Americans make up less than 5 percent of the world's population but consume nearly one-third of the global opioid supply, according to an expert group affiliated with the United Nations, the International Narcotics Control Boardopens in new window. Much of that consumption is misuse: Data from the U.S. Substance Abuse and Mental Health Services Administration show that 11.8 million Americans currently misuse opioids.
Often, that misuse stems from patients seeking to relieve physical pain by taking more medication than prescribed by their physicians, taking someone else's medication or purchasing substances on the black market, according to the 2016 National Survey on Drug Use and Healthopens in new window. But physical pain alone does not predict opioid misuse—and other common reasons for misuse include using drugs to relieve tension, to feel good or to help with negative emotions, according to the survey.
"When we compare people who misuse opioids to people who take them as prescribed, there's no significant difference in their physical pain levels," says Eric Garland, PhD, LCSW, director of the Center on Mindfulness and Integrative Health Intervention Developmentopens in new window at the University of Utah. "What does discriminate these patients is their emotional pain. That's what seems to be driving this problem."
In fact, the biggest predictors of opioid misuse are existing mental health issues, which is one reason the scientific literature has dubbed opioid use disorder a "disease of despair." People who have experienced trauma, received a depression or anxiety diagnosis, or have a personal or family history of substance use disorder are at greatest risk. Other predictors include being younger, heavy tobacco use and engaging in risk-taking behavior, according to research by Lynn R. Webster, MD (Anesthesia & Analgesiaopens in new window, Vol. 125, No. 5, 2017).
Those findings point to the essential role psychologists can play in preventing opioid misuse, not only by diagnosing and treating mental health issues that precede what some providers call "chemical coping," but also by offering nonpharmacological strategies for treating physical pain. A growing body of research supports psychological interventions that are less expensive than, less risky than and often just as effective as opioids for treating pain.
Unless we embrace the prevention approach, the opioid crisis will persist, says Howard Koh, MD, MPH, a professor in Harvard's T.H. Chan School of Public Health and former assistant secretary for health at the U.S. Department of Health and Human Services. "Although we've seen more attention on the opioid epidemic in recent years, there's still very little focus on prevention," he says.
That's why psychologists are working to promote and expand their roles in the opioid crisis by developing, testing and administering pain management strategies that reduce reliance on opioids.
Underlying issues
Opioid use disorder (OUD), which affects 2.1 million Americans, involves chronic opioid misuse and is marked by physical tolerance of the drug, withdrawal symptoms when usage is stopped, and the disruption of daily life, according to the Diagnostic and Statistical Manual of Mental Disorders. OUD has two distinct etiologies, each with its own implications for prevention, according to research by Daniel Bruns, PsyD, a clinical health psychologist in Greeley, Colorado, who studied drug risk in more than 3,000 community members and patients in treatment for pain across 36 states (BHI 2 Medical Intervention Risk Report Manualopens in new window, 2016).
One at-risk group follows what Bruns calls a more traditional pattern of substance use—they are more likely to have engaged in illegal behavior, show greater impulsivity and have a high likelihood of having experienced childhood trauma. These individuals are more likely to use illicit substances or to obtain prescription medications illegally. For this group, a key path to prevention requires psychologists to help patients address underlying mental and behavioral health issues before they begin to self-medicate with substances, says Bruns.
The second at-risk group Bruns identified is patients who have coped badly with a painful illness or injury. "In this case, the opioid use of these high-risk patients has been sanctioned by society," he says. "These patients are often stunned when they become dependent on opioids after simply following the instructions of a physician."
Preventing misuse and addiction among this second group—which Bruns says contributes a substantial portion to today's opioid problem—requires a better understanding of which patients can benefit from opioids, which are at risk for misusing them and alternative methods for treating pain.
Opioids block pain signals, which is useful for treating acute pain, but the drugs become less effective over time as patients build up tolerance. With an estimated 50 million Americans living with chronic pain—defined as pain lasting more than three months—U.S. physicians have relied heavily on opioids, prescribing them to more than 17 percent of the U.S. population in 2017, according to the Centers for Disease Control and Preventionopens in new window.
One of the ways psychologists are advancing prevention of opioid misuse is by creating and administering psychological assessments that predict which patients are at risk for misuse and addiction.
