SUBSTANCE USE & MISUSE, VOL. , NO. , –http.docx

SUBSTANCE USE & MISUSE
–
ORIGINAL ARTICLE
Prescription Opioid Craving: Relationship With Pain and
Substance Use-Related
Characteristics
Lisham Ashrafiouna , b
a Department of Psychology, Bowling Green State University,
Suicide Prevention,
Canandaigua VA Medical Center, Canandaigua, New York, USA
KEYWORDS
Craving; prescription opioids;
pain; desire; opiates
ABSTRACT
Background: Craving is associated with prescription opioid use
in opioid-addicted pain patients. Objec-
tives: This study evaluated the relationship between craving for
prescription opioids and selected
pain and substance use characteristics. Method: In this cross-
sectional study, patients (N = 106) being
treated for opioid dependence were recruited from one of three
sites from December 2012 to April
2013. Participants completed the multi-dimensional Desire for

Drugs Questionnaire to assess crav-
ing, and other questionnaires to assess pain, substance use, and
demographic characteristics. Data
were analyzed using Pearson product-by-moment correlations,
ANOVAs, and multiple linear regres-
sions. Results: At the bivariate level, desire-and-intention to use
prescription opioids and craving for
relief from negative states were positively associated with both
pain severity and interference. Lin-
ear regression analyses revealed significant positive
associations between Desire-and-Intention sub-
scale scores and obsessive thoughts and compulsive behaviors
associated with prescription opioids
and pain severity. Negative Reinforcement subscales scores
were positively associated with obsessive
thoughts and compulsive behaviors associated with prescription
opioids and the outcome expectan-
cies of pain reduction, but not pain severity.
Conclusions/Importance: This study extended previous
research assessing the link between pain and craving by
demonstrating that desire-and-intention, but
not craving for the negative reinforcing effects are associated
with pain severity after considering var-
ious substance use characteristics. Additional research is needed
to clarify the relationship between
pain and aspects of craving while also considering pain-specific
covariates. This study highlights that
the multi-dimensionality of craving is an important aspect to
consider when clinicians and researchers
evaluate the relationship between pain and craving.
Prescription opioid misuse has increased dramatically in
the past decade (Substance Abuse and Mental Health Ser-
vices Administration, 2013a, 2013b). Research has shown
that pain is common among patients with substance use
disorders (SUDs), and in particular with opioid use dis-

orders. For example, Trafton, Oliva, Horst, Minkel, &
Humphreys (2004) reported that 52% of patients receiv-
ing treatment for opioid addiction reported moderate to
severe pain. Among SUD patients, pain has been associ-
ated with higher rates of treatment drop-out, nonmedi-
cal use of prescription sedatives, illicit substance use, and
overdose (Bonar, Ilgen, Walton, & Bohnert, 2014; Britton,
Wines, & Conner, 2010; Caldeiro et al., 2008; Larson et al.,
2007; Potter, Prather, & Weiss, 2008; Trafton et al., 2004).
In addition, Price, Ilgen, and Bohnert (2011) found that
increased nonmedical prescription opioid use was associ-
ated with greater pain severity.
Clinicians and researchers have hypothesized that
craving may contribute to these poorer pain and
CONTACT Lisham Ashrafioun [email protected] V
Center of Excellence for Suicide Prevention, Canandaigua VA
addiction-related clinical outcomes (Martel, Dolman,
Edwards, Jamison, & Wasan, 2014; Trafton et al., 2004;
Wasan et al., 2009; Wasan et al., 2012).Although the
definition of craving has been debated (Skinner & Aubin,
2010; Tiffany & Wray, 2012), researchers have defined
craving as an intense subjective desire to use a sub-
stance, in this case prescription opioids (see Rosenberg,
2009 for a review). Using various definitions of crav-
ing, numerous models of craving have been proposed
with many focusing on the negative reinforcing effects
of substances (Skinner & Aubin, 2010). These negative
reinforcement models generally propose that individuals
are motivated to use substances to relieve a variety of
negative experiences. For example, Khantzian, Mack,
& Schatzberg (1974) proposed that individuals resort

