Findings reported in Pain Medicine show that a targeted form of cognitive behavioral therapy (CBT) is effective in treating chronic pain and substance use disorder in veterans with hepatitis C virus (HCV) infection.1
Although chronic pain and substance use disorders (SUDs) often co-occur, there is limited evidence supporting the effectiveness of integrated treatments addressing both disorders. A previous randomized trial found that more intensive treatment is needed in patients with both disorders to achieve improvements in pain-related function.2 In addition, certain pain medications may not be appropriate in some HCV patients – for example, acetaminophen in patients with cirrhosis or opioids in patients with a history of SUD.3,4
“Thus, patients with HCV may be especially appropriate for nonpharmacological interventions for chronic pain and SUD,” wrote the investigators in the current study. The researchers developed a customized, 8-session CBT program (CBT-cp.sud) in patients who have HCV, SUD, and various types of chronic pain – most commonly back and joint pain. The program was created after a thorough analysis of multiple CBT manuals, peer consultation, and focus group testing.
The investigators then tested the approach in 21 veterans in an outpatient setting. The sessions consisted of a range of relevant topics emphasizing self-management and problem solving: education about chronic pain and substance use, personal triggers for both, identification and challenge of cognitive distortions that contribute to chronic pain and SUD, incorporation of social and leisure activities, and strategies for communicating with primary care physicians.
At baseline, post-treatment, and 3 months post-treatment, patients completed the Multidimensional Pain Inventory (MPI) severity and interference scales, the Beck Depression Inventory–Second Edition (BDI-II), and a 1-item Global Impression of Change with results ranging from “very much worse” to “very much better.” In addition, participants completed measures of current and prior SUDs, including the TimeLine Follow Back (TLFB) method for patients to self-report use, the Penn Alcohol Craving Scale (PACS), and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, DSM-IV (Structured Clinical Interview for DSM-IV, SCID).
The results show a reduction in patients meeting diagnostic criteria for SUD: At baseline, 24% of patients met the criteria, while only 15% of patients post-treatment and 6% of patients at 3-month follow-up met the criteria. In addition, 94% of patients indicated improvement from baseline on the Global Impression of Change, and pain severity and pain interference decreased significantly. There were no changes in depressive symptoms.
These findings suggest that the “integrated CBT-cp.sud may be helpful in improving pain-related function while also reducing cravings for alcohol and other substances, and decreasing past-month alcohol and substance use,” the researchers stated. Future studies on this type of approach should include an active control group and should identify the optimal setting for its delivery.
Summary and Clinical Applicability
A customized CBT program in patients with HCV was found to reduce SUD, pain severity, and pain interference in veterans at an outpatient clinic.
Limitations and Disclosures
The lack of a control group and small sample size represent the main study limitations. Further research on the topic should include long-term follow-up and a larger number of participants.
Dr Turk has received consulting fees from multiple pharmaceutical and medical device companies in the past year, as well as research funding from the NIH and the FDA.
- Morasco BJ, Greaves DW, Lovejoy TI, Turk DC, Dobscha SK, Hauser P. Development and preliminary evaluation of an integrated cognitive-behavior treatment for chronic pain and substance use disorder in patients with the hepatitis C virus. Pain Med. 2016;17(12):2280-2290. doi:10.1093/pm/pnw076 pii: pnw076
- Morasco BJ, Corson K, Turk DC, Dobscha SK. Association between substance use disorder status and pain-related function following 12 months of treatment in primary care patients with musculoskeletal pain. J Pain. 2011;12(3):352-359. doi:10.1016/j.jpain.2010.07.010
- Larson AM, Polson J, Fontana RJ, et al. Acetaminophen-induced acute liver failure: results of a United States multicenter, prospective study. Hepatology. 2005;42(6):1364-1372.
- Dobscha SK, Corson K, Flores JA, Tansill EC, Gerrity MS. Veterans affairs primary care clinicians’ attitudes toward chronic pain and correlates of opioid prescribing rates. Pain Med. 2008;9(5):564-571.