Cognitive-behavioral therapy (CBT) appears to be an effective alternative to opioids for chronic nonmalignant pain, either as a stand-alone treatment or in combination with other nonopioid medications, new research shows.
Investigators at Drexel University College of Medicine, Philadelphia, describe CBT as a “useful and empirically based method of treatment for pain disorders that can decrease reliance on the excessive use of opioids.”
“There is a population that may legitimately need chronic opioid treatment, but most people’s pain can be managed with CBT or acceptance and commitment therapy and, if necessary, nonopioid pharmacotherapy as well as physical and occupational therapy,” study investigator Muhammad Hassan Majeed, MD, attending psychiatrist, Natchaug Hospital, Mansfield Center, Connecticut, told Medscape Medical News.
The study was published in the November issue of the Journal of Psychiatric Practice.
Growing Evidence Base
Dr Majeed said his interest in the use of nonopioid therapies dates back to when he worked in an opioid addiction treatment center.
“Many of the patients had the story of starting on opioid therapy for chronic pain and then escalating to aberrant use and abuse of opioids. Some were on a decent dose of suboxone but were still complaining about pain. I thought, ‘something is missing here,’ ” he said
Dr Majeed contacted study coauthor Donna M. Sudak, MD, professor of psychiatry, Drexel University College of Medicine, Philadelphia, who had been the program director during his psychiatric residency as well as past president of the Academy of Cognitive Therapy.
“We decided to collaborate on this article to further bring to light the role of CBT in treating chronic pain,” he said.
Their article reviews the “growing evidence base,” which encompasses neuroimaging studies, systematic reviews, and randomized trials of CBT in the treatment of chronic pain. They concluded that CBT is “efficacious and cost-effective,” with “long-lasting” impact.
By contrast, no empirical evidence supports the use of opioids for the treatment of chronic noncancer pain lasting more than 1 year. In fact, long-term opioid use is associated with a host of serious risks, including misuse, abuse, addiction, overdose, and death, the authors point out.
Despite the lack of evidence, there has been a “steady increase” in the use of opioid prescription for this indication during the past 2 decades, during which there has been a “steady rise” in opioid-related disorders and deaths from overdose.
The authors attribute the “recent surge in prescription opioid pain medication addiction in the United States” to “aggressive marketing and excessive dispensing” of these agents in the primary care setting.
A Delicate Balance
“When considering long-term opioid treatment for chronic pain, the physician must balance the risk of addiction against the goal of a functioning life,” the authors note.
Patients often request opioids, believing them to be the only means of achieving pain control and functionality. Physicians often prescribe them for this purpose.
Dr Majeed described visiting a pain clinic and observing a patient with chronic headaches. The patient was already being treated with clonazepam for insomnia. The physician prescribed an opioid so that the patient could be pain free and able to function at her child’s wedding.
“I did not want to jump to conclusions because she was not my patient and I had no long-term knowledge of her situation, but I wondered if there were not other nonopioid approaches to increasing this patient’s functionality and reducing her pain for this event.”
The authors advise physicians to discuss the pros and cons of opioid treatments and explore alternatives. Patients may be able to tolerate decreasing their opioid agents in “small increments” as they introduce alternative modalities so that the transition does not impair their functioning.
Dr Majeed added that physicians should discuss with their patients day-to-day functioning as a major treatment goal and that physicians should emphasize to patients that functioning is “more important than the numbers on the pain scale.”
Breaking a Vicious Cycle
The authors characterize the goal of CBT for pain disorders as reconceptualizing “the idea of pain from ‘pain means tissue damage’ and, if no source is found, ‘it’s all in your head’ to the idea that all pain is ‘in the head,’ and that multiple factors influence the perception of pain.”
Reframing pain in these terms enables the patient to begin seeing himself or herself as “a well person who has pain,” thereby lessening the preoccupation with pain and medical help-seeking.
The authors explain that patients with pain often think they would damage their body if they were active. This leads to inactivity, deconditioning, and increasing disability.
This cycle of inactivity and persistent help-seeking centralizes pain as the organizing principle in the patient’s life. Moreover, “the patient becomes governed by fear of pain, and the fear is worse than the real thing,” Dr Majeed commented.
The role of CBT is to help patients recognize the emotional and psychological factors that influence pain perception and the behaviors associated with having pain.
CBT tests the patient’s assumptions about the frequency and severity of pain and its association with activities. It encourages patients to engage in “behavioral experiments” that gradually enable them to engage in “meaningful work projects” and “pleasurable family activities.”
Tasks are divided into small components, and each goal is accomplished incrementally. Relaxation and meditation exercises are used to “manage tension and assist the patient to observe sensations without judgment.”
Cognitive strategies challenge the patient’s beliefs and thoughts about the pain. Then, using cognitive restructuring, the patient learns to modify thoughts to “increase accuracy and usefulness” and use “positive coping self-statements.”
The authors characterize acceptance and commitment therapy as an evidence-based cognitive and behavioral approach that increases effective functioning by helping the patient to accept suffering, use mindfulness, and increase activity and behavior in the service of the patient’s goals and values.
Psychiatrists as Gatekeepers
At present, primary care practitioners are the “gatekeepers” for pain management, Dr Majeed said.
Unfortunately, in the primary care setting, opioids are frequently overprescribed and nonpharmacologic interventions are underutilized. Reasons for this include lack of familiarity on the part of practitioners as well as time pressure, patient demands, ease of prescribing, and low reimbursement rates for psychotherapies.
Dr Majeed suggested that the psychiatrist should assume the role of gatekeeper of a multidisciplinary team that includes primary care practitioners, physical and occupational therapists, psychotherapists who deliver CBT and acceptance and commitment therapy, and pain specialists.
The role of the psychiatrist is particularly important because chronic pain is “complex and multifaceted.” It often occurs in association with depression and anxiety.
“The psychiatrist should define and interpret the goals of treatment, determine how much the pain is interfering with daily life, and prescribe nonopioid pharmacotherapies, such as antidepressants and anticonvulsants, when appropriate, which are medications that psychiatrists prescribe on a regular basis.”
Psychiatrists may also need more training in dosing and prescribing these agents specifically to treat chronic pain and in addressing opioid-related clinical decisions and management, he said.
Practitioners also need training in how to integrate the use of CBT into the treatment of chronic pain. This training may be “resource-intensive,” but may help “ease the clinical, financial, and social burden of pain disorders on society,” the authors emphasize.
Therapeutic Alliance
Many patients with chronic pain are particularly sensitive to receiving a referral to a mental health professional because they believe they are being told that their distress is not “real.” The authors encourage therapists to be attuned to this problem and to focus on building a therapeutic alliance.
“Concerns may be alleviated by emphasizing that many patients with chronic health conditions have benefited from mental health care and learning to cope better with the stressful demands of illness,” the authors advise.
Dr Majeed added that it is important to remind patients that clinicians will work collaboratively with them to create a treatment plan that might include medications or procedures if appropriate
No funding for the study has been described. The authors have disclosed no relevant financial relatioships.
J Psychiatr Pract. 2017;23:409-414. Full text
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