-based modeling was used to test the roles of state and trait anger in mediating and moderating the relationship between PI and pain intensity.

RESULTS

We confirmed a one-factor structure of the IEQ, with excellent reliability. FM+A/D patients demonstrated the highest scores in all measures. Within this group, trait anger moderated the mediating effect of state anger in the relationship between PI and pain intensity.

DISCUSSION

Our findings validate a Hebrew IEQ and highlight the importance of PI and state and trait anger in the differential manifestation of mental health comorbidity in FM.

A Brief Screening Tool for Risk of Self-Medication of Pain With Substance Use

OBJECTIVES

Substance use and pain are both growing public health concerns globally. Evidence suggests that individuals may use substances in order to self-medicate their pain. The Catastrophizing, Anxiety, Negative Urgency, and Expectancy model was developed to provide a theoretical foundation for the modifiable risk factors implicated in self-medication of pain with substance use. This study aimed to use the outcomes in the Catastrophizing, Anxiety, Negative Urgency, and Expectancy model to develop a brief clinical screening tool to identify individuals at risk for self-medication.

METHODS

Participants (N = 520; M age = 38.8) were adults who endorsed the past three-month use of at least one substance and completed an online questionnaire. Logistic regression and receiver operator characteristic analyses were used to reduce the initial 104-item questionnaire to the items needed to achieve a minimum accuracy score of 0.95 and 0.90.

RESULTS

A 14-item and a 7-item questionnaire were derived from the initial larger questionnaire. Both of these questionnaires were significantly correlated with the outcome variables and were significantly associated with health risk and percent of use because of pain. The R2 values between the 14- and 7-item versions were only significantly different for the percent of alcohol use because of pain.

CONCLUSIONS

The study provides two brief screening tools to screen for individuals at risk for self-medication of pain with substance use that can be easily implemented within clinical settings. Further, the screening tools provide insight into modifiable risk factors for self-medication and may also be valuable to monitor treatment response.

The relationship between metacognition, anger, and pain intensity among fibromyalgia patients: a serial mediation model

Fibromyalgia is a burdensome pain causing patients a very negative emotional state that can worsen their clinical profile, perceived disability, and treatment outcomes. In particular, anger can negatively affect pain and patient adjustment to the disease. Recent studies suggest that metacognitions and anger rumination can negatively affect anger, which in turn can amplify the intensity of pain. This study aims to investigate whether anger rumination and state anger serially mediate the relationship between metacognitions and the intensity of pain. The study included 446 subjects who: declared having received a fibromyalgia diagnosis by a rheumatologist/pain physician; completed measures of metacognitions, anger rumination, state-anger, and pain intensity. The serial mediation analysis was conducted using Hayes' PROCESS macro (Model 6). Negative beliefs about worry and beliefs about the need to control thoughts indirectly influenced the intensity of pain through two significant mediating pathways: state-anger and anger rumination to state-anger. Cognitive self-consciousness affected pain intensity directly (β = .11, p < .05) and indirectly through two significant mediating pathways: state-anger and anger rumination to state-anger. This study highlights the role of serial mediation of anger rumination and state-anger in the relationship between metacognitions and pain intensity in the field of fibromyalgia. Our work introduces new targets for anger management interventions for patients with fibromyalgia. Such interventions could be effectively addressed with a metacognitive approach considering its specific focus on dysfunctional metacognitive beliefs and repetitive negative thinking.

Mapping the associations of daily pain, sleep, and psychological distress in a U.S. sample

