Web-based CBT for Opioid-treated, Chronic Pain Patients with Aberrant Behavior
Although opioid therapy has gained increasing acceptance as a treatment for patients with chronic non-malignant pain (CNMP), concerns persist related to achievement of treatment goals (reduction in pain severity and pain interference) and medication misuse/abuse within the clinical context (often described as aberrant drug related behavior). Psychosocial approaches (particularly self-management strategies such as cognitive-behavior therapy [CBT]) have been found to be efficacious for the treatment of CNMP. However, most chronic pain patients are not exposed to comprehensive psychosocial interventions, largely due to the lack of expertise and time among physicians who prescribe opioids.
To address this public health concern, we are developing and will implement and evaluate an innovative CBT intervention for the treatment of chronic pain tailored to the specific needs of patients who are being prescribed opioids and who present with aberrant behaviors. The program will be theoretically grounded in the cognitive-behavioral perspective, incorporating a set of techniques that have been shown to be effective for chronic pain patients with adaptations from the substance abuse literature. Through an iterative development process with both expert consultants and chronic pain patients, we will determine how to best present the information in the program and assess each module’s acceptability, ease of use, likeability, helpfulness, and relevance to the experience of chronic pain patients. To our knowledge, the planned program will be the first interactive, web-based program to provide comprehensive, psychosocial treatment to this population.
We will evaluate the efficacy of the web-based intervention with chronic pain patients with aberrant drug-related behavior in outpatient treatment for chronic pain. Chronic pain patients (at the Department of Pain Medicine at Beth Israel Medical Center) will be randomized to receive either: (1) treatment as usual (TAU; n=55); or (2) TAU plus the computer-delivered psychosocial intervention (n=55). Primary outcomes are pain severity, pain interference behaviors, and drug-related aberrant behavior; secondary outcomes include substance misuse, other pain behaviors, and physical and emotional functioning. We will also examine two therapeutic mechanisms hypothesized to mediate the relationship between the CBT web-based intervention and behavioral outcomes: (1) cognitive distortions (e.g., helplessness) relevant to effective pain management and coping and; (2) expectations about the future. The web-based intervention being developed and evaluated in this project has the potential to markedly improve the treatment of chronic pain by enabling widespread access to evidence-based CBT for chronic pain.