Catastrophic thinking and increased risk for prescription opioid misuse in patients with chronic pain

https://doi.org/10.1016/j.drugalcdep.2013.02.034Get rights and content

Abstract

Background

As a consequence of the substantial rise in the prescription of opioids for the treatment of chronic noncancer pain, greater attention has been paid to the factors that may be associated with an increased risk for prescription opioid misuse. Recently, a growing number of studies have shown that patients with high levels of catastrophizing are at increased risk for prescription opioid misuse.

Objective

The primary objective of this study was to examine the variables that might underlie the association between catastrophizing and risk for prescription opioid misuse in patients with chronic pain.

Methods

Patients with chronic musculoskeletal pain (n = 115) were asked to complete the SOAPP-R, a validated self-report questionnaire designed to identify patients at risk for prescription opioid misuse. Patients were also asked to complete self-report measures of pain intensity, catastrophizing, anxiety, and depression.

Results

Consistent with previous research, we found that catastrophizing was associated with an increased risk for prescription opioid misuse. Results also revealed that the association between catastrophizing and risk for opioid misuse was partially mediated by patients’ levels of anxiety. Follow-up analyses, however, indicated that catastrophizing remained a significant ‘unique’ predictor of risk for opioid misuse even when controlling for patients’ levels of pain severity, anxiety and depressive symptoms.

Discussion

Discussion addresses the factors that might place patients with high levels of catastrophizing at increased risk for prescription opioid misuse. The implications of our findings for the management of patients considered for opioid therapy are also discussed.

Introduction

Over the past decade, there has been a substantial rise in the use of opioids for the treatment of chronic noncancer pain. Despite the potential benefits of opioid therapy, long-term opioid use may lead to a number of adverse outcomes, including prescription opioid misuse and addiction (Ballantyne, 2010, Banta-Green et al., 2009a, Compton, 2008, Edlund, 2011, Jamison et al., 2010, Morasco et al., 2013, Sullivan et al., 2010). Prescription opioid misuse, which refers to the use of opioids in a manner other than prescribed, has become a significant concern for clinicians prescribing opioids (Banta-Green et al., 2009b, Compton, 2008, Jamison et al., 2011, Sehgal et al., 2012). Because of these concerns, many investigators have turned their attention to the factors that may be associated with an increased risk for prescription opioid misuse in patients with chronic pain.

A number of demographic and background variables have been found to be associated with an increased risk for prescription opioid misuse in patients with chronic pain, including young age and history of substance abuse (Edlund et al., 2007a, Michna et al., 2004, Ives et al., 2006, Morasco and Dobscha, 2008, Morasco et al., 2013, Schieffer et al., 2005). Pain-related variables, such as self-reports of pain severity, have also been found to be associated with an increased risk for prescription opioid misuse, with patients reporting high levels of pain being at greater risk for opioid misuse than patients reporting low levels of pain (Adams et al., 2004, Grattan et al., 2012, Jamison et al., 2009, Morasco et al., 2013). In a recent study, it has also been found that patients with high levels of experimental pain sensitivity (i.e., hyperalgesic patients) are at greater risk for prescription opioid misuse than patients with low levels of pain sensitivity (Edwards et al., 2011a).

Associations have also been found between psychological factors and risk for prescription opioid misuse. For example, several studies have found that patients with psychiatric disorders are at greater risk for prescription opioid misuse (Dersh et al., 2008, Grattan et al., 2012, Turk et al., 2008, Wasan et al., 2007). Patients scoring high on measures of negative affect such as anxiety (Edlund et al., 2007b, Morasco et al., 2013, Schieffer et al., 2005, Wasan et al., 2007, Wilsey et al., 2008) and depression (Edlund et al., 2007a, Grattan et al., 2012, Morasco et al., 2013, Wasan et al., 2007) have also been found to be at increased risk for prescription opioid misuse. Finally, an increasing number of studies have shown that patients high in pain catastrophizing, a negative and pessimistic orientation toward pain, are at increased risk for prescription opioid misuse (Edwards et al., 2011a, Ferrari et al., 2012, Jamison et al., 2009, Morasco et al., 2013). Patients who are high in catastrophizing tend to ruminate about pain, to magnify the threat value of pain, and to experience feelings of helplessness when in pain (Edwards et al., 2006, Keefe et al., 2000, Sullivan et al., 2001). In a recent study conducted among patients with chronic pain, Morasco et al. (2013) found that pain catastrophizing was associated with an increased risk for prescription opioid misuse even after controlling for patients’ demographic variables, substance use disorder (SUD) status, and depressive symptoms.

