Emotion Regulation as a Transdiagnostic Factor Underlying Co-Occurring Chronic Pain and Problematic Opioid Use

Chronic pain affects 10-30% of adults and children and is increasingly linked to problematic opioid use (CP-POU), creating a significant public health challenge. This narrative review proposes that emotion regulation (ER)—the process of modifying one's emotional experience—serves as a transdiagnostic factor underlying both chronic pain and problematic opioid use. Understanding shared emotional difficulties between these conditions could enable more targeted and efficient psychological interventions.

The authors systematically reviewed literature on emotion regulation in chronic pain and CP-POU, organizing findings according to prominent ER models, particularly Gross's Extended Process Model. They examined ER across multiple dimensions: emotion identification (awareness and labeling of feelings), down-regulation of negative affect (NA), up-regulation of positive affect (PA), and down-regulation of PA. The review also considered explicit versus implicit strategies, developmental stage, and cultural context as moderating factors influencing ER effectiveness and pain outcomes.

Key findings show that chronic pain is associated with multiple ER difficulties, including alexithymia (inability to label emotions), reduced affect differentiation, pain catastrophizing, and avoidance behaviors. Little research directly examines ER in CP-POU, though initial evidence suggests similar patterns. Problematic opioid use may function as an implicit ER strategy to manage negative emotions and pain, creating reinforcement cycles that maintain addiction. Interventions targeting NA down-regulation (cognitive reappraisal, behavioral activation) and PA up-regulation (mindfulness-based approaches like MORE) show promise for improving pain and reducing opioid misuse.

This work highlights ER as a valuable transdiagnostic intervention target for patients with CP-POU. The authors emphasize the need for more empirical research specifically examining ER in CP-POU, longitudinal designs to understand the transition from prescribed to problematic opioid use, and consideration of developmental and cultural factors in treatment delivery. Better understanding of ER phenotypes could enable personalized intervention approaches and improved long-term outcomes for this vulnerable population.