Jennifer Ellis is a clinical psychologist trained in substance use research. With interests in ecological momentary assessment, patterns of polysubstance use and comorbidity, she delved into a dataset with rich information about pain catastrophizing, craving, stress and affect among people prescribed opioids and cannabis for chronic pain, collected through a study led by Johannes Thrul.

What is the advantage of the ecological momentary assessment (EMA) study?
EMA studies helps measure ephemeral processes in real-life settings. Craving is dynamic and can fluctuate over time, as can pain, pain catastrophizing, affect and stress. EMA allows us to examine the dynamic nature of these processes, and reduces recall bias. This 30-day EMA study deployed four momentary surveys per day that assessed factors such as craving, use, pain severity, pain catastrophizing, affect and stress.

What are your key findings?
About a third of the participants in this study reported little or no craving throughout the entire study. Among those who did experience craving, the strongest predictor was pain catastrophizing, which involves ruminating, worrying and being preoccupied about pain. Pain catastrophizing is distinct from pain intensity.  

There were also some associations with mood, stress and pain intensity, but the effects were smaller, and less clinically meaningful. 

Pain catastrophizing predicted future opioid craving; people who experienced pain catastrophizing in one survey were more likely to experience opioid craving the next survey. However, the strength of this association was lower than associations at the same point in time.

What are the clinical ramifications?
I think that there are two big takeaways. The first is that many patients do not experience  craving when using opioids and cannabis medically. However, it is important for clinicians to recognize that patients can experience craving, even when taking their medications as prescribed. We know from the substance use literature that individuals can experience craving even without a desire or intention to use. Maintaining an open dialogue about craving as a possible medication side effect could destigmatize the experience, and could provide an opportunity to discuss strategies to manage craving. More research should be done to identify best practices for discussing craving with chronic pain patients. 

The second, maybe larger, takeaway is that pain catastrophizing was linked to craving among those people who experienced craving. This suggests that adjunctive interventions that target pain catastrophizing directly — such as mindfulness-based interventions, pain education, cognitive behavior therapy for chronic pain, or acceptance and commitment therapy — might be helpful in reducing craving for some patients.