Fear Avoidance Beliefs and Behaviors Contribute to Unsuccessful Opioid Cessation in CNCP

Some patients with cancer are prescribed unnecessary opioids.
The objective of this study was to describe differences between patients with chronic noncancer pain who could stop using chronic opioid analgesic therapy and those who exhibited refractory COAT reliance.

Fear avoidance beliefs and behaviors in patients with chronic noncancer pain (CNCP) may increase the likelihood of unsuccessful cessation of full mu agonist chronic opioid analgesic therapy (COAT), a study in Pain Medicine suggests.

Anxiety and fear-based beliefs and actions have been associated with greater disability, pain intensity, emotional distress, and absenteeism among individuals who suffer from CNCP. In fact, the anticipation of suffering a reinjury itself is a better predictor of increased physical inactivity.

If expectations of pain result in restricted movement, regardless of actual pain, further disability becomes more likely. Additionally, anxiety-based avoidance of physical activity eventually leads to actual further injury and increased pain, psychological behaviors such as social withdrawal, and, in some cases, depression.

In this multicenter study, a small team of researchers retrospectively evaluated electronic medical record data of 109 patients with CNCP (age range, 27-88 years; 69% women) who previously participated in a multidisciplinary program to stop COAT between 2017 and 2019. The investigators looked at rates of refractory COAT in correlation with responses to the Fear Avoidance Behavior Questionnaire (FAB), Current Opioid Misuse Measure (COMM), Tampa Scale of Kinesiophobia (TSK), and Pain Catastrophizing Scale (PCS).

There was a 90% success rate of COAT cessation across all patients by the time of graduation from the program. Significant psychological indicators of unsuccessful COAT cessation were scores on the PCS (95% CI, 0.62-0.99; P <.0001) as well as the Physical Activity (95% CI, 5.4-9.1; P <0001) and Work (95% CI, -1.9 to -1.1; P <0001) FAB subscales, according to penalized regression.

In contrast, there were no differences observed based on the COMM or TSK scores, while overall PCS scores demonstrated a split pattern that revealed “unclear” levels of significance.

Limitations of this study included its retrospective nature, the small sample size, its inability to blind patients, and the nonrandomized design.

While the findings from this study require validation in larger cohorts, the investigators wrote they remain hopeful their results will help clinicians and researchers alike “narrow the scope of inquiry around useful assessments and interventions for best-practice approaches to COAT cessation in the population with CNCP.”


Jasmine Silva M, Coffee Z, Ho Alex Yu C, Martel MO. 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. Pain Med. Published online February 17, 2021. doi:10.1093/pm/pnab069