Cognitive-Behavioral Therapy (Cbt) for the Treatment of Opioid Use Disorder

By David S. Festinger Ph.D., Michelle R. Lent Ph.D., Christina B. Shook Psy.D. ABPP and Robert A. DiTomasso Ph.D. ABPP

This manual was designed to provide a manualized cognitive-behavioral approach to opioid use disorder (OUD). Developed with the expertise of clinical psychologists and scholars working in the field of addiction treatment, this program utilizes evidence-based CBT techniques that are tailored to the unique clinical needs of individuals living with OUD.

• Language: English
• Publisher: Trafford Publishing
• Release date: Aug 18, 2022
• ISBN: 9781698711942

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Copyright 2022 Dr. Festinger, Dr. Lent, Dr. Shook, Dr. DiTomasso.

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ISBN:

978-1-6987-1193-5 (sc)

ISBN:

978-1-6987-1194-2 (e)

Library of Congress Control Number: 2022909188

Trafford rev. 08/17/2022

ACKNOWLEDGMENTS

The development of this manual was supported by Richard (PCOM D.O., ’81) and Erin Weinberger and Judith Pell Weinberger. We would also like to thank our Expert Committee.

This manual is dedicated to the late David S. Festinger, Ph.D. Dr. Festinger was a pioneer in the field of addictions research. He was also a devoted scholar, clinician, professor, husband, and father.

CONTENTS

Acknowledgments

CBT Treatment for Opioid Use Disorder (OUD)

Learned Behavior

Functional Analysis

Skills Training

Nine Core Principles

Assessment & Ongoing Monitoring

Recommended Timeline for Administration

Measures of Substance Use

Measures of Mood

Additional Measures

Specific Interventions & Approaches

Overview of CBT Treatment Manual for OUD

CBT Session Structure for OUD

Therapeutic Priorities

Module 0: Biopsychosocial & Risk Assessment

Module 1: Introduction & Exploration of Goals

Module 2: Identifying Triggers to Substance Use/Functional Analysis

Module 3: Values & Mindfulness

Module 4: Coping with Craving & Activity Scheduling

Module 5: Identifying Automatic Thoughts & Cognitive Distortions

Module 6: Evaluating Thoughts & Generating Alternatives

Module 7: Peer & Other Social Support

Module 8: Refusal Skills & Assertiveness

Module 9: Identifying & Preparing for High-Risk Situations

Module 10: Disease Prevention & Seemingly Harmless Decisions

Module 11: Problem Solving

Module 12: Medication for Opioid Use Disorder & Reflection

Appendix A: Optional Module—Pain Management

References

About the Author

CBT TREATMENT FOR OPIOID USE DISORDER (OUD)

This manual provides a structured, evidence-based, brief (12 modules) approach to delivering cognitive-behavioral therapy (CBT) that is tailored to the needs of adults with opioid use disorders (both prescription and illicit opioid use). It was designed to bridge an immediate gap identified by scholars and clinicians in the field for a CBT approach that considers aspects of treatment that may be unique to clients with OUD.

Background

The opioid epidemic is a severe public health issue in the United States. In addition to the high rates of overdose and mortality, OUD is associated with several psychiatric and medical comorbidities, including post-traumatic stress disorder, mood and anxiety disorders, and the transmission of infectious diseases including HIV and hepatitis C (Hassan et al., 2017; Martins et al., 2012; Zibbel et al., 2018). Further, individuals with OUD are at an elevated risk of experiencing certain significant life stressors, including housing instability and homelessness, unemployment, and insurance access issues (Han et al., 2017; Iheanacho et al., 2018).

In response to this public health crisis, clinicians, researchers, government agencies, and legislative bodies have worked to increase OUD treatment access and utilization, including establishing federal funding mechanisms to expand treatment capacity. However, treatment engagement can be a complex process for individuals with OUD; studies suggest that the vast majority of individuals with OUD do not receive treatment (Becker et al., 2008; Saloner & Karthikeyan, 2015).

