Review Articles| Volume 22, ISSUE 8, P879-891, August 2021

Pain Catastrophizing, Opioid Misuse, Opioid Use, and Opioid Dose in People With Chronic Musculoskeletal Pain: A Systematic Review

Published:February 10, 2021DOI:


      • Pain catastrophizing was statistically associated with opioid misuse.
      • Pain catastrophizing was not associated with opioid dose.
      • Inconsistencies exist regarding links between pain catastrophizing and opioid use.


      The objective of this study was to analyze the cross-sectional and longitudinal association between pain catastrophizing and opioid misuse, opioid use, and opioid dose in people with chronic musculoskeletal pain. For this systematic review, CINAHL, Embase, PsycINFO, PubMed, manual searches, and grey literature were searched from inception to May 2020. Observational studies were included if they evaluated the association between pain catastrophizing and opioid dose, opioid use, and/or opioid misuse in people with chronic musculoskeletal pain. Two reviewers independently performed the study selection, data extraction, risk of bias assessment, and the certainty of the evidence judgment. Seven observational studies (all cross-sectional designs) satisfied the eligibility criteria, with a total sample of 2,160 participants. Pain catastrophizing was associated with opioid misuse. The results were inconsistent regarding the association between pain catastrophizing and opioid use. A lack of association was found considering pain catastrophizing and the opioid dose. However, the presence of risk of bias and imprecision was serious across the included studies, and therefore, the overall certainty of the evidence was judged as very low for all the outcome measures. This report concludes that pain catastrophizing seem to be associated with opioid misuse in people with chronic musculoskeletal pain. However, the very low certainty of the current evidence confers to interpret the finding of this review as exclusively informative.


      This article shows that pain catastrophizing seem to be associated with opioid misuse in people with chronic musculoskeletal pain. The overall certainty of the evidence was judged to be very low, thus, these results should be interpreted with caution.

      Key words


      MeSH (Medical Subject Headings), GRADE (the Grading of Recommendations Assessment, Development and Evaluation), PRISMA (the Preferred Reporting Items for Systematic Reviews and Meta-Analyses)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Adams LL
        • Gatchel RJ
        • Robinson RC
        • Polatin P
        • Gajraj N
        • Deschner M
        • Noe C
        Development of a self-report screening instrument for assessing potential opioid medication misuse in chronic pain patients.
        J Pain Symptom Manage United States. 2004; 27: 440-459
        • Alho H
        • Dematteis M
        • Lembo D
        • Maremmani I
        • Roncero C
        • Somaini L
        Opioid-related deaths in Europe: Strategies for a comprehensive approach to address a major public health concern.
        Int J Drug Policy Netherlands. 2020; 76102616
        • Arteta J
        • Cobos B
        • Hu Y
        • Jordan K
        • Howard K
        Evaluation of how depression and anxiety mediate the relationship between pain catastrophizing and prescription opioid misuse in a chronic pain population.
        Pain Med Engl. 2016; 17: 295-303
        • Atluri S
        • Sudarshan G
        • Manchikanti L
        Assessment of the trends in medical use and misuse of opioid analgesics from 2004 to 2011.
        Pain Physician United States. 2014; 17: E119-E128
        • Attia A
        Why should researchers report to confidence interval in modern research?.
        Middle East Fertil Soc J. 2005; 10: 78-81
        • Bautista CA
        • Iosif A-M
        • Wilsey BL
        • Melnikow JA
        • Crichlow A
        • Henry SG
        Factors associated with opioid dose increases: a chart review of patients’ first year on long-term opioids.
        Pain Med. 2017; 18: 908-916
        • Birnbaum HG
        • White AG
        • Schiller M
        • Waldman T
        • Cleveland JM
        • Roland CL
        Societal costs of prescription opioid abuse, dependence, and misuse in the United States.
        Pain Med Engl. 2011; 12: 657-667
        • Bohnert ASB
        • Ilgen MA
        Understanding links among opioid use, overdose, and suicide. Reply.