"There are huge individual differences in how people perceive, react to and handle pain, which is why it's important to evaluate patients before we start prescribing opioids," says Robert Jamison, PhD, professor of anesthesia and pain management at Harvard Medical School and a pain psychologist at Brigham and Women's Hospital's Pain Management Center. He and his team have developed a series of validated risk assessment scales that are now widely used in studies and pain clinics around the country (see Who needs opioids? for more on these assessments).
Patients who "catastrophize" about pain, or ruminate on and magnify it, are particularly at risk because they may use opioids to manage their mood as well as the pain itself, says Jamison.
Psychologists can help by teaching people how to reduce that catastrophizing.
"If people are very fearful about pain, if they're saying things to themselves like, 'My life is over, I can't do anything because of pain,' that fear sets off alarm systems in the brain," says Jeannie Sperry, PhD, a pain psychologist at the Mayo Clinic's Pain Rehabilitation Center in Rochester, Minnesota.
To help reduce pain catastrophizing, Sperry provides psychoeducation about pain to patients who enter the clinic's three-week intensive outpatient program. She teaches people with chronic pain from conditions such as fibromyalgia, amputations and Parkinson's disease that their experience of pain does not correlate with actual tissue damage.
Psychological interventions can help people treat pain without medication because of the way the brain processes pain signals: When a person is injured physically, sensory signals travel from the body to the thalamus and are then sent to several other brain areas associated with the subjective experience of pain. But the prefrontal cortex can modulate how the thalamus relays such signals, changing the way pain is perceived.
"By stimulating top-down control from the prefrontal cortex, psychological interventions can improve people's ability to cope with pain," says Garland. "When effective, these therapies can even decrease the pain itself."
The most commonly used—and best studied—psychological treatment for pain is cognitive-behavioral therapy (CBT), which practitioners like Bruns and Sperry use to help wean patients off opioids and prevent others from taking them in the first place. Cognitive therapy addresses how people think about their pain, for instance by teaching them to use non-catastrophizing language, while behavioral strategies help patients interrupt negative thought patterns and encourage them to resume activities they may previously have avoided, such as climbing stairs after a back injury.
Research shows that CBT improves mood and positive function, with numerous studies demonstrating its ability to reduce both pain and catastrophizing (American Psychologistopens in new window, Vol. 69, No. 2, 2014). One study by David Seminowicz, PhD, and his colleagues at the University of Maryland, Baltimore's Center to Advance Chronic Pain Researchopens in new window even indicated that CBT can lead to increases in the volume of the prefrontal cortex and other brain regions involved with modulating the experience of pain (Journal of Painopens in new window, Vol. 14, No. 12, 2013).
Other psychological interventions shown to be effective for pain management include acceptance and commitment therapy, a variation of CBT that incorporates acceptance of pain and commitment to behavior change; biofeedback, which helps patients gain a better understanding of their physical state; and hypnosis. Jamison is even starting to design interventions that employ virtual reality, gamification and voice and facial recognition to better assess mood and teach patients to relax.
Psychologists are also increasingly using mindfulness therapies to treat chronic pain. Building on his research on emotional regulation deficits in people who misuse opioids, Garland developed Mindfulness-Oriented Recovery Enhancement (MORE), a series of eight two-hour sessions to help treat pain and reduce dependence on opioids.
"The labeling of OUD as a 'disease of despair' in the scientific literature isn't just a metaphor," Garland says. "Chronic pain patients who misuse opioids actually have abnormally high rates of anhedonia—their brains and bodies are blunted to the experience of natural pleasure, joy and meaning in life."
MORE teaches patients coping strategies such as practicing three minutes of mindful breathing before each dose of opioids. The intervention has been shown to increase physiological responses to natural pleasure, including heart rate variability and electrophysiological response, which predict decreases in opioid cravings and misuse (Journal of Behavioral Medicineopens in new window, Vol. 38, No. 2, 2015).
Outreach as prevention
Beyond administering psychological assessments and interventions in the clinic, psychologists are deploying new outreach strategies and technologies to reach more people at risk of opioid misuse.