to opioid use to self-medicate negative emotions such
as anxiety and depression. In the case of the relation-
ship between craving and pain, negative reinforcement
models of drug addiction might predict that prescription
This article not subject to US copyright law.
http://dx.doi.org/10.1080/10826084.2016.1188948
mailto:[email protected]
SUBSTANCE USE & MISUSE 1513
opioids are reinforcing because they relieve, attenuate,
help avoid, or help escape negative thoughts, emotions,
and/or experiences related to pain (Garland, Froeliger,
Zeidan, Partin, & Howard, 2013; Skinner & Aubin, 2010).
For example, Garland et al.’s (2013) model of chronic pain
and opioid addiction posits that individuals crave opioids
to maintain psychological well-being when experiencing
recurrent pain. Specifically, individuals use opioids to
relieve pain-related stress and negative emotions. Cues
paired with this opioid use (e.g., sight of pills) capture
and hold one’s attention and such exposure elicits craving
(Garland et al., 2013).
Despite empirical evidence and theoretical support of
the relationship between craving and pain, research on
their relationship is equivocal. For example, several inves-
tigations have found no significant difference in pain lev-
els among pain clinic patients as a function of craving
(Martel, Dolman, et al., 2014; Wasan et al., 2009; Wasan
et al., 2012). These studies are consistent with another
investigation that found no relationship between crav-
ing and pain severity among university students report-
ing prescription opioid use in their lifetime (Ashrafioun &

Carels, 2014). On the other hand, some investigators have
found a relationship between craving and pain severity.
For example, Rosenblum and colleagues (2003) found a
significant relationship between craving and pain severity
among patients in methadone maintenance and inpatient
drug treatment who had chronic pain even after control-
ling for withdrawal pain, demographics, number of drugs
used, pain as a reason for use, chronic illness, psychiatric
diagnosis and distress, and months in drug treatment.
Taken together, the methodological differences in
these studies may provide important insights for the
disparate findings. For example, there were differences in
the setting from which participants were recruited (pain
clinics, a university, inpatient drug treatment), the opera-
tionalization and measurement of pain (e.g., current pain
severity using a visual analog scale, average pain in the
past 24 hours, worst pain level over the last 6 months,
pain interference scores) and the measurement of craving
(visual analog scales for current craving and craving
in past 24 hours, multi-dimensional craving measure,
craving for opioids vs. for any drug). Other differences
might include order of pain and addiction onset and
participant interaction with healthcare professionals over
the course of their treatment for pain and/or addiction.
The current literature on the relationship between
craving and pain could be extended and improved in sev-
eral ways. Assessing prescription opioid craving utilizing
a multi-dimensional measure of current craving would
provide a more nuanced evaluation of craving compared
to that of a single-item rating scale. In addition, recruit-
ing participants with a range of pain severity scores from
several SUD treatment settings would increase the gen-
eralizability of this line of research. Furthermore, it may

be useful to examine other substance use-related factors
that may contribute to or exacerbate craving for prescrip-
tion opioids. Drug use severity and psychiatric sever-
ity are two factors that may impact the extent to which
one craves prescription opioids (e.g., Cicero, Lynskey,
Todorov, Inciardi, & Surratt, 2008; Tiffany & Wray, 2012).
In addition, there are theoretical, relationships between
increased craving and endorsement of several cognitive-
behavioral factors, such as outcome expectancies, and
obsessive thinking; however, there is limited empirical
investigations assessing these relationships (e.g., Franken,
2003; Ilgen et al., 2011; Marlatt, 1985).
Therefore, this study was designed to evaluate the
associations between craving, assessed using a multi-
dimensional questionnaire, and pain-related characteris-
tics, cognitive-behavioral aspects of substance use, and
psychiatric problems. Although this study did not assess
specific chronic pain conditions and specific impacts on
individuals’ psychosocial functioning, its broad objective
was to assess pain intensity and craving in the context
of other key substance use and mental health character-
istics. Specifically, it was hypothesized that more intense
craving would be positively associated with pain sever-
ity, expected reduction of pain from prescription opioids,
obsessive thoughts and compulsive behaviors related to
prescription opioids, and drug use severity. In addition, it
was hypothesized that the relationship between prescrip-
tion opioid craving and pain severity would persist when
controlling for the variance explained by those key sub-
stance use characteristics described above.
Method
Participants and procedure