Chronic pain, sleep problems, and psychological distress (PD) can be disabling conditions and previous research has shown that they are associated. The nuances of the comorbid nature of these conditions may be important to understand for those who treat these conditions. This study examined the bidirectional associations of these health factors concurrently and over time in a sample of U.S. adults (N = 1,008, Mage = 57.68) from the Midlife in the United States (MIDUS) study. Participants reported on their daily pain, sleep quantity, and psychological distress over eight days. A modified Random Intercept Cross-lagged Panel Model was used to analyze the relations, starting with the whole sample and then a comparison of those with and without chronic pain. Results indicated that nightly variation in sleep quantity predicted next day psychological distress for both groups. Sleep quantity also predicted next-day pain, but only for individuals with chronic pain. Associations between pain and psychological distress were found both at the daily level and individual (between-person) level. This between-person association was stronger for those with chronic pain. The lagged associations between sleep, and both pain and psychological distress for the chronic pain group indicate that, increased quantity of sleep predicts decreased next-day pain and psychological distress. Providers could consider this unidirectional lagged relationship when prioritizing treatment for patients with these comorbid conditions. Future research may examine whether responsive, just-in-time treatments might intervene after participants wake from a poor night's sleep to counteract the negative effects of reduced sleep on PD and pain.

Emotional distress predicts palliative cancer care attitudes: The unique role of anger

OBJECTIVE

Although palliative care can mitigate emotional distress, distressed patients may be less likely to engage in timely palliative care. This study aims to investigate the role of emotional distress in palliative care avoidance by examining the associations of anger, anxiety, and depression with palliative care attitudes.

METHODS

Patients (N = 454) with heterogeneous cancer diagnoses completed an online survey on emotional distress and palliative care attitudes. Emotional distress was measured using the Patient-Reported Outcomes Measurement Information System anger, anxiety, and depression scales. The Palliative Care Attitudes Scale was used to measure palliative care attitudes. Regression models tested the impact of a composite emotional distress score calculated from all three symptom measures, as well as individual anger, anxiety, and depression scores, on palliative care attitudes. All models controlled for relevant demographic and clinical covariates.

RESULTS

Regression results revealed that patients who were more emotionally distressed had less favorable attitudes toward palliative care (p < 0.001). In particular, patients who were angrier had less favorable attitudes toward palliative care (p = 0.013) while accounting for depression, anxiety, and covariates. Across analyses, women had more favorable attitudes toward palliative care than men, especially with regard to beliefs about palliative care effectiveness.

CONCLUSIONS

Anger is a key element of emotional distress and may lead patients to be more reluctant toward timely utilization of palliative care. Although psycho-oncology studies routinely assess depression or anxiety, more attention to anger is warranted. More research is needed on how best to address anger and increase timely utilization of palliative cancer care.

Parameters of anger as related to sensory-affective components of pain

Objectives

Comorbid with chronic pain are negative emotions, anger being particularly salient. To evaluate specific relationships between pain and anger, the present study deconstructed anger into five parameters and dichotomized pain into sensory vs. affective components. Hypotheses were (i) anger parameters would be significantly and positively correlated with affective pain more so than with sensory pain, and (ii) individual parameters would be differentially related to pain components.

Methods

The Anger Parameters Scale (APS) was used to rate five parameters of anger: frequency, duration, intensity, latency, and threshold. Also rated was the physical sensation of pain and the degree of distress from pain. The volunteer sample comprised n=51 chronic pain patients, varying in ethnicity/race and educational level.

Results

Descriptive statistics revealed: APS total M=71.52, SD=16.68, Sensory pain M=6.27, SD=2.15, Affective pain M=5.76, SD=2.28. Sensory and affective pain were highly correlated, r=0.70. APS total was significantly associated with affective pain (r=+0.28) but hardly with sensory pain (r=0.12). Two anger parameters significantly correlated with affective pain: anger frequency (r=+0.30, p<0.05) and anger threshold (r=+0.33, p<0.05). Secondarily, certain educational levels (but not gender and ethnicity/race) were associated with significantly higher APS total scores.

Conclusions

Scores for all variables were in the mid-range. As hypothesized, anger was more strongly correlated with distress/suffering of pain than with physical sensation of pain, though both pain components were closely coupled. Specific findings regarding frequency and threshold imply that being angry often and being oversensitive to provocation are associated with greater distress in this context. In deconstructing anger and dichotomizing pain, the present study extends previous research by elaborating on what aspects of anger are most related to which components of pain. Moreover, certain educational levels with higher levels of anger may need special attention. Further research could examine if treatment of anger might lead to corresponding changes in chronic pain.