        N Engl J Med United States. 2019; 380: 71-79
        • Boscarino JA
        • Rukstalis MR
        • Hoffman SN
        • Han JJ
        • Erlich PM
        • Ross S
        • Gerhard GS
        • Stewart WF
        Prevalence of prescription opioid-use disorder among chronic pain patients: Comparison of the DSM-5 vs. DSM-4 diagnostic criteria.
        J Addict Dis Engl. 2011; 30: 185-194
        • Bruce BK
        • Allman ME
        • Rivera FA
        • Abril A
        • Gehin JM
        • Oliphant LM
        • Nordan LM
        • White LJ
        • Martinez D
        • Niazi SK
        Opioid use in fibromyalgia continues despite guidelines that do not support its efficacy or risk.
        J Clin Rheumatol. 2020;
        • Butler SF
        • Budman SH
        • Fernandez K
        • Jamison RN
        Validation of a screener and opioid assessment measure for patients with chronic pain.
        Pain United States. 2004; 112: 65-75
        • Butler SF
        • Budman SH
        • Fernandez KC
        • Houle B
        • Benoit C
        • Katz N
        • Jamison RN
        Development and validation of the current opioid misuse measure.
        Pain. 2007; 130: 144-156
        • Büttner F
        • Winters M
        • Delahunt E
        • Elbers R
        • Lura CB
        • Khan KM
        • Weir A
        • Ardern CL
        Identifying the ’incredible’! Part 2: Spot the difference—a rigorous risk of bias assessment can alter the main findings of a systematic review.
        Br J Sports Med. 2020; 54: 801-808
        • Carriere JS
        • Martel MO
        • Meints SM
        • Cornelius MC
        • Edwards RR
        What do you expect? Catastrophizing mediates associations between expectancies and pain-facilitatory processes.
        Eur J Pain. 2019; 23: 800-811
        • Chou R
        • Fanciullo GJ
        • Fine PG
        • Adler JA
        • Ballantyne JC
        • Davies P
        • Donovan MI
        • Fishbain DA
        • Foley KM
        • Fudin J
        • Gilson AM
        • Kelter A
        • Mauskop A
        • O'Connor PG
        • Passik SD
        • Pasternak GW
        • Portenoy RK
        • Rich BA
        • Roberts RG
        • Todd KH
        • Miaskowski C
        Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain.
        J Pain. 2009; 10: 113-130
        • Chou R
        • Turner JA
        • Devine EB
        • Hansen RN
        • Sullivan SD
        • Blazina I
        • Dana T
        • Bougatsos C
        • Deyo RA
        The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop.
        Ann Intern Med United States. 2015; 162: 276-286
        • Cragg A
        • Hau JP
        • Woo SA
        • Kitchen SA
        • Liu C
        • Doyle-Waters MM
        • Hohl CM
        Risk factors for misuse of prescribed opioids: a systematic review and meta-analysis.
        Ann Emerg Med United States. 2019; 74: 634-646
        • Craner JR
        • Gilliam WP
        • Sperry JA
        Rumination, magnification, and helplessness: how do different aspects of pain catastrophizing relate to pain severity and functioning?.
        Clin J Pain United States. 2016; 32: 1028-1035
        • Dilokthornsakul P
        • Moore G
        • Campbell JD
        • Lodge R
        • Traugott C
        • Zerzan J
        • Allen R
        • Page 2nd, RL
        Risk factors of prescription opioid overdose among colorado Medicaid beneficiaries.
        J Pain United States. 2016; 17: 436-443
        • Dworkin RH
        • Bruehl S
        • Fillingim RB
        • Loeser JD
        • Terman GW
        • Turk DC
        Multidimensional diagnostic criteria for chronic pain: introduction to the ACTTION-American Pain Society Pain Taxonomy (AAPT).
        J Pain United States. 2016; 17: T1-T9
        • Edwards RR
        • Bingham 3rd, CO
        • Bathon J
        • HJ
        Catastrophizing and pain in arthritis, fibromyalgia, and other rheumatic diseases.
