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Chronic Pain and Opioid Use: The Important Role of CBT Therapists

By Allen R. Miller, Ph.D., MBA
CBT Program Director, Beck Institute for Cognitive Behavior Therapy

The epidemic co-occurrence of chronic pain and opioid use has resulted in an expensive ($635 billion per year) and deadly (72,000 overdose deaths per year) problem in the United States. Chronic pain and opioid use sufferers make frequent visits to primary care practices, emergency rooms, and medical specialists. Often physical injuries or illnesses cause painful sensations. It comes as little surprise then, that the first question many pain sufferers ask upon meeting a CBT therapist is, “How can a therapist help me with my physical pain?” Although the true answer is, “A CBT therapist can help quite a lot,” that is the last thing we would say to them.

Why? People who have chronic pain have endured much suffering. They’ve usually tried a number of strategies to get relief--without success. CBT is usually last on their list of things to try. Many have lost hope. To add to their pain, they frequently report that “No one listens” and “No one understands”. So, we need to take care not to cut them off or make guarantees. Empathy, reflective listening, and other counselling skills are essential to develop a solid therapeutic relationship.

A strong alliance helps patients to be more amenable to trying CBT techniques.

It is important to know that adverse experiences (sometimes from childhood) and other psychosocial factors may set the stage for an individual to develop chronic pain, though most of the time treatment focuses on the here-and-now. When individuals experience acute pain, the way that they think about the pain (e.g. “unbearable”) and how they anticipate its effect on their life (e.g. “catastrophic”) may be predictive of whether the individual will develop chronic pain.

When people experience stress (especially social, work, family or physical stress), their bodies become tense.  When that happens, their pain intensifies. Having pain is a problem in and of itself, and people with chronic pain often have additional problems: trouble meeting their role responsibilities at work, keeping up with household needs, and taking care of children, to name a few. Many feel helpless to deal with the pain or to overcome its impact on their lives. When it gets to this point, these patients may become disheartened and believe they are worthless or a burden to those around them. Depression, anxiety and suicidal thoughts often ensue.

Virtually no one likes pain. When we have pain, we want to get rid of it. When pain gets to the point that we “can’t stand it” or when it keeps us from doing things that we have to do, we generally become willing to do whatever it takes to get relief. For many people, their first exposure to opioid medications came through prescriptions from their doctors. Opioid medications provide relief from acute pain. When opioids change “I can’t stand it” to “That feels better” and “I can’t do anything” to “I can do things as usual,” they become a very helpful aid.

So, what is the problem with opioids?

In the beginning, opioids work like magic, but over time they lose their potency. When taken regularly for a relatively short period of time, increasingly higher doses are needed to provide the same benefits. As higher doses are taken, the side effects (e.g. drowsiness, nausea, constipation) become greater. Additionally, as larger doses are taken over longer periods of time, the person taking them must continue taking them to avoid going into withdrawal. Typical withdrawal symptoms include: cramps, diarrhea, nausea, and increased blood pressure. These symptoms indicate that the individual has become physically dependent on the medication. One additional complication resulting from taking opioids over time is the development of hyperesthesia--the medications themselves cause a greater sensitivity to touch which means that the medications that are being taken to relieve pain actually make the pain worse!

Many individual studies and meta-analyses have demonstrated the efficacy of CBT for chronic pain and substance use disorders (SUDs).

CBT can help alleviate suffering for patients who have chronic pain and use opioids with the hope of getting relief.  The CBT therapist uses many strategies. Here are just four:

  • Relaxation and mindfulness. These techniques reduce muscle tension and provide distraction from pain. Paradoxically, by learning to focus on pain and accept it, the painful sensations decrease and become more tolerable. Patients learn a valuable lesson and re-evaluate what they can actually tolerate.
  • Behavioral activation. This serves as a planning process as well as a behavioral learning experience. People with chronic pain often avoid activities because the activity induces pain that they don’t want and will “pay for” the next day. By working with a CBT therapist, people with pain can learn to pace their activities in increments they can tolerate. By doing so, they improve their physical condition and their mood. By learning that they can engage in some level of activity without “paying for it” the next day, they are rewarded by feeling better and learn that activity is not something that has to be avoided to escape pain. Increased movement and changed beliefs reduce depression, anxiety and suicidal thoughts.
  • Problem-solving. This reduces stress, helps patients feel stronger and more in control, and improves mood.
  • Cognitive restructuring. This helps patients evaluate and respond effectively to their inaccurate or unhelpful thinking.

It is rarely a good idea to broach the subject of reducing or eliminating opioid medications until after patients have coping skills for dealing with their pain. Once they are practicing skills and are better able to tolerate their pain, therapists can bring up their medication use—though a medical professional should provide a tapering schedule. Many patients do not like taking the medications and are willing to talk about weaning off of them when they no longer think they are facing a “sure hell” without them. A cost benefit analysis is a good place to start: What does the patient see as the advantages and disadvantages of continuing to take opioids? What are the advantages and disadvantages of not taking opioids? Motivational techniques and strategies to cope with urges are important. Other techniques tailored to substance use such as cognitive restructuring, contingency management, and relapse prevention can be introduced to provide long-term relief and stability.

CBT has a great deal to offer clients with chronic pain.

Listen carefully and empathize. Provide an initial rationale for treatment that emphasizes techniques for coping with stress. Invite patients’ initial skepticism and praise them for voicing their misgivings. Help them understand that they have already done the experiment of not trying CBT; see if they’re willing to try the experiment of using CBT to reduce their stress. Use standard CBT techniques to help patients tolerate their pain, return to daily activities (as approved by their health care provider), solve problems, and respond to their negative thoughts and beliefs. Use motivational techniques to encourage them to taper the medication. And as a final note, read up on opioids and CBT for substance abuse so you yourself can be better informed.

Upcoming Workshop

CBT for Chronic Pain and Opioid Use

February 24-25, 2020