Cognitive behavioral therapy (CBT) was found to be more effective in reducing the use of nonmedical opioids compared with standard methadone drug counseling in patients with chronic pain and opioid use disorder (OUD) enrolled in methadone maintenance treatment programs, according to a study published in Drug and Alcohol Dependence.
In this 12-week clinical trial pilot study (Clinicaltrials.gov identifier NCT01334580), 40 participants with low back pain recruited between April 2011 and July 2013 were randomly assigned to receive CBT (n=21; mean age, 38.4; 66.7% men; mean OUD duration, 10.6 years; mean pain duration, 15.8 years) or methadone drug counseling (n=19; mean age, 37.7; 57.9% men; mean OUD duration, 13.2 years; mean pain duration, 16.2 years). A stable methadone dosing regimen was established during a 3-week period preceding the randomization, with an 80- to 90-mg/ day target maintenance dose.
Participants assigned to the CBT group attended twelve 30- to 45-minute sessions and patients in the methadone drug counseling group received four 15- to 20-minute sessions that focused on OUD but not pain. Primary outcomes to determine program feasibility were completion rates and frequency of session attendance, and patient satisfaction ratings post-session were used to assess program acceptability. Program efficacy was evaluated by examining abstinence rates, reductions in pain intensity and interference — both assessed with the Brief Pain Inventory — and number of consecutive weeks of abstinence. A logistic regression model was constructed to evaluate treatment group effects.
Study completion rates were comparable in patients receiving CBT or methadone drug counseling, with 95% of participants in each group attending sessions for the 12-week period. Mean session attendance was 8.4 (out of 12) for CBT and 3.8 (out of 4) for methadone drug counseling. Mean satisfaction rating was 6.6 and 6.0 for participants receiving CBT and methadone drug counseling, respectively, as assessed with a 7-point Likert scale (P <.001). Abstinence rates were higher in the CBT vs methadone drug counseling group (P =.02).
Clinically significant changes in pain interference were comparable in both programs (42.9% for CBT vs 42.1% for methadone drug counseling; P =.96). Participants in the CBT group had a greater number of consecutive abstinence weeks compared with patients in the MDC group.
Study limitations include the small sample size, possible lack of generalization to other conditions or pain sites, and lack of assessment of pain treatments that may have occurred offsite.
“The findings of this study suggest that methadone drug counseling combined with CBT is feasible, acceptable, and — compared [with] standard drug counseling — may be associated with greater reductions in nonmedical opioid use,” noted the authors. They recommended that future studies focus on long-term outcomes and examiner additional pain management interventions.
Barry DT, Beitel M, Cutter CJ, et al. An evaluation of the feasibility, acceptability, and preliminary efficacy of cognitive-behavioral therapy for opioid use disorder and chronic pain. Drug Alcohol Depend. 2019;194:460-467. doi:10.1016/j.drugalcdep.2018.10.015