Since March 2020, one public health crisis has dominated our attention: the COVID-19 pandemic. For people who use opioids or have opioid use disorder, feelings of social isolation increased during the pandemic, especially during the first several months.
It’s now been three years since we first heard of COVID-19. For the most part, we’ve achieved and settled into a new normal, with vaccines, boosters, variants, and effective treatments all part of the mix. That’s not to say COVID-19 is not still a threat: it is. Over a million people have died of COVID-19 and people continue to die. That’s a tragedy we’re still grappling with.
With that said, that crisis is now a known quantity. We understand how to deal with it. Vulnerable populations still need to wear masks and do their best to maintain social distance in many situations. The rest of us receive advice from the experts to get our vaccines, our boosters, and see a doctor for the latest available medications and advice if we do test positive for COVID-19.
This article will address the public health crisis that was here before the pandemic and continues to cause significant harm to individuals, families, and communities across the U.S.: the opioid crisis.
We know the opioid crisis is back in the public view – after being eclipsed by COVID-19 for three years – because of a headline we saw in a recent morning newsletter published by the New York Times:
That article is about the treatment gap that exists between the number of people diagnosed with opioid use disorder (OUD) and the number of people who receive the gold-standard treatment for OUD, which is medication-assisted treatment (MAT) with medications for opioid use disorder (MOUD). To learn more about the MAT treatment gap for people with OUD, please navigate to the blog section of our website and read these two articles:
This article is about a different topic: the effect of the long-term use of opioids for pain on feelings of social isolation and social rejection.
Long-Term Opioid Therapy for Chronic Pain
This topic is different, but not at all unrelated to one aspect of the COVID-19 pandemic: isolation, and the loneliness that can result from feelings of isolation and social disconnection. An article published recently in the Annals of Family Medicine called “When Physical and Social Pain Coexist: Insights Into Opioid Therapy” offers unique insight into the relationship between opioids, social isolation, pain, and emotion. Specifically, the article explores the relationship between chronic pain and negative emotional states related to social rejection – and how long-term opioid therapy can exacerbate both.
That’s something we’ve never written about: the impact of long-term pain management on negative emotions connected to social connection and interactions, a.k.a., the connection between opioids and social isolation. To understand how two physicians who wrote the article – Dr. Mark D. Sullivan and Dr. Jane C. Ballantyne of the University of Washington, it’s important to understand the point of view which informs their work.
Here’s their starting point:
“Understanding emotions only as reactions to pain may not be adequate. Despite the persistent belief that emotions develop in reaction to pain, and that emotional responses worsen as pain becomes chronic, new epidemiological and neuroscientific evidence suggests that the relationship between chronic pain and emotional distress is bidirectional. Physical pain and negative emotions reinforce each other in patient populations and involve activation of the same limbic brain structures.”
What’s interesting in that statement is the idea that negative emotion can compound and increase sensations of pain. The typical point of view – what we consider common knowledge or common sense – is that chronic pain leads to negative emotional states. The longer the pain, the worse the emotions get.
It’s a cycle that can lead to years of physical and emotional pain.
The idea the authors want us to understand is that the emotional pain people on long-term opioid therapy may experience may not only result from the physical pain: it may also be a side-effect of the opioids themselves.
Physical Pain and Emotional Pain: What’s the Difference?
The National Institutes of Health (NIH) offer this definition of pain:
“Pain is an unpleasant signal that something hurts. It warns you that something is not quite right in your body and can cause you to take certain actions and avoid others.”
That’s physical pain. In the context of this article, we’ll refer to emotional pain as social pain. That will help in understanding what we mean by this statement from the article we’re discussing:
“Whereas physical pain serves as a signal for adaptive responses that promote tissue healing and avoidance of further injury, social pain may prompt adaptive responses that protect against further social rejection.”
Hold that thought: physical pain tells us what to do to avoid the root cause of that type of pain, i.e. avoid specific activities, while social pain tells us what to do to avoid the root cause of that type of pain, i.e. avoid specific social situations or behaviors.
Now let’s get back to that NIH resource on pain.
The medical experts at the NIH indicate there are two types of pain: acute and chronic.