Following approval of the project by the Institutional
Review Board, participants were recruited from Decem-
ber 2012 to April 2013 at one of three addiction treatment
centers: an urban community based outpatient substance
abuse and methadone maintenance program that serves
mostly those from the inner city of Detroit; (2) a sub-
urban community-based behavioral health care agency
that has inpatient and outpatient programs serving rural,
suburban, and urban populations in northwest Ohio; or
(3) an outpatient university-based addiction medicine
clinic providing methadone and buprenorphine mainte-
nance serving rural, suburban, and urban populations
in Western New York. Individuals were eligible if they
were between the ages of 18 and 65, were able to read
English, were opioid dependent, and preferred prescrip-
tion opioids as their primary drug of choice. Clinical staff
1514 L. ASHRAFIOUN
Mean (SD) or % of
Recruitment site area
Sex

Ethnicity
Education level
Some college, but d
Marital status
Sources of paina
Face/mo

a In the past three months.
imaginable).
(completely interferes).
provided the researcher with individuals who had been
using prescription opioids to further assess eligibility and
interest. After providing consent, participants completed
a multi-item craving questionnaire and a battery of other
questionnaires (described below). To conclude, partici-
pants were debriefed and given a card with $20 credit for
compensation.
A total of 127 individuals were approached to assess
their interest in participation, 12 of whom were not
interested or were unavailable. Of the remaining 115
individuals, nine were excluded because they did not
meet the eligibility criteria. Tables 1 and 2 display infor-
mation regarding demographic, pain, and substance use
characteristics on the 106 participants.
.
Mean (SD) or % of

Addiction Severity Indexa
Drug
# of days in current treatment
Opioid maintenance therapy
Opioids usedb
Routes of administration

Method of procurement
Stolen
Any non-
Last time used prescription opioids
OCDS-
PMEQd
DDQe
Desire-and-
maintenance treatment
drug.
c Obsessive Compulsive Drinking Scale-Revised; scores range
d Pain Medication Expectancy Questionnaire; scores range from

for the Desire-and
Inte
subscale.
Measures
Desires for Drug Questionnaire (DDQ)
The DDQ, which originally written for heroin crav-
ing (Franken, Hendriks, & Van Den Brink, 2002), was
adapted to assess current craving for prescription opioids.
Respondents were asked to indicate their level of agree-
ment with each of 13 items using a seven-point Likert
Scale, so that higher scores indicated stronger craving.
Franken et al. (2002) reported support for the validity and
reliability for three subscales: (1) Desire-and-Intention
(i.e., the desire and intention to use prescription opi-
oids), (2) Negative Reinforcement (i.e., craving for the
relief from negative states), and (3) Control (i.e., per-
ceived control over use). In the present sample, internal
consistency reliabilities were .90 for the Desire-and-
Intention subscale, .80 for the Negative Reinforcement
subscale, and .54 for the Control subscale. Given the
relatively low internal consistency reliability for the
Control subscale, only the Desire-and-Intention and
Negative Reinforcement subscales were included in the
analyses.
Obsessive Compulsive Drinking Scale-Revised

