CBT May Reduce Pain, Decrease Opioid Use

Pauline Anderson

November 15, 2018

Nihar Gala, MD

BOSTON – Mounting evidence points to the importance of cognitive behavioral therapy (CBT) as a tool to help manage pain, according to two new studies presented here at the Academy of Integrative Pain Management (AIPM) Inaugural Global Pain Clinician Summit 2018.

One small study showed that integrating CBT into a primary care office reduced opioid use among chronic pain patients without significantly altering their pain intensity.

"This was a very feasible venture," study investigator Nihar Gala, MD, Alpha Care Medical, Harrington, Delaware, told Medscape Medical News.

"It's easy to add ancillary services, including counseling, into a primary care practice," Gala added.

Preliminary results from a second study showed that group CBT offered remotely reduced pain and improved sleep and mood.

Americans are in the midst of an opioid epidemic of "unprecedented scale," with more than 100 deaths occurring every day because of overdoses with these drugs, said Gala.

He referred to research showing that, since 2000, the rate of drug overdose has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids.

There has been a corresponding growth in the number of opioids prescribed in the United States, Gala added.

Proven Benefits

CBT is a nonpharmacologic treatment that has previously been proven beneficial in managing chronic pain. As an alternative to opioids, the Center for Disease Control and Prevention (CDC) recommends that clinicians consider CBT as well as physical therapy, exercise, and non-opioid medications, such as acetaminophen or ibuprofen.

Within an established primary care practice, it is relatively easy to incorporate ancillary CBT services, said Gala.

He anticipated that doing so would improve overall treatment in patients with pain without leading to the use of higher doses of opioids. He said he also believes that patients would tolerate opioid tapers better when also receiving CBT.

The study included 10 patients at Gala's primary care practice who had chronic pain (average age, 56.8 years; 60% men; 80% white).

All patients were being treated with opioid therapy. Many were on opioid doses above the CDC recommended threshold of 90 morphine milligram equivalents (MME) per day, and had been for some time, Gala reported.

They received monthly hour-long CBT therapy sessions for 12 months, which was provided by a licensed professional counselor.

At the end of the study, the average reduction in MME was 38.5%, but ranged from 14.3% to 57.1%.

There was no significant difference in pain scores on the visual analog scale between baseline and study end (5.6 to 5.7, P  > .05)

"From a public health standpoint, we are reducing overall opioids that are prescribed without increasing the risks that are associated with reducing the opioids; and from a business standpoint, this is a good business venture," said Gala.

Not only were opioid amounts successfully reduced but the patients' mood and anxiety improved, too, he noted.

Offering CBT more frequently, such as once or twice a week, might provide even better results, with some patients possibly being able to stop taking opioids altogether, said Gala.

He reported that the investigators plan to do a future, larger study of CBT in pain patients.

"Exciting Research Development"

Commenting on the findings for Medscape Medical News, president of the AIPM Clayton Jackson, MD, clinical assistant professor of family medicine and psychiatry, University of Tennessee College of Medicine, Memphis, describes the research as "fascinating."

"Since CBT doesn't have the adverse event profile that opioids do, I find this to be an exciting research development. It's proof of concept and we are very pleased to have it presented at our meeting," Jackson said.

Also commenting on the poster, Robert N. Jamison, PhD, professor, Pain Management Center, Department of Anesthesia and Psychiatry at Brigham and Women's Hospital,  Boston, Massachusetts, said CBT for pain management is an "important and timely" topic.

"Unfortunately," this new study is based on only 10 participants who were included in a retrospective review, said Jamison.

He noted that he would have also liked to have had more details on the intervention.

"The results are encouraging, but a prospective study using a randomized design and a clear description of the treatment compared with a suitable control condition among a larger number of subjects who are followed for 3 to 6 months would lend strength to these findings," said Jamison.

"The author should be commended for presenting this poster — and be given a strong suggestion to use these preliminary results to initiate a more rigorous controlled trial," he added.

Pilot, Preliminary Results

Jamison's own pilot trial using CBT remotely is also encouraging, he said. The study is enrolling patients with lower back pain (mean age, 54.1 years).

The CBT participants meet online every week for 2 hours in small groups led by Jamison or a colleague who is a psychiatrist. They use technology that allows each to view and hear the rest of the group.

Some participants prefer group CBT to one-on-one therapy because they get connected to others who are going through the same experience, said Jamison.

A group environment can be "very powerful," he noted. "Pain is pretty isolating and some people think they're the only one going through this, so it's nice to hear other people have similar stories."

The structured online CBT group sessions include a review of the previous week's assignments and discussions on such things as being more active, setting goals, problem-solving, and coping skills, and end with a relaxation strategy. Relaxation exercises change every week and include breathing, imagery, and mindfulness meditation.

Preliminary study results from 42 participants, some from as far away as Texas and Louisiana, showed that after 8 weeks of CBT, "everything improved in the right direction," said Jamison.

There were consistent and significant decreases (P < .05) in pain intensity, pain-related interference, disability, and catastrophizing, which Jamison described as having a negative and persistent focus on pain and continued worries that life will get worse.

"Patients might believe that they will be totally disabled, with pain racked throughout their whole body, and they will be left alone with no friends," he explained.

Opioid Misuse Measure

Patients also improved on a risk outcome that Jamison and his colleagues developed called a "current opioid misuse measure."

"So this has some relevance with regard to concerns about the opioid crisis," he said.

Most patients reported that the online group was as good as if not better than a face-to-face group. Participants commented that they appreciated not only the group dynamics but also being able to connect to the intervention from home.

"For some, travel can be a real challenge physically and some are caring for someone else at home, or the expense is an issue," said Jamison.

He said he is keen to compare outcomes of this online CBT program with face-to-face CBT.

Jackson has reported having investments in Aspire Healthcare and is a consultant for Otsuka Pharmaceuticals. Jamison is the author of "Learning to Master Your Chronic Pain."

Academy of Integrative Pain Management (AIPM) Inaugural Global Pain Clinician Summit 2018. Both abstract 2 and Jamison's presentation were presented November 9, 2018.

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