To date, little is known on the specific mechanisms by which catastrophizing may lead to an increased risk for prescription opioid misuse. One possibility is that patients with high levels of catastrophizing are at increased risk for prescription opioid misuse because they experience high levels of clinical pain. Another possibility is that patients with high levels of catastrophizing are at increased risk for prescription opioid misuse due to heightened basal pain sensitivity, or alterations in central pain processing. Finally, it is possible that high catastrophizers are at increased risk for prescription opioid misuse due to high levels of negative affect. Past research has shown that catastrophizing is associated with heightened levels of pain severity (for a review, see Sullivan et al., 2001), pain sensitivity (for a review, see Quartana et al., 2009), and negative affect (for a review, see Edwards et al., 2011b).

The primary purpose of the present study was to examine the mechanisms that might underlie the association between catastrophizing and risk for prescription opioid misuse in patients with chronic pain. In this study, a sample of patients with chronic musculoskeletal pain were asked to complete the SOAPP-R (Butler et al., 2008), a self-report questionnaire designed to identify patients at risk for prescription opioid misuse. Analyses examined the potential role of patients’ pain severity, pain sensitivity, and negative affect as mediators of the association between catastrophizing and risk for prescription opioid misuse. Follow-up analyses examined the unique (i.e., independent) influence of catastrophizing on risk for prescription opioid misuse.

Section snippets

Participants

Participants were 115 patients recruited from the Pain Management Center at Brigham and Women's Hospital (BWH). Patients with a diagnosis of spinal pain, with or without radicular symptoms, and who had been experiencing pain for at least 6 months were invited to participate. Patients were excluded if they had a diagnosis of cancer or other malignant disease, or had cognitive limitations that precluded providing self-report data. Patients were also excluded if they had any active substance use

Descriptive statistics

Descriptive statistics for all study measures are presented in Table 1, separately for men and women. Analyses revealed no significant sex differences in age, self-reported pain severity (BPI), pain interference (BPI), pain sensitivity (TPThs), pain-related anxiety (PASS), depression (BDI), catastrophizing (PCS), or risk for prescription opioid misuse (SOAPP-R) (all p's > .05). Men and women did not differ significantly in the use of opioids, X2(1) = .38, ns.

Independent samples t-tests were

Discussion

The primary purpose of the present study was to examine the factors that underlie the association between catastrophizing and heightened risk for prescription opioid misuse in patients with chronic pain. Consistent with previous research (Edwards et al., 2011a, Ferrari et al., 2012, Jamison et al., 2009, Morasco et al., 2013), we found that higher levels of catastrophizing were associated with higher scores on the SOAPP-R, a self-report questionnaire designed to identify patients at risk for

Role of funding source

Funding for this study was provided by the National Institutes of Health (NIH): Grants AG034982 and CA 120500. NIH had no further role, whether in terms of study design, data collection, data analysis, or data interpretation. NIH was neither involved in the writing of the manuscript, nor in the decision to submit the manuscript for publication.

Contributors

RR Edwards designed the study. MO Martel conducted statistical analyses, interpreted study data, and wrote the major part of the manuscript. RR Edwards, AD Wasan, and RN Jamison all contributed to data interpretation. They also contributed and approved the final manuscript.

Conflict of interest

The authors have no financial interests in the results of this research, and all authors declare that they have no conflicts of interest.

References (95)

  • S.F. Butler et al.

    Validation of the revised screener and opioid assessment for patients with pain (SOAPP-R)

    J. Pain

    (2008)
  • K.R. Conner et al.

    Meta-analysis of depression and substance use and impairment among cocaine users

    Drug Alcohol Depend.

    (2008)
  • M. D’Acremont et al.

    How is impulsivity related to depression in adolescence? Evidence from a french validation of the cognitive emotion regulation questionnaire

    J. Adolesc.

    (2007)
  • M.J. Edlund et al.

    Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain

    Pain

    (2007)
  • M.J. Edlund

    Chronic opioid therapy for chronic noncancer pain in the United States: long day's journey into night?

    Gen. Hosp. Psychiatry

    (2011)
  • R.R. Edwards et al.

    Quantitative assessment of experimental pain perception: multiple domains of clinical relevance

    Pain

    (2005)
  • R.R. Edwards et al.

    Association of catastrophizing with interleukin-6 responses to acute pain

    Pain

    (2008)
  • R.R. Edwards et al.

    Elevated pain sensitivity in chronic pain patients at risk for opioid misuse

    J. Pain

    (2011)
  • P. Franques et al.

    Sensation seeking as a common factor in opioid dependent subjects and high risk sport practicing subjects. A cross sectional study

    Drug Alcohol Depend.

    (2003)
  • R.N. Jamison et al.

    Substance misuse treatment for high-risk chronic pain patients on opioid therapy: a randomized trial

    Pain

    (2010)
  • F.J. Keefe et al.