(OCDS-R)
Morgan, Morgenstern, Blanchard, Labouvie, & Bux
(2004) revised the original OCDS (Anton, Moak, &
Latham, 1995) that asks about experiences such as the fre-
quency of obsessive thoughts of drug use, amount of dis-
tress associated with thoughts of drug use, amount of time
spent using drugs, drug-related interference in daily activ-
ities, and perceived degree of control over drug use over
the last week. Higher scores on the OCDS-R suggest more
obsessive thoughts and compulsive behaviors associated
with prescription opioids. Morgan et al. (2004) provided
support for the psychometric properties for the OCDS-R.
Internal consistency reliability for the current sample was
.90.
Pain Medication Expectancies Questionnaire (PMEQ)
The PMEQ is a 38-item measure designed to assess out-
come expectancies of prescription opioids (Ilgen et al.,
2011). Respondents are asked to rate the likelihood from
1 (“Not at all likely”) to 10 (“Very likely”) that they would
use a pain medication for each of the 38 reasons divided
into three subscales: (1) pleasure/social enhancement, (2)
pain reduction, and (3) negative experience reduction.
Higher scores suggest greater endorsement of prescrip-
tion opioid use outcome expectancies. Ilgen et al. (2011)
found initial psychometric support for these subscales.
Internal consistency reliabilities in the current sample
were .98 for the pleasure/social enhancement subscale, .92
for the pain subscale, and .97 for the negative experience
reduction subscale.
Self-administered Addiction Severity Index (ASI)
The drug use and psychiatric severity indices of the ASI
were utilized (McLellan, Luborsky, Woody, & O’Brien,
1980). Computational formulas were used to generate

composite scores that range from 0 (no endorsement of
any problems) to 1 (maximal endorsement of all prob-
lems). Research supports the psychometric properties of
the self-administered ASI (McLellan et al., 1980; Rosen,
Henson, Finney, & Moos, 2000).
Brief Pain Inventory-Short Form
The Brief Pain Inventory was used to assess a partici-
pant’s pain severity and interference in daily functioning
due to pain (Cleeland & Ryan, 1994). The first two ques-
tions asked if respondents had experienced pain other
than everyday types of pain (e.g., minor headaches, tooth
aches, sprains) over the last three months and, if so, the
location of the pain. Pain severity is calculated by aver-
aging respondents’ worst, least, and average pain in the
last three months, and their current pain each of which
based on an 11-point rating scale from 0 (“No Pain”)
to 10 (“Worst Pain Imaginable”). Respondents were also
asked to rate how much their pain interfered with func-
tioning in seven domains from 0 (“Does not interfere”)
to 10 (“Completely interferes”). Cleeland (2009) provides
support for the psychometric properties of the origi-
nal BPI. Internal consistency reliabilities for the present
sample were .93 for pain intensity and .89 for pain
interference.
Demographics and prescription opioid questionnaire
This questionnaire assessed participants’ demographic
characteristics (e.g., race/ethnicity, age), and prescription
opioid use history (e.g., opioids used, routes of adminis-
tration).
Data analysis
Frequency counts and means and standard deviations
were calculated to summarize features of the sample. Pre-
liminary analyses included the testing of bivariate rela-

tionships between craving and other measured variables
using t-tests, ANOVAs, and Pearson product-by-moment
correlations. Primary analyses were tested using linear
regression analyses with DDQ-Desire-and-Intention and
DDQ-Negative Reinforcement scores as dependent vari-
ables and with simultaneous entry of ASI-Drug Use and
Psychiatric Indices, OCDS-R, PMEQ, and BPI pain sever-
ity scores as the independent variables. Basic statistical
assumptions were met and suggestions for decreasing
the likelihood of overfitting were taken (Babyak, 2004).
Variables entered in the regression models were selected
because research has found them to be associated with
craving (e.g., Cicero et al., 2008; Franken, 2003; Ilgen
et al., 2011; Tiffany & Wray, 2012). Analyses were con-
ducted with the entire sample regardless of one’s pain
status.
1516 L. ASHRAFIOUN
Results
Relationship between craving and other key
variables
Demographics
There were no significant associations between the crav-
ing subscale scores and gender (tDesire-and-intention(103)
= −1.00, p = .32; tNegativeReinforcement(103) = −.52,
p = .61), race (tDesire-and-intention(103) = −1.83, p
= .07; tNegativeReinforcement(103) = −.14, p = .89),
level of education (FDesire-and-intention(3,97) = .99,
p = .40; FNegativeReinforcement(3,97) = 1.44, p = .24),
marital status (tDesire-and-intention(103) = .06, p =
.95;tNegativeReinforcement(103) = .19, p = .85). In addition,

