Cognitive behavioral therapy recommended for opioid use disorder

LAS VEGAS —Patients with pain combined with opioid use disorder could realize benefits from cognitive behavioral therapy, Ravi Prasad, PhD, said at PAINWeek 2022.

Prasad, clinical professor and director of behavioral health in the division of pain medicine at the University of California Davis School of Medicine, said that one-fifth of the U.S. population has chronic pain, with one-third having high-impact chronic pain, according to statistics from HHS. Many of these patients were rapidly tapered off of their medications during the opioid crisis, often resulting in substance use disorder.

“There was a dramatic rise in overdose deaths in this country with the shelter-in-place orders during the pandemic,” Prasad said. According to the CDC, drug overdose deaths rose to 93,000 in 2020. About 100,306 deaths occurred between April 2020 and April 2021, and 75,673 were attributed to opioids.

Ravi Prasad

“We don’t have exact data on how the pandemic caused this,” he said. “One factor could be access to treatment centers. And then there are mental health implications with the shelter-in-place orders themselves. We saw an increase in depression and anxiety. And illness related to COVID-19 was given priority.”

“The approach to treating most chronic pain is focusing on quality of life and function for the person living with pain,” he said.

Chronic pain management starts with medical optimization, which is overseen by physicians, nurse practitioners or physician assistants, he said.

Next comes physical reconditioning.

“Patients may protect the area in pain and not use it,” Prasad said. “Help patients keep the regions of the body affected by pain as toned as possible.”

This requires involvement with physical therapists.

Next comes integrative therapies and then behavioral/lifestyle modification with a pain psychologist.

“Optimal pain management is a combination of all of these factors working together,” Prasad said. “The patient can’t pick and choose which areas they’ll adhere to, although they try. Most will choose medical optimization because it’s easier. But that is typically how we treat acute pain, and that’s how people are conditioned to think about pain treatment.”

The first step is assessing for problematic behaviors, Prasad said. Evaluate behavior during clinic visits, feedback from staff, comments from family and friends, urine drug screens and the use of a prescription drug monitoring program and available screening tools.

Pharmacological treatment and behavior interventions must be used together in OUD.

“At first a patient may not perceive there’s a problem,” Prasad said. “Try to keep them safe during this time period. Use motivational interviewing to tap into the patient’s own intrinsic motivation to create change. Bring up things they told you on their own, such as interactions with family members, desire to get back to work, etc. These are the patient’s internal motivations.”

Cognitions have a large role, and many of our maladaptive behaviors are rooted in dysfunctional thought patterns, he said.

“Say, I wake up and I feel bad,” Prasad said. “I can’t control this situation, the day is ruined, so I need to take something for this.”

The goal of CBT is to target a maladaptive thought process to achieve healthier outcomes, Prasad said. He explained that cognitive restructuring involves assessing thought processes for accuracy and helpfulness.

“Turn ‘There is nothing I can do to control this,’ into ‘I can practice self-management skills’,” he said.

There is a strong evidence base for psychological/behavior interventions to address OUD, Prasad concluded.