CBT As a Replacement for Opioids

Emerging research suggests cognitive behavioral therapy (CBT) can be an important strategy to help individuals learn to manage chronic pain. Experts believe CBT has the potential to help millions of Americans overcome opioid dependency.

“Cognitive behavioral therapy is a useful and empirically based method of treatment for pain disorders that can decrease reliance on the excessive use of opiates,” write Drs. Muhammad Hassan Majeed of Natchaug Hospital, Mansfield Center, Conn., and Donna M. Sudak of Drexel University College of Medicine, Philadelphia.

In a new paper they discuss evidence supporting the use of CBT to avoid or reduce the use of opioids for chronic pain. The acknowledgement that use of opioid (sometimes called opiate) medications to treat chronic noncancer pain has reached epidemic proportion has lead researchers to search for pain management alternatives.

Even with use of opioids, there has been little change in the amount and severity of pain reported by Americans over the past decade.

“There is no evidence that supports the use of opioids for the treatment of chronic pain for more than one year, and chronic use increases the serious risks of misuse, abuse, addiction, overdose, and death,” Drs. Majeed and Sudak write.

They believe that CBT is an important alternative to opioids for treatment of chronic pain. The goal of CBT is to help patients change the way they think about and manage their pain.

The idea is not that pain (in the absence of tissue damage) “is all in your head” — but rather that all pain is “in the head.”

Cognitive behavioral therapy helps patients understand that pain is a stressor and, like other stressors, is something they can adapt to and cope with.

Interventions may include relaxation training, scheduling pleasant activities, cognitive restructuring, and guided exercise — all in the context of an “empathic and validating” relationship with the therapist.

These interventions “have the potential to relieve pain intensity, improve the quality of life, and improve physical and emotional function,” according to the authors.

“Therapy helps the patient see that emotional and psychological factors influence perception of pain and behaviors that are associated with having pain,” explain Majeed and Sudak.

“Therapy… puts in place cognitive and behavioral strategies to help patients cope more successfully.”

The authors cite several recent original studies and review articles supporting the effectiveness of CBT and other alternative approaches for chronic pain. Many publications suggest CBT has a “top-down” effect on pain control and perception of painful stimuli.

CBT has also been found useful in normalizing reductions in the brain’s gray matter volume, which are thought to result from the effects of chronic stress.

Overall, cognitive behavioral therapy is moderately effective in reducing pain scores, while avoiding or reducing the opioid risks of overuse, addiction, overdose, and death.

It can be used as a standalone treatment; in combination with other treatments, including effective non-opioid medications; or as part of efforts to reduce the opioid doses required to control chronic pain.

Unfortunately, CBT and other non-pharmacological approaches are underused due to unfamiliarity, time pressure, patient demands, ease of prescribing medications, and low reimbursement rates.

Researchers note that significant investment of resources will be needed to train practitioners and to widely integrate the use of CBT into chronic pain treatment. The authors suggest that the President’s Commission on the opioid crisis might fund such training programs as a preventive strategy to curb opioid abuse.

“There is a need for a paradigm shift from a biomedical to a biopsychosocial model for effective pain treatment and prevention of opioid use disorder,” Dr. Majeed comments.

“Increased use of CBT as an alternative to opioids may help to ease the clinical, financial, and social burden of pain disorders on society.”

Source: Wolters Kluwer Health/EurekAlert