Acute pain is typically the result of an injury and appears suddenly. Acute pain typically responds to treatment or therapy, and depending on the injury, can fade in a relatively short period of time: note pain from a broken leg takes longer to fade than a sprained ankle, but pain from both, in most cases, will resolve completely.
Chronic pain, on the other hand, may originate with an injury or illness, but, in the words of the NIH, “…chronic pain persists over a long period of time and can be hard to manage.” Chronic pain may be the result of an acute injury where the pain does not fade. It may also be associated with chronic medical conditions, such as cancer, diabetes, arthritis, and others. In either case, the NIH indicates chronic pain can increase “…problems with physical functioning, cognition, and emotional reactions.”
Hold that thought, too: chronic pain can affect emotions.
Next, we’ll talk about the different physical systems that contribute to the experience of pain.
The Anatomy of Pain: Brain and Body
Our body and brain both contribute to the experience of pain. Our nervous system – which we’ll think of as the body, for now, even though the brain is part of the nervous system – includes thousands of specialized cells that trigger specific responses to painful stimuli. When an external or internal stimulus triggers these cells, they send electrical impulses to the brain, which processes those signals in three ways:
- Sensory-discriminative. This tells a person in pain the location of the injured/affected body part.
- Affective-motivational. This tells a person in pain how unpleasant the feeling of pain is.
- Cognitive-evaluative. This tells a person how to avoid the pain in the future.
The brain systems involved in these three processes receive input from various neurotransmitter systems about the pain experiences. Neurotransmitters related to pain include:
That last bullet point brings us to the core of the topic of this article: the complex contribution of the endogenous – i.e. internal – opioid system to the experience of chronic pain. That means it’s time to return to those two thoughts that are on hold: the ideas physical and social pain tell us what to avoid, and that chronic pain can affect emotions.
For the rest of this article, we’ll discuss what those two ideas mean for people on long-term opioid therapy for chronic pain. We’ll end by presenting alternatives to long-term opioid therapy for people who experience chronic pain.
Chronic Pain and Social Pain: A Negative Cycle Affected by Opioids
To understand the ideas we’re about to present, it’s important to deconstruct our concept of chronic pain.
Let’s recap: physical pain protects us against subsequent injury, and social pain protects us from subsequent social pain caused by rejection.
Most of us – physicians and other medical professionals included – operate under the assumption that the pain experienced by people with common pain conditions, such as headaches, fibromyalgia, and back pain, is caused by unhealed/persistent injury or disease in the body part in pain. However, a study on chronic pain revealed surprising results in patients with back pain:
- In the early phases of the pain experience, brain activity associated with pain appeared only in brain areas commonly associated with pain, as well as the reward circuit of the brain
- As the pain receded, the activity in the brain areas associated with acute pain decreased
- As the pain receded, the activity in the reward circuit decreased
- For chronic pain patients, brain activity appeared in brain circuits associated with acute pain early in the overall pain experience, as well as in the reward circuit
- When the acute phase of pain ended, activity in brain areas associated with acute pain decreased, but the pain persisted
- As the pain persisted, brain activity transferred to brain areas related to emotion, as opposed to acute pain
- As the pain persisted, brain activity in the reward circuit persisted
What that study tells us is that when back pain transitions from acute to chronic, brain activity transitions as well. In patients with chronic back pain, the source of the pain may not be nerve cells that sense and transmit information about pain to the brain, but rather regions of the brain and brain systems related to emotion and reward.
That’s where opioids come in.
Opioids, Social Isolation, and Rejection
Drs. Sullivan and Ballantyne observe that the overwhelming majority of research on the endogenous opioid system – the naturally occurring opioid system that exists in our nervous system – revolved around the analgesic (pain relieving) and reward (pleasurable/euphoric) components of the endogenous opioid system.
