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Chronic Opioid Analgesic Therapy: Fear Avoidance in Patients May Determine Outcomes

Jasmine Silva, DO, shares key findings on opioid cessation, patient behavior, and the importance of having thorough clinical discussions with patients before prescribing opioids.

A high Fear Avoidance Behavior Score may be a stronger indicator of a patient’s inability to cease chronic opioid analgesic therapy (COAT), according to findings from a recent study.1 The program, led by Marcelina Jasmine Silva, DO, focused on patients with chronic non-cancer pain and aimed to cease COAT among 109 patients based in Northern California via a multidisciplinary program run between October 2017 and December 2019.

Incoming morphine milligram equivalence (MME) of the subjects, Current Opioid Misuse Measure (COMM) scores, and Tampa Scale of Kinesiohobia (TSK) scores showed no significant differences while scores on the Pain Catastrophizing Scale (PCS) were inconclusive. Overall, the results may be deemed be useful for clinicians struggling help patients on COAT taper off opioids.

PPM spoke to Dr. Silva, who is based at the Integrated Pain Management Medical Group in Walnut Creek, California, about her work and potential clinical implications.

Dr. Silva developed a program to help patients with chronic non-cancer pain cease the use of chronic opiate analgesic therapy (COAT). (Image: iStock)


Chronic Opioid Therapy in the US

PPM: Why did you select this area of research in terms of clinical importance?

Dr. Silva: The risks of chronic opioid use are well-publicized and, as a chronic pain specialist, I found that most of my patients were exposed to those risks while also experiencing side effects and poor satisfaction about their analgesia, function, and overall well-being. So, I developed a program to try to help patients with chronic non-cancer pain cease the use of chronic opiate analgesic therapy (COAT). As the program developed, I wanted to collect some markers along the way to see what was and what wasn’t working.

It was a group program, so we had to go on a hiatus because of social distancing for COVID-19. That gave me time to write up the research. It’s been fascinating to take a step back and reflect on the motivations and beliefs that drive behavior in ways that can dramatically affect a person’s life. The question of why people believe what they believe, despite sometimes abundant evidence to the contrary is a very relevant question right now:

     Can you ever change a person’s passionately held belief, and thus, motivation and behavior?

To me, that’s the billion-dollar question in this country right now, and has always been at the crux of good medical care planning.

Fear Avoidance and Pain Catastrophizing as Opioid Risk Factors

PPM: You based your research on the fear avoidance model of behavior. Can you elaborate on this model and its role in COAT?

Dr. Silva: The fear avoidance model was first described in the early 1980s by an English team led by an author named Lethem. The central concept is that there are two basic responses to fear: confrontation or avoidance. Confrontation leads, over time, to the reduction of fear and recovery. Avoidance, however, leads to the maintenance and even exaggeration of fear.

They introduced the idea that there are two roads: the first road, avoidance of fear, leads to a cycle of sequela that exacerbates the disability of chronic pain and creates a revolving, self-fulfilling prophecy of avoidance, depression, deconditioning, and more pain. Confrontation, on the other hand, is the road to rehabilitation. The original and subsequent authors have diagramed the fear avoidance model. The similarities between disability perpetuation – independent of pain level, injury type, or musculoskeletal exam — is strikingly similar to dynamics we have found to reinforce chronic opioid analgesia use.

A lot of the curriculum we used in the program was designed to treat patients about pain coping, resiliency building, and fear confrontation. There is a triad of chronic pain, disability, and opiate use that seems to travel together for many patients. They can stay stuck in the cycle for sometimes decades.

Risk Factors for Opioid Cessation, Tapering

PPM: Were you surprised by the results?

Dr. Silva: Yes! I was flabbergasted by the idea that a positive COMM screen wasn’t a significant factor in those who were not able to cease COAT use. Also, patients on high MME are often quickly stereotyped by clinicians as being more refractorily reliant upon COAT and less likely to cease use, making them simultaneously the most at risk for COAT sequela and the least likely to receive help. Our study suggests that MME level was not a factor in COAT reliance.

These outcomes highlight the fact that, among people who rely on COAT, there are potentially several diverse subgroups, motivated by different things, who may require different treatment approaches. It also underscores the need for better parsing out of these motivations so that assessment, identification, and treatment can be tailored for more effectiveness. We lack adequate language to describe the nuances within the population of people who use COAT. I believe the devil behind the expanding opioid epidemic is in these details.

Patient Anxiety and Opioid Cessation

PPM: Can you speculate on why fear avoidance and anxiety might make it more difficult for patients to stop chronic opioid therapy?

Dr. Silva: I think it comes down to a lack of belief in one’s resiliency, either not having internal or external resources to overcome adversity or not knowing how to access these resources. Much of my clinical approach is informed by Adverse Childhood Experiences studies and the powerfully negative chronicity that adult and childhood trauma can have on a person’s health trajectory.

Analgesic Options for Pain: Opioid Alternatives and Patient Counseling

PPM: How can the results of your study help pain-treating clinicians and those considering analgesic medication options?

Dr. Silva: As a clinician, these results cause me to think more deeply about a patient’s behavioral motivations, especially when they are making high-risk or detrimental choices. What I’d love to have come out of this is to have a better identification of patients’ motivations and real areas of need. For example, when someone comes into your clinic with chronic pain and you’re considering starting them on opioids, or they are on opioids and you’re not sure what the next step is, perhaps understanding if they have a high fear avoidance behavior score might direct you to spend a little more time investing in education about their condition and about chronic pain, and helping them get some pain coping skills on board. It also might guide a treatment discussion in the format of motivational interviewing, rather than a confrontation of logic and facts.

Currently, the common approach of clinicians is to immediately engage in a conversation about reducing or eliminating opioid use. As humans, we all know that when you are afraid of losing something, you hold on tighter. This is such a frustrating and detrimental dynamic between patients and their prescribers. I am hoping that research like ours gives clinicians a more effective line of approach to the subject of ineffective and potentially dangerous chronic opioid use and gives patients access to more satisfying solutions.

Also, it would be nice if reimbursement models supported investing in patient education and robust early supportive multi-disciplinary therapies. The current model incentivizes rushed conversations and a model of opioid subtraction which leads to long recovery efforts for both the patient and the physician. Overdoses are up 17% from last year. We’re not winning this battle – we weren’t even before COVID. The entire medical community needs to try a new approach.

If we incentivize clinicians to have more in-depth conversations and interactions with patients, rather than making them see a high volume of patients a day, the insurance carriers might actually save money because we could have more impact sooner, we’d be more effective in our treatment, and we’d see more impact in our efforts against the opioid epidemic.


Last updated on: April 19, 2021
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