Response: “Re: Predicting Risk for Opioid Misuse in Chronic Pain with a Single-Item Measure of Catastrophic Thinking”

To the Editor: We thank Ayodeji Otufowora, MB.BS, MPH for the thoughtful commentary regarding our brief report on predicting risk of opioid misuse with a single-item measure of pain catastrophizing. It is accurate to note that the evidence for catastrophizing as a distinct construct completely separate from negative affect is by no means clear, and further research is needed to explore these relationships and interactions, particularly regarding the relationship among pain catastrophizing, fear, and depression.^1,2,3 Regarding the previous research by Hirsh et al⁴, we are not surprised that by controlling for negative mood, catastrophizing had a more limited impact on the prediction of pain severity, especially given the shared variance of these constructs. However, we should point out that the goal of our study was not to examine the relationship among subjective measures of affective distress (ie, fear, depression, and pain severity); rather, we were examining the relationship of negative affect in predicting risk of aberrant medication use. Regardless, the point is well taken regarding interpretation of elevated scores as higher levels of catastrophizing that may reflect a myriad of maladaptive thoughts, emotions, and behaviors. With this single-item screen, we are hopeful that it will prompt the primary care physician to engage in a follow-up discussion with the patient to explore what may be contributing to pain-related distress (eg, fear of harm, fear of pain, and helplessness). Our recommendation would be in agreement with Hirsh et al⁴ that the primary care physician focus less on interpreting the single item and more on probing the patient to better understand what may underlie this report. In this manner, the primary care provider can directly impact maladaptive thinking and hopefully mitigate, to some extent, a risk factor for opioid misuse.

Finally, the commentary makes an excellent second point regarding the importance of potential and actual ethnic differences in pain coping/catastrophizing. We agree that caution is warranted in overinterpretation of this or any other assessment measure across a diverse sociocultural population. Again, we offer this measure as a clinical tool that will hopefully lead to further questions from the primary care provider and perhaps more importantly, an opportunity for education and reassurance.