Fear of Distress Signals Risk for Opioid Misuse in Chronic Pain Patients

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In this research:

  • Among patients with chronic pain, those who reported less ability to tolerate physical or emotional distress were more likely to misuse opioid analgesics.
  • Neither pain severity nor pain sensitivity was associated with the risk of opioid misuse.
Figure. Distress Intolerance Is Associated With Opioid Misuse Patients who met the criteria for opioid misuse had significantly higher scores on the Distress Intolerance Index than did those who had no opioid misuse. See full text description at end of article.

Drs. R. Kathryn McHugh and Roger D. Weiss from Harvard Medical School and colleagues administered the Distress Intolerance Index (DII) to a group of patients who were receiving prescription opioid treatment for chronic neck or back pain. Respondents to the DII report how strongly they identify with 10 statements expressing fear and anxiety at the prospect of physical or emotional distress. Of 51 patients in the study, the 31 who met diagnostic criteria for prescription opioid misuse scored higher on the instrument than the 20 who did not (see Figure). Among those who misused opioids, higher DII scores were associated with more severe misuse.

Dr. McHugh says, "These data from the DII as well as from some of our other work suggest that a brief measure of self-reported distress intolerance is strongly associated with [opioid misuse] outcomes." The relationship likely occurs because patients who are intensely apprehensive of distressing experiences may seek quick stress relief through behaviors such as substance use, risk taking, avoidance, and escapism.

Based on the study findings, Dr. McHugh recommends that physicians who treat patients for chronic pain assess their distress intolerance. For those with high intolerance, close prescription monitoring will be warranted, and behavioral interventions to build adaptive responses and foster resilience to stress may improve outcomes. Dr. McHugh says, "Enhancing tolerance of distress has great potential for mitigating the risk of opioid misuse and treating opioid use disorder."

Dr. McHugh suggests that the DII can function well as a clinical tool. "The tool we used included only 10 items and is easy to administer and score," she says. She notes that the researchers also assessed the study participants’ persisting pain levels and pain sensitivity thresholds, neither of which showed an association with the risk of opioid misuse.

Dr. McHugh comments, "One rarely discussed aspect of the opioid crisis is the impact of stress-related dysfunction and co-occurring psychiatric disorders. Among people struggling with opioid use disorders, heightened stress reactivity and stress-related disorders like anxiety and traumatic stress disorders are the norms rather than the exceptions."

Dr. Yu Lin, a Health Science Administrator in NIDA’s Integrative Neuroscience Branch, agrees that clinicians “should assess negative affect and psychiatric conditions regularly. Distress-intolerant patients may be less responsive to analgesia and are certainly more prone to opioid misuse because they are less adaptive to and tolerant of negative emotional and somatic states.”

This study was supported by NIH grants DA034102, DA022288, and DA015831.

Text Description of Figure

The bar chart compares the distress intolerance scores of patients with chronic pain who were treated with opioid pain medications and who did or did not meet the criteria for opioid misuse. The vertical (y) axis shows the mean score on the Distress Intolerance Index (DII) on a scale from 0 to 30. The left bar represents the patients who met the criteria for opioid misuse. They had a mean DII score of approximately 25. The right bar represents the patients who did not meet the criteria for opioid misuse. These patients had a significantly lower mean DII score of approximately 16.