At the Intersection of Anger, Chronic Pain, and the Brain: A Mini-Review

Chronic pain remains one of the most persistent healthcare challenges in the world. To advance pain treatment, experts have recently introduced research-driven subtypes of chronic pain based on proposed underlying mechanisms. Nociplastic pain (e.g., nonspecific chronic low back or fibromyalgia) is one such subtype which may involve a greater etiologic role for brain plasticity, painful emotions induced by life stress and trauma, and unhealthy emotion regulation. In particular, correlational and behavioral data link anger and the ways anger is regulated with the presence and severity of nociplastic pain. Functional neuroimaging studies also suggest nociplastic pain and healthy anger regulation demonstrate inverse patterns of activity in the medial prefrontal cortex and amygdala; thus, improving anger regulation could normalize activity in these regions. In this Mini-Review, we summarize these findings and propose a unified, biobehavioral model called the Anger, Brain, and Nociplastic Pain (AB-NP) Model, which can be tested in future research and may advance pain care by informing new treatments that address anger, anger regulation, and brain plasticity for nociplastic pain.

Is psychological distress associated with carpal tunnel syndrome symptoms and nerve conduction study findings? A case-control study from Syria

BACKGROUND

Carpal tunnel syndrome (CTS) is a common entrapment neuropathy of the median nerve at the wrist which causes severe symptoms. However, psychological aspects can affect patients' perception of this pain and can cause similar pain in some instances. This study aims to determine the association between symptoms severity, functional status, and nerve conduction studies (NCS) of adult patients with CTS and their anger, anxiety, and depression status.

METHODS

This case-control study was conducted in clinics in Damascus, Syria. Controls were frequency matched by gender and age from a general clinic. Interviews based on questionnaires were used that included the Boston Carpal Tunnel Questionnaire (BCTQ-A), Hospital Anxiety and Depression Scale (HADS), Dimensions of Anger Reactions Scale-5 (DAR-5), and NCS.

RESULTS

Overall, 242 patients (121 cases) were included in this study. Cases with CTS had significantly higher anxiety and depression when compared to controls, but not higher anger. Cases with higher anxiety, depression, and anger had significantly more CTS symptoms and less functional status. Anxiety was also higher in cases with normal NCS in the case group. When using regression, anxiety and depression remained significantly associated with having CTS.

CONCLUSION

Anxiety and depression are more prominent with CTS. Furthermore, having anxiety and depression were associated with more CTS symptoms in the hand. Having anger was also associated with more CTS symptoms among cases. These findings emphasize the importance of psychological aspects when having hand pain or CTS symptoms as these patients might have these symptoms despite having normal NCS.

Associations between anger and chronic primary pain: a systematic review and meta-analysis

OBJECTIVES

Anger is a negative emotion characterized by antagonism toward someone or something, is rooted in an appraisal or attribution of wrongdoing, and is accompanied by an action tendency to undo the wrongdoing. Anger is prevalent in individuals with chronic pain, especially those with chronic primary pain. The associations between anger and pain-related outcomes (e.g., pain intensity, disability) have been examined in previous studies. However, to our knowledge, no systematic review or meta-analysis has summarized the findings of anger-pain associations through a focus on chronic primary pain. Hence, we sought to summarize the findings on the associations of anger-related variables with pain and disability in individuals with chronic primary pain.

METHODS

All studies reporting at least one association between anger-related variables and the two pain-related outcomes in individuals with chronic primary pain were eligible. We searched electronic databases using keywords relevant to anger and chronic primary pain. Multiple reviewers independently screened for study eligibility, data extraction, and methodological quality assessment.

RESULTS

Thirty-eight studies were included in this systematic review, of which 20 provided data for meta-analyses (2,682 participants with chronic primary pain). Of the included studies, 68.4% had a medium methodological quality. Evidence showed mixed results in the qualitative synthesis. Most anger-related variables had significant positive pooled correlations with small to moderate effect sizes for pain and disability.

CONCLUSIONS

Through a comprehensive search, we identified several key anger-related variables associated with pain-related outcomes. In particular, associations with perceived injustice were substantial.