    Pain coping strategies that predict patients’ and spouses’ ratings of patients’ self-efficacy

    Pain

    (1997)
  • F.J. Keefe et al.

    The relationship of gender to pain, pain behavior, and disability in osteoarthritis patients: the role of catastrophizing

    Pain

    (2000)
  • F.J. Keefe et al.

    The social context of gastrointestinal cancer pain: a preliminary study examining the relation of patient pain catastrophizing to patient perceptions of social support and caregiver stress and negative responses

    Pain

    (2003)
  • F.J. Keefe et al.

    Gender differences in pain, coping, and mood in individuals having osteoarthritic knee pain: a within-day analysis

    Pain

    (2004)
  • R.S. Khan et al.

    Catastrophizing: a predictive factor for postoperative pain

    Am. J. Surg.

    (2011)
  • G.F. Koob et al.

    Drug addiction, dysregulation of reward, and allostasis

    Neuropsychopharmacology

    (2001)
  • L.M. McCracken et al.

    The pain anxiety symptom scale: development and validation of a scale to measure fear of pain

    Pain

    (1992)
  • J.R. McKay et al.

    Predicting proximal factors in cocaine relapse and near miss episodes: clinical and theoretical implications

    Drug Alcohol Depend.

    (1999)
  • E. Michna et al.

    Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history

    J. Pain Symptom Manage.

    (2004)
  • M.J. Millan

    Multiple opioid systems and pain

    Pain

    (1986)
  • B.J. Morasco et al.

    Prescription medication misuse and substance use disorder in VA primary care patients with chronic pain

    Gen. Hosp. Psychiatry

    (2008)
  • B.J. Morasco et al.

    Risk for prescription opioid misuse among patients with a history of substance use disorder

    Drug Alcohol Depend.

    (2013)
  • M.K. Nicholas

    The pain self-efficacy questionnaire: taking pain into account

    Eur. J. Pain

    (2007)
  • A. Pertovaara et al.

    Descending inhibitory systems

  • M.L. Peters et al.

    The joint contribution of physical pathology, pain-related fear and catastrophizing to chronic back pain disability

    Pain

    (2005)
  • T.L. Rosenthal et al.

    Substance abuse patterns reveal contrasting personal traits

    J. Subst. Abuse

    (1990)
  • B.M. Schieffer et al.

    Pain medication beliefs and medication misuse in chronic pain

    J. Pain

    (2005)
  • R.A. Shelby et al.

    Domain specific self-efficacy mediates the impact of pain catastrophizing on pain and disability in overweight and obese osteoarthritis patients

    J. Pain

    (2008)
  • M.J.L. Sullivan et al.

    Psychological determinants of problematic outcomes following Total Knee Arthroplasty

    Pain

    (2009)
  • M.D. Sullivan et al.

    Regular use of prescribed opioids: association with common psychiatric disorders

    Pain

    (2005)
  • M.D. Sullivan et al.

    Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and medicaid insurance plans: The TROUP Study

    Pain

    (2010)
  • G. Tan et al.

    Validation of the brief pain inventory for nonmalignant pain

    J. Pain

    (2004)
  • J.A. Trafton et al.

    Somatization is associated with non adherence to opioid prescriptions

    J. Pain

    (2011)
  • K.E. Vowles et al.

    Predicting work status following interdisciplinary treatment for chronic pain

    Eur. J. Pain

    (2004)
  • T.M. Williams et al.

    Brain opioid receptor binding in early abstinence from alcohol dependence and relationship to craving: an [11C] diprenorphine PET study

    Eur. Neuropsychopharmacol.

    (2009)
  • S.A. Ball et al.

    Sensation seeking, substance abuse, and psychopathology in treatment-seeking and community cocaine abusers

    J. Consult. Clin. Psychol.

    (1994)
  • J.C. Ballantyne

    Opioid controls: regulate to educate

    Pain Med.

    (2010)
  • Cited by (116)

    • Emotional distress and pain catastrophizing predict cue-elicited opioid craving among chronic pain patients on long-term opioid therapy

      2022, Drug and Alcohol Dependence
      Citation Excerpt :

      By contrast, emotional distress is common among this population and is associated with tonic opioid craving (Epstein et al., 2009; Higgins et al., 2020; Huhn et al., 2016; Martel et al., 2014a) and misuse (Adams et al., 2004). Likewise, pain catastrophizing, which refers to a negative cognitive-affective response to actual or anticipated pain (Quartana et al., 2009), has been linked to tonic opioid craving and misuse among chronic pain patients (Arteta et al., 2016; Frimerman et al., 2021; Lutz et al., 2017; Martel et al., 2013, 2014b). As with pain, negative cognitive-affective states (e.g. distress, catastrophizing) may function as second-order conditioned stimuli that amplify opioid cue-reactivity.

    View all citing articles on Scopus
    View full text