A key factor may be something called pain catastrophizing — heightened negative thoughts and emotions in response to actual or anticipated pain. New research recently published in Anesthesiology shows that pain catastrophizing is a risk factor for prescription opioid misuse, and the role it plays is different for men and women. I connected with Beth Darnall, PhD, a Stanford clinical associate professor of anesthesiology, perioperative and pain medicine, to learn more about her new study, whose first author is Yasamin Sharifzadeh-Moghaddam, a medical student at Virginia Commonwealth University.
What is pain catastrophizing?
Pain catastrophizing is the rumination and magnification of pain and feelings of helplessness about it. People who catastrophize have a hard time thinking of anything but their pain. It’s common for people with chronic pain to catastrophize to some degree, but when it gets into the clinical ranges it indicates a need for treatment. Treatment involves learning targeted ways to redirect one’s attention, calm the nervous system in the face of pain and stress and cultivate awareness about what one can do to feel better. I think virtually everyone with chronic pain can benefit from learning skills that empower them to have better control over their pain and distress—even those who are not high catastrophizers.
What inspired you to research pain?
First, I was intensely curious about pain and why it varies between individuals — a lot of the 'why' ends up involving psychological factors. I was fascinated with the connection between stress and pain and wanted to learn more about how they relate... I also wanted to help people on a broader scale. I can only see a few individual patients in the clinic, but if I develop a treatment that others can use, the ripple effect potential is tremendous.
How did you investigate the impact of pain catastrophizing on opioid use?
Pain catastrophizing is associated with greater use of opioids after surgery and with opioid misuse. Across multiple studies, catastrophizing associates strongly with pain intensity, so we wanted to better understand how it might relate to pain medication.
In our study, we looked at patients receiving a new evaluation at the Stanford Pain Management Center. We examined the relationships between pain intensity, pain catastrophizing and existing opioid prescription. We used the Collaborative Health Outcomes Information Registry, a free open source health outcomes platform, to collect data on almost 1,800 patients. We aimed to reveal whether sex differences existed for opioid prescription and our other variables of interest, using modeling to explore the associations. We found that almost 60 percent of patients referred to our center are taking prescription opioids, and people with greater pain were more likely to be taking opioids.
We also found that sex matters in the equation. For women, the relationship between pain catastrophizing and opioids occurred at much lower levels of pain catastrophizing than for men. Our data suggest that catastrophizing may be more impactful for women, and that these associations begin to appear at what we previously called 'subthreshold' levels. More research is needed to replicate our findings and to understand why we see these sex differences in catastrophizing and opioid prescription. I’m speculating, but women may be better communicators of pain-related distress — verbally and nonverbally — and this may translate into a prescription at the end of a medical visit.
How can your results improve future clinical practice?
If replicated, our findings signal that we should be treating our patients before frank problems arise. If we address psychosocial distress early on, we may prevent worsening of symptoms into clinical problems and the need for various treatments. We also need more research to develop a deeper understanding of the relationships between prescription opioids and psychological factors... Our findings suggest that we need to further examine the prescribing doctor-patient interaction.
What’s the next step?
We are currently examining whether presurgical treatment for catastrophizing can reduce post-operative opioid use. Right now we are studying this in women only, but our planned studies include men and women so we can test sex differences in treatment response.
Previously: Shifting the focus from opioids to life beyond pain: a Q&A with pain expert Beth Darnall and Research reveals circuit that clarifies how stress exacerbates pain and meditation eases it
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