Cognitive behavioral therapy modestly reduces chronic pain in patients on opioids

Patients with chronic pain receiving long-term opioid therapy who were assigned to cognitive behavioral therapy reported reductions in pain and pain-related disability, data show.

However, opioid use by the patients did not decrease, according to results from a randomized controlled trial published in Annals of Internal Medicine.

“Opioids have historically been touted as a solution to long-term management, despite the lack of rigorous evidence. This approach created a host of patient and societal adverse effects. Consequently, viable nonopioid options for long-term management of chronic pain in primary care are needed,” Lynn DeBar, PhD, MPH, a senior investigator at Kaiser Permanente Washington Health Research Institute, and colleagues wrote.

Patients on long-term opioid therapy can benefit from behavioral treatment “that doesn’t carry corresponding risks that more biomedically focused treatment can have,” DeBar told Healio Primary Care.

Lynn DeBar

The researchers randomly assigned 850 adult patients on long-term opioid therapy for chronic pain to receive usual care (n = 417) or a cognitive behavioral therapy (CBT) intervention (n = 433). Overall, the mean age of patients was 60.3 years; 67.4% were women and 76.6% were white.

A behaviorist, nurse, physical therapist and pharmacist jointly taught pain self-management skills to patients in the intervention cohort during 12 weekly, 90-minute group sessions. The sessions were yoga-based and incorporated relaxation techniques, activity-rest cycling, pleasant activity scheduling, guided imagery and other distraction techniques, emotional regulation skills, cognitive restructuring, problem solving and relapse prevention and maintenance, according to DeBar and colleagues. The intervention team met with primary care physicians to review intake summaries and evaluations before and after the group sessions.

The most common pain diagnoses among participants were limb or extremity pain, joint pain and arthritic disorders (81%); back and neck pain (74%); and general and widespread pain (70%). The median daily dose of opioids taken by participants was 29.6 morphine milligram equivalents.

DeBar and colleagues found that patients in the intervention group experienced greater reductions in pain impact and pain-related disability compared with the usual care group. Also, one in four patients receiving CBT experienced clinically meaningful reductions in pain (greater than 30%) compared with one in six patients receiving usual care.

While opioid use did not significantly decrease, the researchers noted that patients taking benzodiazepine in the intervention group showed greater reductions in use than patients in the usual care group.

Behavioral treatments like CBT can be provided effectively within everyday clinical care delivery systems, DeBar said.

“This study shows the potential for skill-based, CBT interventions delivered by frontline clinicians to reduce pain impact and improve function among patients with chronic pain receiving long-term opioid treatment,” DeBar and colleagues wrote. “Although effects were modest, they persisted after treatment through the final 12-month follow-up.”