there was no significant correlations between craving
subscales scores and age (rDesire-and-intention(102) = .09,
p = .36; rNegativeReinforcement(102) = −.08, p = .42) or
days worked (FDesire-and-intention(102) = −.10, p = .34;
rNegativeReinforcement(102) = −.03, p = .75).
Pain
To identify whether current craving was associated with
several aspects of pain, the associations between Desire-
and-Intention scores and Negative Reinforcement scores
with four specific pain-related variables were assessed
(see Table 3). Scores on the Desire-and-Intention sub-
scale were significantly greater among those participants
who reported experiencing pain in the last three months
(M = 25.5, SD = 13.4) compared to those who did not
(M = 18.0, SD = 8.2), t(104) = −2.33, p < .05. Desire-
and-intention of using prescription opioids was also sig-
nificantly correlated with pain severity, r(104) = .35, p <
.001, pain interference, r(102) = .28, p < .01, and num-
ber of pain locations, r(104) = .20, p < .001. There was
no significant association between pain reported in the
past three months and Negative Reinforcement scores,
t(104) = −1.35, p > .05 (see Table 3). However, Nega-
tive Reinforcement scores were significantly, though not
as strongly, associated with both pain severity, r(104) =
.20, p < .05, and pain interference, r(102) = .23, p < .05,
but not with number of pain locations, r(104) = .16, p >
.05.
Prescription opioid use
The relationships between craving subscale scores several
prescription opioid use characteristics were also evaluated
(see Table 3). Those who reported having used prescrip-
tion opioids within the past seven days had significantly
higher craving scores (M = 31.5, SD = 2.5) than those
who reported having last used within in the previous 31

to 90 days (M = 16.4, SD = 2.8) and those who reported
having last used more than 90 days previously (M = 17.4,
Table
pre-
scription opioid use characteristics.
DDQ-Desire-and-
Intentiona
DDQ-Negative
Reinforcementa
F-, t-, or r F-, t-, or r
Characteristics M (SD) statistic M (SD) statistic
Pain experienced in
pa
∗
# of days since last
use
∗ ∗
# of pain locationsb — ∗ —
Pain severity — ∗ ∗ ∗ — ∗
Pain interferenceb — ∗ ∗ — ∗
OCDS-Rc — ∗ ∗ ∗ — ∗ ∗ ∗
PMEQd
Pleasure/social
enhancement

— ∗ ∗ — ∗ ∗ ∗
Pain relief — ∗ ∗ ∗ — ∗ ∗ ∗
Negative
experience
reduction
— ∗ ∗ — ∗ ∗ ∗
ASIe
Psychiatric
status
— ∗ — ∗
Drug use — ∗ —
∗ ∗ ∗ ∗ ∗ ∗
for the Desire-and
subscale.
b In the past three months.
c Obsessive Compulsive Drinking Scale-Revised.
d Pain Medication Expectancy Questionnaire.
e Addiction Severity Index
SD = 2.4), F(3,69) = 7.19, p < .001, partial η2 = .24.
However, Negative Reinforcement from using prescrip-
tion opioids did not differ as a function of the number of
days since last use, F(3,69) = 1.03, p > .05, partial η2 =
.04.