However, subsequent research shows the endogenous opioid system plays a role in a broad range of human behavior. Areas that involve the endogenous opioid system include:
- Social bonding
- Reward properties of opioids reward the protective elements of group belonging
- Hormonal balance
- The opioid system plays a role in balancing the effect of stress hormones during challenging or stressful situations
- General homeostasis
- The opioid system plays a role in integrating and balancing both adverse and rewarding input
This is where the discussion gets slightly complex. When stress and pain – either from social interactions or physical pain – exceed the parameters of a typical stress response, the endogenous opioid system can overreact, which can result in an inability to experience natural rewards, including those rewards associated with social connection. In addition, research shows that social rejection events, during which an individual experiences a severance of important social bonds, can disrupt the endogenous opioid system and increase risk of depressive symptoms. One thing that means is that long-term use of opioids can increase feelings of social isolation.
Or, in the words of Sullivan and Ballantyne:
“These states of reward deficiency may contribute to both chronic pain and addiction risk.”
The complicated part here is that we need to separate the idea that pain always has a physical source. In patients with persistent and chronic pain, continued or extreme stress can heighten the experience of physical pain. This physical pain feels and presents to patients and physicians as real, actual pain – and it is. However, social stress and emotion drive the pain more than input from the nerve cells that typically sense and report harmful stimuli to the brain.
A New Paradigm: Opioids, Social Isolation, Pain Management
That information leads us to a new way of understanding the relationship between opioids, chronic pain, and opioid use disorder. When a person with chronic pain engages in opioid therapy for months, or years, weaning off opioids becomes difficult on many levels. The combination of physical withdrawal, opioid cravings, and an impaired endogenous opioid system make it challenging to experience natural reward, and feel something that’s essential for long-term recovery: a sense of social belonging and connection.
Again, we’ll allow Sullivan and Ballantyne to comment:
“Rather than helping the pain for which the opioid was originally sought, persistent opioid use may be chasing the pain in a circular manner, diminishing natural rewards from normal sources of pleasure, and increasing social isolation…this may be one reason that discontinuation of long-term opioid therapy has been associated with suicide and all-cause mortality.”
Let’s be clear: there are some individuals for whom long-term opioid therapy works. For people with chronic diseases such as cancer, the benefits may outweigh risks. The decision to participate in long-term opioid therapy should be made only after a thorough discussion of the facts between the medical provider, the patient, and any family members involved in medical decisions.
In most cases, medical experts now recommend an approach to chronic pain management called multimodal pain care. In order to mitigate the harm caused by opioids and reduce the social isolation an sense of rejection that can result from long-term opioid use and increase likelihood of opioid use disorder (OUD), there are several options available.
National Institute of Health: Ten Recommendations for Chronic Pain Management
This evidence-based technique is safe and effective, and in common use in Veterans Administration (VA) clinics and hospitals across the U.S.
Non-opioid pain relieving non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen, and acetaminophen can help reduce chronic pain,
These medications can help manage musculoskeletal pain, neuropathic pain, and headaches.
4. Anti-inflammatory Diets
Evidence indicates eating anti-inflammatory foods can help reduce severity of chronic pain.
5. Botox (botulinum toxin)
This medication is Food and Drug Administration (FDA) approved for pain associated with chronic migraines.
6. Chiropractic Care
Evidence indicates this technique can help reduce chronic back pain, neck pain, headaches, and musculoskeletal conditions.
This form of psychotherapy helps people develop coping skills to manage negative patterns of thought and emotion that can exacerbate pain. CBT therapists teach relaxation methods to help prepare for pain and manage stress. Evidence shows CBT can help treat chronic pain, pain associated with surgery, and pain associated with cancer.
Evidence shows exercise and physical activity can help individuals with chronic pain manage symptoms, participate in daily activities, and maintain overall health. Exercise supervised by physical therapists is effective in reducing chronic low back pain.
9. Sleep Hygiene
Practicing good sleep hygiene can reduce stress that exacerbates chronic pain
Practices like meditation, yoga, and tai chi can help people manage stress and manage their reactions to pain. Mindfulness practices can help change negative automatic reactions to pain, which in some cases can magnify the intensity of the pain, and replace the automatic, negative reactions with alternative reactions that don’t exacerbate or increase the pain.
We’re on board with all of these tips: if we can encourage physicians to suggest these approaches, and patients to adopt them, then we can reduce the likelihood that people with chronic pain conditions will participate in long-term opioid therapy, which can ultimately reduce rates of opioid use disorder (OUD), opioid overdose, and overdose fatality.