Catastrophic thinking and increased risk for prescription opioid misuse in patients with chronic pain
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.
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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.
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2023, Preventive Medicine ReportsEmotional distress and pain catastrophizing predict cue-elicited opioid craving among chronic pain patients on long-term opioid therapy
2022, Drug and Alcohol DependenceCitation Excerpt :These results add to prior studies demonstrating that psychological factors have stronger relationships to opioid craving than pain intensity among chronic pain patients (Martel et al., 2014a, 2016, 2014b; van Rijswijk et al., 2019; Wasan et al., 2012). They also converge with research indicating that chronic pain patients who present with psychological disturbances characterized by high levels of emotional distress (Gilam et al., 2020; Wasan et al., 2007), as well as those that engage in pain catastrophizing (Arteta et al., 2016; Lutz et al., 2017; Martel et al., 2013, 2014; Morasco et al., 2013), are at increased risk for opioid misuse. There are several potential explanations for the observed relationship between emotional distress, catastrophizing, and opioid cue reactivity.