Furthermore, desire-and-intention to use prescrip-
tion opioids was significantly associated with obsessive
thoughts and compulsive behaviors related to prescrip-
tion opioids, r(103) = .49, p < .001. This dimension of
craving was also significantly associated with outcomes
expectancies of pleasure and social enhancement, r(103)
= .30, p < .005, pain reduction, r(103) = .43, p < .001, and
anticipation of relief from negative experiences, r(102)
= .28, p < .005. Similarly, craving for relief from neg-
ative states was significantly associated with obsessive
thoughts and compulsive behaviors related to about pre-
scription opioids, r(103) = .44, p < .001. In addition,
scores were significantly positively associated with out-
comes expectancies of pleasure and social enhancement,
r(103) = .43, p < .001,pain reduction, r(103) = .47, p <
.001, and anticipation of relief from negative experiences,
r(102) = .47, p < .001.
desires for drug questionnaire (DDQ) desire-and-intention
and DDQ negative reinforcement subscale and drug use
characteristics.
DV IV β B SE t-value
DDQ-Desire-and-
Intention
OCDS- ∗ ∗
∗
PMEQ-
ASI-

ASI-
DDQ-Negative
Reinforcement
OCDS- ∗
PMEQ- ∗
ASI-
ASI-
DDQ-Desire-and-
-
Negative Rei
∗ ∗
∗
Abbreviations: DV—Dependent Variable; IV—Independent
Variable; OCDS-
R—Obsessive Compulsive Drinking Scale-Revised; PMEQ—
Pain Medication
Expectancy Questionnaire; ASI—Addiction Severity Index.
Both psychiatric status, r(101) = .26, p < .01, and drug
use severity, r(103) = .21, p < .05, were significantly asso-
ciated with Desire-and-Intention scores. Although psy-
chiatric status was significantly associated with Negative
Reinforcement scores, r(101) = .33, p < .001, drug use
severity was not, r(103) = .17, p > .05.
Regression analyses assessing unique associations
between craving and selected pain and drug use
characteristics
Results of regression analyses revealed a significant model
for DDQ-Desire-and-Intention scores, F(5,95) = 8.80, p
<.001, adjusted R2 = .28 (see Table 4). Specifically, obses-

sive thoughts and compulsive behaviors (β = .33), and
pain severity scores (β = .20) were significantly positively
associated with DDQ-Desire-and-Intention scores. This
indicates that obsessive thoughts and compulsive behav-
iors related to prescription opioids were the strongest cor-
relate of desire-and-intention to use prescription opioids,
although pain severity was also significantly associated
with this type of craving.
For the regression with DDQ-Negative Reinforcement
scores as the dependent variable, the overall model was
significant, F(5,96) = 7.74, p <.001, adjusted R2 = .25.
Obsessive thoughts and compulsive behaviors (β = .24)
and the outcome expectancy of pain reduction (β = .29)
were significantly associated with DDQ-Negative Rein-
forcement scores (see Table 4). This suggests that greater
craving to reduce negatives states was associated with
obsessive thoughts and compulsive behaviors related to
prescription opioids and greater expectancies of prescrip-
tion opioids to relieve pain when controlling for the vari-
ance explained by the other key characteristics.
Discussion
The current findings indicate that desire-and-intention
to use prescription opioids and, to a lesser extent, craving
for relief from negative states, were significantly asso-
ciated with a number of pain-related characteristics,
including having experienced pain over the past three
months, pain severity, number of pain locations, and pain
interference. When included in a regression model, the
significant association between pain severity and desire-
and-intention persisted after including key substance
use characteristics (i.e., pain medication expectancies,
obsessive thoughts and compulsive behaviors related
to prescription opioids, drug use severity). This lat-