"Tens of millions of Americans live in isolated areas without access to pain psychologists," says Robert Edwards, PhD, associate professor of anesthesia at Harvard Medical School and a pain psychologist at Brigham and Women's Hospital's Pain Management Center. "We can reach many more people if we make our assessment tools and interventions available via telepsychology and smartphone applications."
Edwards and Jamison developed a five-question self-report scale, delivered daily to patients via a mobile application, that can identify people at risk for misusing opioids in just five days (see Who needs opioids?). The instrument helps fill a data gap on how patients are faring.
"Patients may see their provider periodically, but we often lack information about their moods and behaviors between visits," Jamison says.
Cross-disciplinary collaboration among health-care providers is also key for effectively treating pain, says Sperry. The pain management program at the Mayo Clinic, for instance, is staffed with an addiction psychiatrist, a pain psychologist, a physical therapist, an occupational therapist, a nurse, a pharmacist and a chaplain. Patients practice Tai Chi, yoga and relaxation each day in addition to attending several hours of rehabilitation and pain management classes. This sort of integrative care helps pain patients learn long-term coping strategies and taper off high doses of opioids, and has been shown to reduce depression and pain catastrophizing (Journal of Painopens in new window, Vol. 19, No. 6, 2018).
Integrative chronic pain management programs that include psychologists are not only more effective than solely medical approaches; they also save money. After Bruns helped develop and pass the Colorado Chronic Pain Guidelines, statewide regulations for treating pain in workers' compensation cases, he measured the results of regularly replacing surgery with psychological interventions.
"Compared to certain spinal surgeries for pain, studies show that CBT is equally effective, while surgery is much riskier and costs about 168 times more," Bruns says. Colorado's annual medical costs for workers' compensation dropped as much as $859 million after the pain guidelines were implemented in 1992 (Rehabilitation Psychologyopens in new window, Vol. 57, No. 2, 2012). And an analysis of the Mayo Clinic's pain rehabilitation program in Jacksonville, Florida, by Christopher D. Sletten, PhD, and colleagues, revealed a 90 percent drop in health-care costs 18 months post-treatment (Pain Medicineopens in new window, Vol. 16, No. 5, 2015).
Cultural shift
As helpful as psychological interventions are for preventing opioid misuse, experts say widespread adoption of such treatments requires a broader cultural shift toward a biopsychosocial treatment model.
"If you watch TV, it looks like there's a pill for everything," Sperry says. "Instead of promoting drugs to treat pain, unhappiness or sleep problems, we should be teaching people how their brains and bodies work together from a young age," via teachers, pediatricians and parent education.
More extensive education is also needed for both psychologists and physicians, who currently receive no systematic training in pain management. In a national survey, more than half of psychology practitioners polled said they did not have adequate training to treat individuals experiencing pain (Pain Medicineopens in new window, Vol. 17, No. 2, 2016).
"When therapists don't feel competent in a certain area, they avoid it," says Beth Darnall, PhD, clinical professor in the department of anesthesiology, perioperative and pain medicine at Stanford University and lead author of the study. "Psychologists aren't going to ask people about their pain if they feel they have nothing to offer," which is problematic because a high percentage of patients seeking help for mental health issues are also experiencing pain.
To help train psychologists in pain management, APA published Darnall's book "Psychological Treatment for Patients With Chronic Pain" and is developing an online continuing-education module in pain psychology. Darnall also created a single-session pain psychology class (Journal of Pain Researchopens in new window, Vol. 7, 2014) and offers certification workshopsopens in new window to clinicians who hope to gain foundational knowledge and training in the area.
As researchers continue to amass data on opioid misuse, pain and treatment approaches, psychologists and other health-care providers can develop tools to prescribe personalized interventions for managing pain.
"Using a combination of brain imaging, genetics and patient self-reports, we can begin to create algorithms that prescribe each patient the optimal combination of treatments as quickly as possible," Edwards says, which may include medications, psychological treatments or a combination of both. Ultimately, this personalized, integrative approach can reduce dependence on opioids, especially in cases where they're likely to be misused.
"When we know that pain is multidimensional and multi-determined, to only prescribe one modality is doomed to fail," says Sperry. "Prescribing only medication for chronic pain is highly likely to be ineffective."