Negative effect of anger on chronic pain intensity is modified by multiple mood states other than anger: A large population-based cross-sectional study in Japan

OBJECTIVES

To investigate whether mood states other than anger can modify the association between anger and pain intensity in individuals with chronic pain.

METHODS

We analysed 22,059 participants with chronic pain, including 214 participants with rheumatoid arthritis (RA), who completed a questionnaire. The Profile of Mood States short form (POMS-SF) was used to assess six dimensions of mood states (anger-hostility, tension-anxiety, depression-dejection, confusion, fatigue, and vigour). A numerical rating scale (NRS) assessed pain intensity. We examined the association between anger-hostility and the NRS and the relationship between POMS-SF components. Moderation analyses were used to investigate whether the five mood states other than anger-hostility modified the effect of anger-hostility on the NRS.

RESULTS

Anger-hostility contributed to pain intensity. Although increased mood states other than vigour were associated with increased pain intensity, these increased mood states appeared to suppress the effect of anger-hostility on pain intensity. Increased vigour was associated with decreased pain intensity and increased the effect of anger-hostility on pain intensity.

CONCLUSIONS

Mood states other than anger may influence the association between anger and pain intensity in individuals with chronic pain. It is important to focus on complicated mood states and anger in individuals with chronic pain, including RA.

Anger as a Mechanism of Injustice Appraisals in Pediatric Chronic Pain

Mechanisms explaining the relationship between pain-related injustice appraisals and functional outcomes in youth with chronic pain have yet to be examined. In studies of adults, greater pain-related injustice is associated with worse depressive symptoms and greater pain through greater anger. No study to date has examined anger expression as a mediator in the relationships between pain-related injustice appraisals and physical and psychosocial functioning in youth with chronic pain. The current sample consisted of 385 youth with varied pain conditions (75% female, 88% White, M_age=14.4 years) presenting to a university-affiliated pain clinic. Patients completed self-report measures assessing anger expression (anger-out and anger-in), pain-related injustice, pain intensity, functional disability, and emotional, social, and school functioning. Bootstrapped mediation analyses indicated that only anger-out (indirect effect= -.12, 95% CI: -.21, -.05) mediated the relationship between pain-related injustice and emotional functioning, whereas both anger-out (indirect effect= -.17, 95% CI: -.27, -.09) and anger-in (indirect effect= -.13, 95% CI: -.09, -.001) mediated the relationship between pain-related injustice and social functioning. Neither mode of anger expression mediated the relationship between pain-related injustice and pain intensity, functional disability, or school functioning. Collectively, these findings implicate anger as one mechanism by which pain-related injustice impacts psychosocial outcomes for youth with chronic pain. Perspective: Anger expression plays a mediating role in the relationship between pain-related injustice appraisals and psychosocial outcomes for youth with chronic pain. Anger represents one target for clinical care to decrease the deleterious impact of pain-related injustice on emotional and social functioning.

Orofacial musculoskeletal pain: An evidence-based bio-psycho-social matrix model

Pain is a multidimensional experience comprising sensory-discriminative, affective-motivational, and cognitive-evaluative dimensions. Clinical and research findings have demonstrated a complex interplay between social burdens, individual coping strategies, mood states, psychological disorders, sleep disturbances, masticatory muscle tone, and orofacial musculoskeletal pain. Accordingly, current classification systems for orofacial pain require psychosocial assessments to be an integral part of the multidimensional diagnostic process. Here, we review evidence on how psychosocial and biological factors may generate and perpetuate musculoskeletal orofacial pain. Specifically, we discuss studies investigating a putative causal relationship between stress, bruxism, and pain in the masticatory system. We present findings that attribute brain structures various roles in modulating pain perception and pain-related behavior. We also examine studies investigating how the nervous and immune system on cellular and molecular levels may account for orofacial nociceptive signaling. Furthermore, we review evidence pointing towards associations between orofacial musculoskeletal pain and neuroendocrine imbalances, sleep disturbances, and alterations of the circadian timing system. We conclude with several proposals that may help to alleviate orofacial pain in the future.