Unlike most other types of substance use disorders (SUDs), there are effective medications for the treatment of OUD, including agonists (e.g., methadone, buprenorphine) and antagonists (e.g., naltrexone). Systematic reviews, including one conducted by the American Society of Addiction Medicine (ASAM, 2013), demonstrate that medications for opioid use disorder (MOUD) are both cost and clinically effective in reducing opioid use, opioid-related withdrawal, and cravings. Although medications are viewed by ASAM and governmental agencies as the standard of care, they are not a panacea (Substance Abuse and Mental Health Services Administration [SAMHSA], 2021). Problems with medication adherence and retention in treatment are common as is ongoing substance misuse (Moore et al., 2016). Unlike medication-only or drug-free approaches (e.g., 12-step programs), CBT has the potential to complement and enhance the use of MOUD and to help address these concomitant issues. Given the widespread use of MOUD and the availability of OUD medications in office-based primary care settings, a tailored approach to providing CBT to this population is needed. Although OUD shares similarities with other SUDs, it is different from most SUDs in a number of ways. Specifically, effective medications are available for its treatment, the severity of withdrawal symptoms, and the fact that opioids are available in both prescription and illicit forms.

Psychosocial interventions can be an important part of recovery-oriented treatment, yet there is little empirical evidence regarding which psychosocial treatments work best in conjunction with OUD medications (Dugosh et al., 2016). Dugosh et al. (2016) conducted a systematic review on the effectiveness of psychosocial interventions in the context of agonist maintenance treatment for opioid addiction, including CBT-based interventions, and found mixed results supporting the efficacy of standard CBT in reducing opioid use and improving psychosocial functioning. In addition, the review found mixed support for standard CBT as a function of type of opioid problem (i.e., prescription vs. heroin). In general, the research literature supports the need for a CBT approach that is tailored more specifically to the needs of clients with OUD and the unique factors associated with opioids.

What are Opioids?

Opioids are a class of substances that have the potential to induce a variety of somatic and psychotropic effects on the brain and body, including relief of pain (analgesics) and euphoria. Endogenous opioids are organically produced within the body (e.g., endorphins), while exogenous, natural, opioids are derived from the poppy plant and include medications such as morphine and codeine. Exogenous, semi-synthetic or synthetic, opioids include fentanyl, oxycodone, hydrocodone, heroin, tramadol, and methadone, among others. Given the high addictive potential of opioid medications, prescribing is highly regulated through prescription drug monitoring programs (PDMPs). Unfortunately, however, some opioid medications prescribed and sold legitimately are then diverted and sold illegally; additionally, these medications may also be illicitly manufactured and sold.

In the body, opioid receptors are present in the central and peripheral nervous systems and in the gastrointestinal tract. Opioids have a high potential for addiction, particularly in individuals who use opioids for extended time periods. Individuals who use opioids may experience the need to use increasing amounts of opioids (tolerance) to produce desired physical or psychological effects, commonly pain relief or euphoria. Additionally, opioid users may become physically dependent on these substances, characterized by the emergence of notable aversive symptoms when opioid use is discontinued (withdrawal), including muscle aches, nausea or vomiting, chills, sweating, restlessness or insomnia, abdominal cramping, or diarrhea. The severity of this dependence can be extreme, even when compared to other substances with high addiction potential, setting the stage for the need for a multifaceted approach to treatment that addresses both the physiological and psychological sequelae of opioid dependence.

Opioid use is associated with a high risk for fatal and non-fatal overdose given that opioids can slow breathing and induce respiratory distress. Further, heroin may contain illicitly produced fentanyl, which is 50–100 times more potent than morphine and one catalyst for the high overdose rates in individuals with opioid use disorder. Naloxone, however, can instantly restore breathing and reverse an opioid overdose. We recommended that clinicians utilizing this manual complete training for naloxone administration and consider having this medication readily available when treating clients with OUD. Further, clinicians utilizing this manual may benefit from reviewing SAMHSA’s Opioid Overdose Prevention Toolkit to prepare for potential client overdose episodes (Substance Abuse