        Arthritis Rheum. 2006; 55: 325-332
        • Edwards RR
        • Wasan AD
        • Michna E
        • Greenbaum S
        • Ross E
        • Jamison RN
        Elevated pain sensitivity in chronic pain patients at risk for opioid misuse.
        J Pain. 2011; 12: 953-963
      1. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement : guidelines for reporting observational studies. Lancet 370:1453-1457, 2007.

        • Ferguson E
        • Zale E
        • Ditre J
        • Wesolowicz D
        • Stennett B
        • Robinson M
        • Boissoneault J
        CANUE: a theoretical model of pain as an antecedent for substance use.
        Ann Behav Med kaaa072,. 2020; PMID: 32914834
        • Flink IL
        • Boersma K
        • Linton SJ
        Pain catastrophizing as repetitive negative thinking: a development of the conceptualization.
        Cogn Behav Ther. 2013; 42: 215-223
        • Gatchel RJ
        • Peng YB
        • Peters ML
        • Fuchs PN
        • Turk DC
        The biopsychosocial approach to chronic pain: scientific advances and future directions.
        Psychol Bull. 2007; 133: 581-624
        • Glare P
        • Ashton-James C
        • Han E
        • Nicholas M
        Deprescribing long-term opioid therapy in patients with chronic pain.
        Intern Med J Australia. 2020; 50: 1185-1191
        • Guyatt GH
        • Oxman AD
        • Vist G
        • Kunz R
        • Brozek J
        • Alonso-Coello P
        • Montori V
        • Akl EA
        • Djulbegovic B
        • Falck-Ytter Y
        • Norris SL
        • Williams JW
        • Atkins D
        • Meerpohl J
        • Schünemann HJ
        GRADE guidelines: 4. Rating the quality of evidence—study limitations (risk of bias).
        J Clin Epidemiol. 2011; 64: 407-415
        • Haddaway NR
        • Collins AM
        • Coughlin D
        • Kirk S
        The role of google scholar in evidence reviews and its applicability to grey literature searching.
        PLoS One. 2015; 10: 1-17
        • Helmerhorst GT
        • Teunis T
        • Janssen SJ
        • Ring D
        An epidemic of the use, misuse and overdose of opioids and deaths due to overdose, in the United States and Canada: is Europe next?.
        Bone Joint J Engl. 2017; 99-B: 856-864
        • Hirsh AT
        • George SZ
        • Riley 3rd, JL
        • Robinson ME
        An evaluation of the measurement of pain catastrophizing by the coping strategies questionnaire.
        Eur J Pain Engl. 2007; 11: 75-81
        • Huysmans E
        • Leemans L
        • Beckwée D
        • Nijs J
        • Ickmans K
        • Moens M
        • Goudman L
        • Buyl R
        • Putman K
        • Coppieters I
        The relationship between cognitive and emotional factors and healthcare and medication use in people experiencing pain: a systematic review.
        J Clin Med. 2020; 9: 2486
        • Jamison RN
        • Link CL
        • Marceau LD
        Do pain patients at high risk for substance misuse experience more pain? A longitudinal outcomes study.
        Pain Med Engl. 2009; 10: 1084-1094
        • Jamison RN
        • Martel MO
        • Edwards RR
        • Qian J
        • Sheehan KA
        • Ross EL
        Validation of a brief opioid compliance checklist for patients with chronic pain.
        J Pain. 2014; 15: 1092-1101
        • Kwon Y
        • Lemieux M
        • McTavish J
        • WN
        Identifying and removing duplicate records from systematic review searches.
        J Med Libr Assoc. 2015; 103: 184-188
        • Lami MJ
        • Martínez MP
        • Miró E
        • Sánchez AI
        • Guzmán MA
        Catastrophizing, acceptance, and coping as mediators between pain and emotional distress and disability in fibromyalgia.
        J Clin Psychol Med Settings United States. 2018; 25: 80-92
        • Lawrence R
        • Mogford D
        • Colvin L
        Systematic review to determine which validated measurement tools can be used to assess risk of problematic analgesic use in patients with chronic pain.