Lack of Consensus Across Clinical Guidelines Regarding the Role of Psychosocial Factors Within Low Back Pain Care: A Systematic Review

It is widely accepted that psychosocial prognostic factors should be addressed by clinicians in their assessment and management of patient suffering from low back pain (LBP). On the other hand, an overview is missing how these factors are addressed in clinical LBP guidelines. Therefore, our objective was to summarize and compare recommendations regarding the assessment and management of psychosocial prognostic factors for LBP chronicity, as reported in clinical LBP guidelines. We performed a systematic search of clinical LBP guidelines (PROSPERO registration number 154730). This search consisted of a combination of previously published systematic review articles and a new systematic search in medical or guideline-related databases. From the included guidelines, we extracted recommendations regarding the assessment and management of LBP which addressed psychosocial prognostic factors (ie, psychological factors ["yellow flags"], perceptions about the relationship between work and health, ["blue flags"], system or contextual obstacles ["black flags") and psychiatric symptoms ["orange flags"]). In addition, we evaluated the level or quality of evidence of these recommendations. In total, we included 15 guidelines. Psychosocial prognostic factors were addressed in 13 of 15 guidelines regarding their assessment and in 14 of 15 guidelines regarding their management. Recommendations addressing psychosocial factors almost exclusively concerned "yellow" or "black flags," and varied widely across guidelines. The supporting evidence was generally of very low quality. We conclude that in general, clinical LBP guidelines do not provide clinicians with clear instructions about how to incorporate psychosocial factors in LBP care and should be optimized in this respect. More specifically, clinical guidelines vary widely in whether and how they address psychosocial factors, and recommendations regarding these factors generally require better evidence support. This emphasizes a need for a stronger evidence-base underlying the role of psychosocial risk factors within LBP care, and a need for uniformity in methodology and terminology across guidelines. PERSPECTIVE: This systematic review summarized clinical guidelines on low back pain (LBP) on how they addressed the identification and management of psychosocial factors. This review revealed a large amount of variety across guidelines in whether and how psychosocial factors were addressed. Moreover, recommendations generally lacked details and were based on low quality evidence.

Self-compassion predicting pain, depression and anger in people suffering from chronic pain: A prospective study

Self-compassion is associated with disability, pain-related anxiety as well as depression and anger in patients with chronic pain. However, the unique value of self-compassion versus other concepts such as psychological flexibility and self-esteem is unknown. The present study therefore aimed to clarify these relationships. Individuals with chronic pain (N_CP = 872) and without chronic pain (N_NP = 356) took part in a longitudinal study. Participants completed self-report instruments: Pain Disability Index (PDI), Pain Catastrophizing Scale (PCS), Pain Anxiety Symptom Scale (PASS-20), Patient Health Questionnaire (PHQ-9), State Trait Anger Expression Inventory (STAXI), Self-Compassion Scale (SCS), Psychological Inflexibility in Pain Scale (PIPS) and Rosenberg Self-Esteem Scale (RSES). Assessments were repeated after 8 weeks. We found differences in baseline levels of all relevant variables except for anger-out and anger-control between people with and without chronic pain. Subsequently, we computed a path model analysis regarding individuals suffering from chronic pain (N_CP), addressing the predictive value of reduced uncompassionate self-responding (RUS), compassionate self-responding (CS), avoidance (PIPS), cognitive fusion (PIPS) and self-esteem (RSES) regarding pain-related (PDI, PCS, PASS) and emotional variables (PHQ-9, STAXI). Avoidance predicted disability, catastrophizing, anxiety and depression. RUS predicted catastrophizing and pain-related anxiety. Self-esteem predicted depression. CS and cognitive fusion had no unique predictive value. The model explained 65.4%-72.1% of the variance in pain-related variables, 68.7% of the variance in depression and 38.7%-60.7% in the variance of anger-related variables. In conclusion, psychological flexibility, in terms of avoidance, seems to be more relevant for chronic pain than self-compassion. Future research should focus on subgroups and tailored-treatment approaches. SIGNIFICANCE: Applying a longitudinal design, this study examined the predictive value of self-compassion regarding pain, depression and anger. The relevance of self-compassion was compared to psychological flexibility and self-esteem. We can conclude that psychological flexibility, in terms of avoidance behaviour, is the most relevant predictor concerning pain.

