Pain Catastrophizing Moderates Relationships Between Pain Intensity and Opioid Prescription

Nonlinear Sex Differences Revealed Using a Learning Health System

Yasamin Sharifzadeh, B.S.; Ming-Chih Kao, Ph.D., M.D.; John A. Sturgeon, Ph.D.; Thomas J. Rico, B.S.; Sean Mackey, M.D., Ph.D.; Beth D. Darnall, Ph.D.


Anesthesiology. 2017;127(1):136-146. 

In This Article

Abstract and Introduction


Background: Pain catastrophizing is a maladaptive response to pain that amplifies chronic pain intensity and distress. Few studies have examined how pain catastrophizing relates to opioid prescription in outpatients with chronic pain.

Methods: The authors conducted a retrospective observational study of the relationships between opioid prescription, pain intensity, and pain catastrophizing in 1,794 adults (1,129 women; 63%) presenting for new evaluation at a large tertiary care pain treatment center. Data were sourced primarily from an open-source, learning health system and pain registry and secondarily from manual review of electronic medical records. A binary opioid prescription variable (yes/no) constituted the dependent variable; independent variables were age, sex, pain intensity, pain catastrophizing, depression, and anxiety.

Results: Most patients were prescribed at least one opioid medication (57%; n = 1,020). A significant interaction and main effects of pain intensity and pain catastrophizing on opioid prescription were noted (P < 0.04). Additive modeling revealed sex differences in the relationship between pain catastrophizing, pain intensity, and opioid prescription, such that opioid prescription became more common at lower levels of pain catastrophizing for women than for men.

Conclusions: Results supported the conclusion that pain catastrophizing and sex moderate the relationship between pain intensity and opioid prescription. Although men and women patients had similar Pain Catastrophizing Scale scores, historically "subthreshold" levels of pain catastrophizing were significantly associated with opioid prescription only for women patients. These findings suggest that pain intensity and catastrophizing contribute to different patterns of opioid prescription for men and women patients, highlighting a potential need for examination and intervention in future studies.


WITH up to 40% of the global population experiencing ongoing pain,[1,2] there is a need to better understand the experience of pain and associated treatment patterns. Pain catastrophizing[3,4]—a cascade of negative thoughts and emotions in response to actual or anticipated pain—is a key factor in pain-related outcomes. In experimental and clinical settings, pain catastrophizing is associated with amplified pain processing,[5,6] greater pain intensity,[7] and greater disability.[7,8] Pain catastrophizing may explain up to 20% of the variance in chronic pain intensity [9] and thus may influence other pain treatments, including opioid medications.

Pain catastrophizing has been identified as a risk factor for prescription opioid misuse in patients with chronic pain generally[10] and among those with a history of substance use disorder.[11] Postsurgically, opioid use is quantified commonly either by dose or by time-to-opioid cessation.[12,13] Perioperative studies have yielded mixed findings for pain catastrophizing, with some reporting a direct relationship with morphine dose delivered either by patient-controlled analgesia devices[14] or by hospital staff,[15] whereas other studies reported no association[16] or an inverse association.[17] Findings from a recent longitudinal study of 145 patients undergoing musculoskeletal trauma surgery suggested that pain catastrophizing predicted delayed opioid cessation after surgery.[18] Using multivariate analyses, the authors found that pain catastrophizing was the strongest predictor of postsurgical opioid use 1 to 2 months after surgery. After the authors controlled for anxiety, depression, posttraumatic stress disorder symptoms, and disability, pain catastrophizing accounted for 23% of the unique variance in persistent postsurgical opioid use.

In the outpatient setting, catastrophizing has been associated with opioid craving,[19] long-term opioid use in veterans,[20] and opioid misuse.[21] Given the positive associations found between catastrophizing and the aforementioned opioid responses and behaviors, it would follow that a similar association might exist for catastrophizing and receipt of an opioid prescription in a larger civilian chronic pain population. However, to our knowledge, this latter relationship is unexplored. Characterization of the relationship between catastrophizing and opioid prescription in a larger chronic pain sample could enhance understanding and potentially reveal a therapeutic target for reducing need and use of opioids in chronic pain outpatients.

Accordingly, the purpose of this study was to characterize the relationship between existing opioid prescription and pain catastrophizing in a large sample of patients presenting for new evaluation at a chronic pain clinic. It has been found that in individuals with chronic noncancer pain, the presence of comorbid mental health diagnoses, particularly mood disorders, predicts the likelihood of opioid prescription,[21] the degree of opioid use,[11] and the likelihood of aberrant opioid use (e.g., opioid abuse or dependence).[22] Consequently, we sought to characterize the relationship between pain catastrophizing and opioid prescription independent of the influences of these and other factors, including age,[11] sex,[23] and pain intensity,[16,24] known to be relevant to opioid use, and pain catastrophizing, such as symptoms of anxiety and depression.[22] We aimed solely to identify any relationships between our variables of interest, in turn allowing for future investigations to further explore any clinically significant findings.