        Br J Anaesth Engl. 2017; 119: 1092-1109
        • Lazaridou A
        • Franceschelli O
        • Buliteanu A
        • Cornelius M
        • Edwards RR
        • Jamison RN
        Influence of catastrophizing on pain intensity, disability, side effects, and opioid misuse among pain patients in primary care.
        J Appl Biobehav Res. 2017; 22: 1-13
        • Lee SJ
        • Koussa M
        • Gelberg L
        • Heinzerling K
        • Young SD
        Somatization, mental health and pain catastrophizing factors associated with risk of opioid misuse among patients with chronic non-cancer pain.
        J Subst Use. 2020; 25: 357-362
        • Leeuw M
        • Goossens ME
        • Linton SJ
        • Crombez G
        • Boersma K VJ
        The fear-avoidance model of musculoskeletal pain: current state of scientific evidence.
        J Behav Med. 2007; 30: 77-94
        • Lentz TA
        • Rhon DI
        • George SZ
        Predicting opioid use, increased health care utilization and high costs for musculoskeletal pain: what factors mediate pain intensity and disability?.
        J Pain. 2020; 21: 135-145
        • Liberati A
        • Altman DG
        • Tetzlaff J
        • Mulrow C
        • Gøtzsche PC
        • Ioannidis JP
        • Clarke M
        • Devereaux PJ
        • Kleijnen J
        • MD
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        J Clin Epidemiol. 2009; 62: e1-34
        • Macfarlane GJ
        • Beasley M
        • Jones GT
        • Stannard C
        The epidemiology of regular opioid use and its association with mortality: prospective cohort study of 466 486 UK biobank participants.
        E Clin Med. 2020; 21100321
        • Malfliet A
        • Coppieters I
        • Van Wilgen P
        • Kregel J
        • De Pauw R
        • Dolphens M
        • Ickmans K
        Brain changes associated with cognitive and emotional factors in chronic pain: a systematic review.
        Eur J Pain. 2017; 21: 769-786
        • Marshall PWM
        • Schabrun S
        • Knox MF
        Physical activity and the mediating effect of fear, depression, anxiety, and catastrophizing on pain related disability in people with chronic low back pain.
        PLoS One. 2017; 12: 1-15
        • Martel MO
        • Petersen K
        • Cornelius M
        • Arendt-Nielsen L
        • Edwards R
        Endogenous pain modulation profiles among individuals with chronic pain: relation to opioid use.
        J Pain. 2019; 20: 462-471
        • Martel MO
        • Wasan AD
        • Jamison RN
        • Edwards RR
        Catastrophic thinking and increased risk for prescription opioid misuse in patients with chronic pain.
        Drug Alcohol Depend. 2013; 132: 335-341
        • Martell BA
        • O'Connor PG
        • Kerns RD
        • Becker WC
        • Morales KH
        • Kosten TR
        • Fiellin DA
        Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction.
        Ann Intern Med United States. 2007; 146: 116-127
        • Martinez-Calderon J
        • Jensen MP
        • Morales-Asencio JM
        • Luque-Suarez A
        Pain catastrophizing and function in individuals with chronic musculoskeletal pain.
        Clin J Pain. 2019; 35: 279-293
        • Morasco BJ
        • Yarborough BJ
        • Smith NX
        • Dobscha SK
        • Deyo RA
        • Perrin NA
        • Green CA
        Higher prescription opioid dose is associated with worse patient-reported pain outcomes and more health care utilization.
        J Pain. 2017; 18: 437-445
        • Prel J-B du
        • Hommel G
        • Röhrig B
        • Blettner M
        Confidence interval or P-Value? Part 4 of a series on evaluation of scientific publications.
        Dtsch Aerzteblatt Online. 2009; 106: 335-339
        • Quartana PJ
        • Campbell CM
        • Edwards RR
        Pain catastrophizing: a critical review.
        Expert Rev Neurother. 2009; 9: 745-758
        • Racine M
        Chronic pain and suicide risk: a comprehensive review.
