Anxiety and Fear Avoidance Beliefs and Behavior May Be Significant Risk Factors for Chronic Opioid Analgesic Therapy Reliance for Patients with Chronic Pain—Results from a Preliminary Study

Abstract

Objective To describe differences between patients with chronic, non-cancer pain (CNCP) who were successfully able to cease full mu agonist chronic opioid analgesic therapy (COAT), and those who exhibited refractory COAT reliance, amongst those who participated in a multidisciplinary program designed for COAT cessation. Design A retrospective review of electronic medical records (EMR) data was organized for preliminary analysis. Setting A multi-center private practice specializing in CNCP, which received patient referrals from the surrounding geographical area of primary and specialty care offices in Northern California. Subjects Data from 109 patients with CNCP who participated in a multidisciplinary program to cease COAT between the dates of October 2017 to December 2019 were examined. Methods EMR data, pre-COAT cessation, of oral morphine milligram equivalence (MME) and validated questionnaire responses assessing anxiety and fear-based beliefs and behavior, as well as opioid misuse, were extracted and compared between those who successfully ceased COAT and those who did not. Results Patients who were unsuccessful at COAT cessation reported significantly higher Fear Avoidance Behavior Questionnaire (FAB) scores. No significant differences were found based on incoming MME amounts, Current Opioid Misuse Measure (COMM) or Tampa Scale of Kinesiophobia (TSK) scores. Pain Catastrophizing Scale (PCS) scores showed a split pattern with unclear significance. Conclusions Results suggest that fear avoidance beliefs and behavior, as measured by the FAB, play a significant role in refractory COAT reliance for patients with CNCP.

Changes in Psychological Outcomes after Cessation of Full Mu Agonist Long-Term Opioid Therapy for Chronic Pain

“…De-identified data were collected via a retrospective review of electronic medical records (EMR) from October 2017 to December 2019, comparing the pre- and post-psychological assessment questionnaire scores of 98 patients with CNCP who successfully ceased LTOT use through participation in a previously described, group multidisciplinary program [ 14 , 30 ]. Questionnaires were given to each patient at orientation and at graduation.…”

“…Less severe, but still disturbing, adverse full mu agonist opioid medication effects are numerous and well documented, ranging from immediate (cognitive impairment, dry mucous membranes, slowed intestinal motility) [ 2 ] to long-term and insidious (hypogonadism [ 3 ], immune compromise [ 4 ], and hyperalgesia) [ 5 , 6 ]. Associations between opioid use and declining mood states have also been well documented, such as a decline in patient-perceived quality of life [ 7 ], and increased measures of depression [ 8 , 9 , 10 , 11 ], catastrophizing [ 10 , 12 , 13 ], fear avoidance [ 14 ], and anxiety [ 10 , 12 , 15 , 16 ]. However, unforeseen complications regarding efforts to reduce or discontinue opioid dosing within the patient population that utilizes LTOT are becoming apparent [ 17 , 18 ], with recent reports documenting associated overdose and suicide [ 19 , 20 , 21 ].…”

“…The primary aim of this study was to identify changes between psychological assessment questionnaires, pre and post LTOT cessation, for patients with CNCP. We present findings from a retrospective analysis in a cohort of patients with CNCP who were successfully able to cease LTOT through participation in a group, multidisciplinary program [ 14 , 30 ] that offered therapeutic options that included buprenorphine. This study took place prior to reports of declining clinical outcomes after LTOT cessation, which notably did not include the option of buprenorphine in care planning [ 2 , 3 , 4 , 5 , 6 ].…”

“…This study took place prior to reports of declining clinical outcomes after LTOT cessation, which notably did not include the option of buprenorphine in care planning [ 2 , 3 , 4 , 5 , 6 ]. Informed by multiple reports of declining mood with opioid initiation [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ], the researchers hypothesized that LTOT cessation would result in improved mood outcomes.…”

Pain catastrophizing, pain anxiety, and substance use among Black individuals with chronic pain who use opioids.

“…Pain catastrophizing and pain anxiety are also central within the Fear-Avoidance Model of Pain, which states that fear-related reactions to pain directly lead to activity avoidance, ultimately perpetuating chronic pain and disability (Crombez et al, 2012). Recent evidence indicates that fear avoidance contributes to higher rates of substance use (Morasco et al, 2017; Silva et al, 2021). However, existing research has focused on White populations.…”