The Pain-to-Well-Being Relationship in Patients Experiencing Chronic Orofacial Pain

Introduction: Orofacial pain features may negatively influence a person's well-being and vice versa. Some aspects of well-being can be measured with axis II instruments that assess patients' psychosocial and behavioral status. The aim of this study was to investigate associations between pain features and psychosocial variables as indicators of well-being. Materials and Methods: Seven hundred ninety-nine anonymized datasets collected using the Web-based Interdisciplinary Symptom Evaluation (WISE) of patients reporting to the Interdisciplinary Orofacial Pain Unit, University of Zurich, between March 19, 2017 and May 19, 2019, were analyzed. Pain features including intensity, number of locations, impact, and duration were evaluated. Psychometric measures assessed pain-related catastrophizing and disability, illness perception, distress, anxiety, depression, injustice experience, dysmorphic concerns, and insomnia. Results: Most patients were between 30 and 59 years old (58.3%), female (69.8%), working (66.0%), and experienced pain for more than 6 months (68.5%). Pain intensities were higher in women than men and higher in disabled than working patients. Scores indicating elevated stress and depression were also observed in disabled patients. The sample prevalence rates of clinically relevant axis II instrument scores were as follows: Graded Chronic Pain Scale for the Head (GCPS-H), 27%; Patient Health Questionnaire 4 (PHQ4), 21%; PHQ9, 21%; Pain Catastrophizing Scale (PCS), 20%; General Anxiety Disorder 7 (GAD7), 15%; Insomnia Severity Index (ISI), 15%; Injustice Experience Questionnaire (IEQ), 14%; GCPS for the Body (GCPS-B), 13%; PHQ for Stress (PHQstr), 6%; and Dysmorphic Concern Questionnaire (DCQ), 2%. Noteworthy results of correlation analysis of the clinically relevant axis II scores and pain measures were as follows: the PHQstr had moderate associations (0.34-0.43) with the sum of pain intensity at rest and during function, number of pain locations, and typical pain intensity. The IEQ scores were moderately associated with typical pain intensity at 0.39. The DCQ scores were moderately associated with pain extension at 0.41. Conclusions: Moderate correlations of certain pain and well-being measures were found in patients reporting clinically relevant stress, injustice experience, and dysmorphic concern, all of which reflect impaired well-being. PHQ4 is suitable for routine distress screening in the clinical setting.

CANUE: A Theoretical Model of Pain as an Antecedent for Substance Use

BACKGROUND

Pain and substance use are frequently comorbid and have been shown to exert bidirectional effects. Self-medication of pain and distress via substance use is common and can be understood via negative reinforcement, ultimately strengthening the pathway between pain to substance use over time. As such, a testable model of the potentially modifiable candidate mechanisms that underlie the pain to substance use pathway is needed.

PURPOSE

This review proposes a testable model of pain as an antecedent to substance use to guide future research and inform clinical practice.

METHODS

An integrative review of current evidence regarding pain, substance use, and associated risk factors (i.e., negative affect, pain-related attitudes, negative urgency, and substance use outcome expectancies) was conducted.

RESULTS

The Catastrophizing, Anxiety, Negative Urgency, and Expectancy (CANUE) model highlights modifiable risk factors for self-medicating pain with substance use, including increased negative affect and maladaptive pain-related attitudes (i.e., pain catastrophizing, pain anxiety, and fear of pain), negative urgency, and substance-related outcome expectancies for pain relief and enhanced pain coping.

CONCLUSIONS

Targeted behavioral and psychological interventions that address these factors may facilitate more adaptive pain-coping responses, thereby reducing the impacts of pain on substance use. Systematic research is needed to evaluate the validity and clinical utility of this model.