ter finding is important because it suggests that those
theoretically-driven substance use characteristics did not
account for the relationship between desire-and-intention
to use and pain severity.
This study provides further evidence that pain and
craving are associated among addiction treatment
patients (Rosenblum et al., 2003) and may provide
an explanation for the inconsistent results in previous
research on the relationship between pain and craving.
This study examined the relationship between craving
and pain using a multi-dimensional measure of craving,
which provides a more nuanced evaluation of prescrip-
tion opioid craving. Previous research has largely utilized
single-item scales and respondents may find it difficult
to characterize a complex phenomenon using a single
numeral (Rosenberg, 2009). This finding highlights
the importance of using a more sophisticated measure
of craving among chronic pain and opioid-addicted
patients.
The results of the current study provide partial sup-
port for the hypothesis that pain would be associated with
craving for prescription opioids to relieve negative states.
Although this relationship was significant in the bivari-
ate analysis, it was no longer significant after adjusting
for other substance use-related variables. This is perhaps
surprising given that addicted individuals might take pre-
scription opioids for pain and/or other associated nega-
tive thoughts or emotions (Garland et al., 2013; Martel,
Dolman, et al., 2014; Martel, Jamison, Wasan, & Edwards,
2014). One possibility for the relatively weak relationship
in this study was that the wording of the statements on
the Negative Reinforcement subscale did not adequately
assess the negative experiences of those with co-occurring
pain and addiction. The Negative Reinforcement sub-

scale consists of statements about general life problems
(e.g., “I would feel as if all the bad things in my life had
disappeared if I used prescription opioids right now”)
and negative experiences focused on pain-related nega-
tive experiences (e.g., anxiety, physical pain/discomfort,
1518 L. ASHRAFIOUN
pain catastrophizing) may better capture their experi-
ences. Another possibility is that people’s beliefs about
the effects of prescription opioids are more important
than their pain severity. This would be consistent with
the finding that pain reduction outcome expectancies
were associated with craving to relieve negative states and
pain severity was not. Additional research is needed to
assess pain reduction outcome expectancies as a poten-
tial mediator of pain and craving for relief from negative
states.
Another novel contribution to the pain and craving lit-
erature is that obsessive thoughts and compulsive behav-
iors related to prescription opioids appear to be another
key factor when considering craving for prescription opi-
oids. This was among the strongest correlates of desire-
and-intention to use prescription opioids and craving
to relieve negative states, which is consistent with pre-
vious research with heroin (Franken, 2002) and alco-
hol (Bohn, Krahn, & Staehler, 1995; Flannery, Volpicelli,
& Pettinati, 1999; Rosenberg & Mazzola, 2007). While
these obsessive thoughts and compulsive behaviors may
be conceptualized as craving, researchers have indicated
that the construct measured in the OCDS is a “cogni-
tive correlate” of craving that seems to be examining
a different aspect of substance use dependence that is

largely independent of craving (Anton, Moak, & Latham,
1996). This distinction is consistent with Franken’s model
of drug craving, which posits that obsessive thoughts
are one of several factors that are affected by and can
affect one’s level of craving (Franken, 2003). Specifi-
cally, he proposed that attentional bias to drug cues
can elicit or enhance existing craving which, once acti-
vated, can increase attentional bias, obsessive thoughts,
and the likelihood of relapse (Franken, 2003).Further
research is needed to better understand how pain sever-
ity specifically may contribute to the relationship between
obsessive thoughts, attentional bias, and current craving
among individuals with chronic pain who are addicted to
opioids.
These findings should be taken in consideration in
the context of several limitations. For example, many of
the participants were African American which may affect
ratings of pain severity and craving. Carter et al. (2010)
found that African Americans reported lower craving to
smoke cigarettes compared to Caucasian counterparts.
Furthermore, Riley and colleagues (2002) found that
African Americans report greater emotional responses
to pain and unpleasantness relative to Caucasians. These
studies suggest that results observed in the current study
may differ with a sample with a smaller proportion of
African Americans. However, it is important to note that
there were no differences in craving as a function of race
in this study. Another limitation is that the majority of the
sample was receiving opioid maintenance therapy and no
information was collected on the dosing or when those
participants last took their medication. This is significant
given that size and timing of the last dose of methadone
can impact craving (Ilgen, Jain, Kim, & Trafton, 2008).
In addition, withdrawal from opioids can impact pain

