Pain Acceptance’s Two Faces: One Predicts Opioid Misuse, the Other Protects Against It

More than 13 million Americans remain on long-term opioid therapy for chronic pain, despite well-established risks and a striking lack of quality evidence that the drugs deliver lasting benefit. Against that backdrop, a new study from Virginia Commonwealth University offers a deceptively simple insight with potentially far-reaching consequences: the psychological construct known as pain acceptance is not one thing but two, and its two halves pull in opposite directions when it comes to opioid misuse and the willingness to cut back on these medications. The findings, published in Frontiers in Psychology, suggest that clinicians hoping to reduce opioid-related harm may need to look far more closely at which component of acceptance a patient actually possesses.

The research team, led by Lara Rose LoBrutto of Virginia Commonwealth University’s Department of Psychology, recruited 157 adults with a variety of chronic pain conditions who were currently taking prescribed opioid medications. Participants were drawn from ResearchMatch.org, a national volunteer registry, and completed an online battery of validated questionnaires. The central instrument was the Chronic Pain Acceptance Questionnaire, a 20-item scale that yields two distinct subscores: activity engagement, which captures the pursuit of meaningful life activities regardless of pain levels, and pain willingness, which reflects a person’s openness to experiencing pain rather than avoiding or fighting it. Misuse was screened with the Prescription Opioid Misuse Index, an eight-item yes/no measure on which two or more affirmative answers indicate a likely opioid misuse diagnosis. Readiness and confidence to taper were captured with single-item visual analog scales adapted from the readiness ruler used in motivational interviewing.

The statistical approach was straightforward but revealing. The researchers entered pain severity and the two acceptance subscales simultaneously into three regression models: a logistic regression predicting whether participants screened positive for opioid misuse, and two linear regressions predicting readiness and confidence to reduce opioid use. All three models were statistically significant. The surprise lay in the direction of the individual effects, which the authors had not anticipated.

Pain willingness behaved exactly as theory would predict. Participants who reported greater willingness to experience their pain without avoidance had lower odds of misusing their opioids, with an odds ratio of 0.89 per unit increase on the subscale. This aligns with a growing literature linking acceptance-based constructs to safer medication use, including studies in chronic low back pain and spinal cord injury populations. The logic is intuitive: someone who can tolerate discomfort without reaching for relief is presumably less likely to take medication in ways not prescribed.

Activity engagement, by contrast, was associated with greater odds of opioid misuse, with an odds ratio of 1.08 per unit increase. The authors offer several possible explanations, all necessarily speculative because the data are cross-sectional. One possibility is that opioid use, including patterns that would trigger a positive misuse screen, enables some individuals to keep pursuing valued activities despite their pain. Another is that the questionnaire’s activity engagement subscale may not fully distinguish flexible, values-consistent engagement from more rigid patterns of persisting with activity even as pain worsens. Prior research has linked overactivity to greater opioid use, though the current measure does not directly assess overactivity, and the authors are careful to flag this interpretation as tentative. Longitudinal studies incorporating specific measures of activity pacing will be needed to untangle cause from effect.

The readiness and confidence findings added a second layer of nuance. Higher activity engagement predicted greater readiness and confidence to taper opioid use, while higher pain willingness predicted lower readiness and confidence. In other words, the two acceptance dimensions flipped their associations entirely between the misuse outcome and the change-readiness outcomes. The authors note that this pattern makes it difficult to label either factor straightforwardly protective. Readiness and confidence, they point out, are measures of intention, whereas misuse is a behavior, and intentions do not always map cleanly onto what people actually do. A person may genuinely believe they could reduce their opioid use without fully accounting for the barriers involved.

Several mechanistic hypotheses could explain the counterintuitive pain willingness result. Because tapering opioids can temporarily increase pain exposure, one might expect openness to pain to correspond with greater willingness to cut back. Instead, the authors suggest that pain willingness may support a realistic assessment of one’s pain management needs, producing a more measured approach to medication and, consequently, less interest in tapering among those who are already using opioids appropriately. Alternatively, higher activity engagement may favor behavior change precisely because it is associated with greater misuse, or because people who pursue valued activities despite pain are more inclined to take action in the face of obstacles and feel prepared to reduce their medication.

Notably, pain severity was not a significant predictor in any of the three models. This finding is consistent with the authors’ hypothesis that pain acceptance would outperform raw pain intensity as a predictor of opioid-related outcomes. When pain acceptance measures were removed from the models, pain severity did show associations with the outcome measures, suggesting that acceptance accounts for variance previously explained by severity. Given that the literature links higher pain severity to riskier opioid use and worse recovery outcomes, the implication is that psychological flexibility may be a more actionable target than pain intensity itself.

The study has clear limitations that the authors acknowledge. The sample was predominantly female and Caucasian, limiting generalizability. Recruitment and data collection were conducted entirely online, and the analyses were secondary, with sensitivity analyses indicating limited power to detect small effects. The cross-sectional design precludes any causal conclusions, and the single-item readiness and confidence measures, while efficient, may have introduced measurement error. Roughly 29 percent of the analyzable sample screened above the opioid misuse cutoff, and more than half reported diagnoses of depression or anxiety, underscoring the clinical complexity of this population.

Even with those caveats, the study is the first to examine pain acceptance and opioid use across a range of pain diagnoses and etiologies in a community sample of non-treatment-seeking individuals on long-term opioid therapy, a group that typically shows low motivation for nonpharmacological pain care. The results broadly align with prior disease-specific findings that acceptance facilitates reduced opioid use after spinal cord injury and in chronic low back pain. They also carry practical weight for Acceptance and Commitment Therapy, or ACT, a third-wave behavioral treatment whose Hexaflex model treats acceptance as one of six dimensions of value-based living. ACT has already shown promise for reducing postoperative opioid use and improving outcomes in patients with comorbid pain and opioid use disorder. If the two components of acceptance have divergent relationships with misuse and change readiness, then ACT-based interventions for chronic pain may need to target those components deliberately rather than treating acceptance as a monolithic goal. Future work, the authors suggest, should compare the two acceptance dimensions in long-term opioid therapy patients versus those not on such therapy, and track longitudinal associations between acceptance and stages of change in patients receiving ACT. In a crisis that claims more than 105,000 overdose deaths annually in the United States, understanding which psychological levers actually move the needle on opioid risk is not an academic luxury. It may be one of the few remaining paths toward safer pain care.

Subject of Research: The divergent associations between the two dimensions of pain acceptance and opioid misuse and readiness to change among adults with chronic pain on long-term opioid therapy

Article Title: Two dimensions of pain acceptance: divergent links to opioid misuse and readiness to change

Article References: LoBrutto, L. R., Donovan, E., Burke, S., Smith, W., Svikis, D., & Crouch, T. (2026). Two dimensions of pain acceptance: divergent links to opioid misuse and readiness to change. Frontiers in Psychology, 17, Article 1879837. https://doi.org/10.3389/fpsyg.2026.1879837

Image Credits: AI Generated

DOI: 10.3389/fpsyg.2026.1879837

Keywords: chronic pain, pain acceptance, opioid misuse, long-term opioid therapy, Acceptance and Commitment Therapy, readiness to change, activity engagement, pain willingness, Transtheoretical Model, self-efficacy, opioid tapering, health psychology