Fig. 1

This model highlights the links between emotion dysregulation, opioid misuse, and suicide risk among chronic pain patients as outlined in this review. The recurrent experience of pain and long-term opioid exposure may drive emotion dysregulation in the form of negative emotional hyperreactivity and hedonic hyporeactivity, as well as deficits in the ability to proactively regulate emotions. Chronic pain patients prescribed long-term opioids who experience emotion dysregulation may respond with risky or maladaptive behaviors through a process of negative cognitions and affect. Specifically, as chronic pain patients become caught up in negative thoughts and feelings about their pain (e.g., pain catastrophizing), they may experience craving for opioids as a way to relieve those negative thoughts and feelings or thoughts of suicide as a way of escaping their present experiences. If they engage in opioid-misusing behaviors and experience either relief from negative affect or increased positive affect, they become more likely to engage in those behaviors as ways to manage distress through a process of reinforcement. Relatedly, suicidal behaviors, such as planning or preparatory behaviors, may result in relief from negative affect or increased positive affect when chronic pain patients feel like they have the means to escape their pain and distress. For example, hoarding medications, an indication of opioid misuse, can also be considered a preparatory behavior given the primary method of suicide planning endorsed by chronic pain patients is medication overdose. These links likely represent recursive processes, e.g., just as chronic pain and opioid use lead to emotion dysregulation, so does emotion dysregulation likely contribute to increased pain and opioid use. Similarly, although opioid misuse and suicidal behaviors may be employed in response to emotion dysregulation, they ultimately may lead to more frequent instances of emotion dysregulation