severity given that symptoms include back and muscle
aches, cramps, and joint pain among others. The inter-
pretation of the results is also complicated by the varying
time points in which the variables were measured (e.g.,
current craving, past year drug use severity, three-month
pain scores, past-week obsessive thoughts and compul-
sive behaviors). For example, assessing one’s craving in
the past three months may depict a different relationship
with pain intensity in the past three months compared
to one’s current craving. In addition, this study was lim-
ited in its sample size, which restricted the number of
variables that could be accounted for in the multivariate
analyses.
When considering the findings of this investigation in
the context of the extant literature on pain and craving,
this study does not provide definitive evidence for the
pain-craving relationship but does provide some impor-
tant insights. This adds to the evidence that pain and
craving are associated among patients involved in opioid
maintenance programs. In this study, pain and craving
were both measured as continuous variables rather than
dichotomous or categorical variables, which decrease
loss of variability subsumed within groups, effect size,
power, spurious statistical significance, and measurement
reliability. Nonetheless, perhaps setting may be impor-
tant such that substance use disorder treatment centers
are places in which patients have their drug of choice
(e.g., oxycodone, hydrocodone) taken away thus increas-
ing their pain and craving for it. On the other hand,
pain clinics, where several studies have recruited par-
ticipants, may be viewed as a place in which patients
receive their drug of choice and thus their craving and
pain is reduced with receipt of the opioids. The current
study also encourages further research recruiting African
Americans, given that previous research was primarily

in Caucasians. Furthermore, it also encourages further
use of multi-dimensional measures, such as the DDQ.
Single-item measures are advantageous due to their
brevity; however, the DDQ takes minutes to complete
and can provide more specific information. Nonetheless,
the modest relationship between pain severity and crav-
ing after accounting for only select substance use char-
acteristics highlights that clinicians should be cognizant
of not overestimating the relationship between pain and
craving. Clinicians and patients may be better served
by addressing the relationship between craving and pain
medication expectancies and/or obsessive thoughts and
compulsive behaviors given the more robust relationships
with these other substance use factors compared to pain.
Future research should also consider other pain-related
factors, such as pain condition and cognitive-behavioral
constructs of pain. Research has found a significant rela-
tionship between pain catastrophizing and craving (Mar-
tel, Jamison, et al., 2014) and studies could also assess
the association between craving and use and pain-related
coping skills and pain avoidance. In addition, although
research has demonstrated that craving prospectively pre-
dicts prescription opioid use (Tsui, Anderson, Strong, &
Stein, 2014), less is known regarding longitudinal trajec-
tories of opioid and nonopioid pain interventions on crav-
ing. This type of research could provide useful informa-
tion regarding the relative effectiveness of various pain
treatments on craving and the onset of prescription opi-
oid dependence. This may also provide an opportunity
to understand provider contributions to patient prescrip-
tion opioid outcome expectancies (e.g., patient knowledge

of opioid-induced hyperalgesia and withdrawal pain).
In sum, this study found that pain severity was associ-
ated with desire-and-intention to use prescription opi-
oid after accounting for key substance use characteristics.
For future studies, multi-dimensional craving measures
should be used and pain-related factors should also be
considered.
Glossary
Craving: An intense subjective desire to use a substance.
Negative reinforcement craving: Craving for the relief from
neg-
ative states.
Obsessive compulsive substance use: Frequent and distressing
preoccupation with using substances that interferes with
daily activity and is associated with little control over drug
use.
Pain interference: The extent to which pain interferes with var-
ious aspects of one’s life such as mood, engagement in daily
activities, etc.
Declaration of interest
The author reports no conflicts of interest. The author alone is
responsible for the content and writing of the article.
Funding
This work was funded by the American Psychological Associ-
ation, the APF/COGDOP, and the Katzner Graduate Student
Research and Professional Development Award.

Notes on contributor
Lisham Ashrafioun, PhD, is
a post-doctoral fellow at the
Department of Veterans Affairs
VISN 2 Center of Excellence
for Suicide Prevention and the
Department of Psychiatry at the
University of Rochester Med-
ical Center. Dr. Ashrafioun’s
research interests are related to
the intersection between sui-
cidal thoughts and behaviors,
substance use, and pain.
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