        Prog Neuro-Psychopharmacol Biol Psychiatry. 2018; 87: 269-280
        • Sacks HA
        • Stepan JG
        • Wessel LE
        • Fufa DT
        The relationship between pain-related psychological factors and postoperative opioid use after ambulatory hand surgery.
        J Hand Surg Am United States. 2019; 44: 570-576
        • Schreiber KL
        • Campbell C
        • Martel MO
        • Greenbaum S
        • Wasan AD
        • Borsook D
        • Jamison RN
        • Edwards RR
        Distraction analgesia in chronic pain patients: the impact of catastrophizing.
        Anesthesiology. 2014; 121: 1292-1301
      2. Schünemann H Brożek J Guyatt G Oxman A GRADE Handbook for Grading Quality of Evidence and Strength of Recommendations. 2013 (The GRADE Working Group, 2013. Available at:)
        • Schünemann HJ
        • Oxman AD
        • Vist GE
        • Higgins JPT
        • Deeks JJ
        • Glasziou P
        • Guyatt GH
        • on behalf of the Cochrane Applicability and Recommendations Methods Group
        Chapter 12: interpreting results and drawing conclusions.
        (editor(s)., editor)in: Higgins JPT Green S Cochrane Handb Syst Rev Interv Version 510. 2011 (updated March 2011). Available at: Accessed February 24, 2021
        • Shaygan M
        • Böger A
        • Kröner-Herwig B
        How does reduction in pain lead to reduction in disability in patients with musculoskeletal pain?.
        J Pain Res. 2019; 12: 1879-1890
        • Stoicea N
        • Costa A
        • Periel L
        • Uribe A
        • Weaver T
        • Bergese SD
        Current perspectives on the opioid crisis in the US healthcare system: a comprehensive literature review.
        Medicine (Baltimore). 2019; 98: e15425
        • Sullivan MJ
        • Thorn B
        • Haythornthwaite JA
        • Keefe F
        • Martin M
        • Bradley LA
        • LJ
        Theoretical perspectives on the relation between catastrophizing and pain.
        Clin J Pain. 2001; 17: 52-64
        • Tkacz J
        • Pesa J
        • Vo L
        • Kardel PG
        • Un H
        • Volpicelli JR
        • Ruetsch C
        Opioid analgesic-treated chronic pain patients at risk for problematic use.
        Am J Manag Care United States. 2013; 19: 871-880
        • Travaglini LE
        • Highland KB
        • Rojas W
        • Buckenmaier CC
        • Kent M
        Identification of functioning domains in the presurgical period and their relationships with opioid use and pain catastrophizing.
        Pain Med Engl. 2019; 20: 1717-1727
        • Vlaeyen JWS
        • Linton SJ
        Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art.
        Pain. 2000; 85: 317-332
        • Wasan AD
        • Butler SF
        • Budman SH
        • Benoit C
        • Fernandez K
        • Jamison RN
        Psychiatric history and psychologic adjustment as risk factors for aberrant drug-related behavior among patients with chronic pain.
        Clin J Pain United States. 2007; 23: 307-315
        • Wertli MM
        • Eugster R
        • Held U
        • Steurer J
        • Kofmehl R
        • Weiser S
        Catastrophizing—a prognostic factor for outcome in patients with low back pain: a systematic review.
        Spine J. 2014; 14: 2639-2657
        • Zhang Y
        • Alonso-Coello P
        • Guyatt GH
        • Yepes-Nuñez JJ
        • Akl EA
        • Hazlewood G
        • Pardo-Hernandez H
        • Etxeandia-Ikobaltzeta I
        • Qaseem A
        • Williams JWJ
        • Tugwell P
        • Flottorp S
        • Chang Y
        • Zhang Y
        • Mustafa RA
        • Rojas MX
        • Schünemann HJ
        GRADE Guidelines: 19. Assessing the certainty of evidence in the importance of outcomes or values and preferences-Risk of bias and indirectness.
        J Clin Epidemiol United States. 2019; 111: 94-104