Author: Nancy Swezey, RN

Recovery from addiction means reaching your greatest potential with maximum independence. Cognitive behavioral therapy (CBT) is a type of psychotherapy that challenges your habitual thoughts and actions to help you create a healthier life. Growing evidence shows that CBT for opioid addiction is an effective tool to help those in recovery.¹

What is Cognitive Behavioral Therapy?
Cognitive Behavioral Therapy Techniques
CBT for Opioid Addiction

What is Cognitive Behavioral Therapy?

Cognitive behavioral therapy is a psychological model created by Aaron Beck that helps you challenge thoughts, feelings, and actions that create distress or problems in your life. Beck believed that it is not your experiences that cause distress, but how you interpret them.¹ CBT looks at how you assign meaning to your experiences and respond to these interpretations.²

Classic psychotherapy relies heavily on using your past to understand your current experiences and to engage in the ongoing resolution of unconscious drives.¹ CBT is not concerned with your past or the root causes of your problematic thinking and behavior as much as it seeks to change your maladaptive assumptions.¹

Treatment involving CBT is time-limited, typically lasting between 8-24 weeks, with the goal of empowering you to independently recognize and challenge maladaptive interpretations of your experience.² Although there is a lot of variation in practice, classical CBT has a predictable course.

During the first few sessions, the therapist is the more active participant, facilitating the initiation of therapy, which involves:^(1,2)

• Creating a healthy relationship between you and your therapist. “Therapeutic alliance” is an essential component of progress in CBT.
• Identifying particular issues to address
• Helping you understand why your problems may be related to unhealthy mental habits
• Learning new strategies to start to get relief

As treatment progresses, you become more active, taking on the primary role in the relationship. This phase consists of:²

• Shifting from simply finding relief to changing your underlying negative patterns
• Doing homework between sessions to assess and change problematic patterns
• Beginning to identify problems on your own and develop solutions

Cognitive Behavioral Therapy Techniques

Cognitive behavioral therapy techniques work as tools to help you recognize and challenge false or negative perceptions. A cornerstone CBT principle is the understanding that undue stress caused by false beliefs, or “cognitive distortions,” leads to behavioral patterns that create additional problems. This can feed a cycle of ongoing troublesome thoughts and actions.

Different CBT techniques are employed according to the stage of change you’re in and the level of care you’re receiving.¹

Stages of change include:¹

• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Relapse

Of course, relapse is not a necessary stage in addiction recovery, but for some, it is a natural part of the recovery process.

Examples of CBT techniques particularly effective for opioid addiction include:¹

• Cost-benefit analysis: a technique that helps you decide what your goals of therapy are, and what tools might be helpful to you
• Relaxation techniques: breathing exercises, meditation, and body awareness
• Mindfulness: a method of controlling your attention and returning to the present moment
• Distress tolerances: attitudinal shifts in learning to accept what can’t be changed and taking action to alter what can be
• Distractions: self-initiated activities and mental exercises to shift your focus
• Emotional regulation: an approach that incorporates mental skills and environmental factors that can help stabilize emotions, such as a wholesome diet, regular exercise, and good sleep hygiene
• Identifying values: an exercise to help you make critical decisions when you clarify your goals and what matters to you
• Activity scheduling: a way to look at how you spend your time to make progress toward your goals and to enjoy your recovery
• Socratic questioning: challenges you to ask yourself about what evidence supports your assumptions (e.g., “I have to use opioids to feel comfortable), and alternative ways of looking at the situation

CBT for Opioid Addiction

As CBT has gained popularity, studies have confirmed its usefulness in the treatment of addiction. Many of the studies evaluating CBT for opioid addiction look at how it can enhance adherence to one’s treatment plan and help prevent relapse.³

CBT for opioid addiction specifically aims to promote:¹

• Physiological healing
• Peace of mind
• Emotional stability
• Positive decision-making
• Clarifying your values and goals
• Finding solutions for relationship conflicts
• Achieving a healthy lifestyle
• Accepting the situation and moving forward
• Harm reduction
• Abstinence
• Handling cravings and urges
• Improved motivation

CBT for opioid addiction borrows from general cognitive behavioral therapy techniques approaches with special attention given to issues related to substance misuse:³ The process for treating opioid addiction with CBT typically occurs as follows:

1. The initial stages of CBT for opioid addiction focus on enhancing your motivation to stick with your recovery plan.
2. Your therapist helps you understand how your social, family, legal, employment, financial, and mental health issues may be related to your addiction.
3. You establish goals and milestones with your therapist to track your progress.
4. In the later stages of CBT for opioid addiction, you learn about coping skills to use when facing triggers for your addiction.
5. You create plans to help you prepare for difficult circumstances that may come up.
6. As you complete your CBT sessions, you focus on finding balance as you move forward into a sober lifestyle.

The Effectiveness of CBT in Opioid Addiction Treatment

As evidenced by the opioid epidemic, treatment for opioid addiction can often come with a number of challenges. Many opioid users face barriers to treatment that increase the difficulty of making progress in their recovery. These include:^(4,5)

• Concurrent emotional problems and mental disorders
• Unfavorable attitudes or beliefs about treatment programs
• A history of repetitive relapse
• Social and personal stressors that must be addressed with abstinence
• Lack of social support and community

That being said, CBT is increasingly a standard tool of treatment for opioid addiction due to its effectiveness in increasing motivation and a sense of self-sufficiency.⁵ Studies show that implementing CBT for opioid addiction treatment can:⁴

• Help prevent relapse
• Improve work function and opportunities
• Reduce emotional stress
• Prevent depression and other mental health problems following treatment

The most important part of CBT is the therapeutic alliance you have with your counselor. This is the foundation for every other tool that CBT asks you to employ. If your therapy is not grounded in a strong connection to your counselor, it is much more difficult to achieve behavioral change.¹ Counselors that use cognitive behavioral therapy techniques are trained to focus on building rapport with patients to optimize their outcomes.⁵

Another therapeutic approach often used as part of CBT is motivational interviewing. Although debated whether it falls under the umbrella of CBT, motivational interviewing is one of the most effective therapeutic tools for treating opioid and other substance addictions.⁵ It is often used as part of CBT-based therapy to help enhance a person’s motivation in recovery.⁵

Action plans are a key component of CBT that require you to do assignments outside of your therapy sessions. Usually, this involves practicing new thought processes and skills that are reviewed during your sessions. In early recovery, action plans may not be as effective as other tools in CBT because you may be focused on more basic needs and logistical changes in your life. After you achieve a certain degree of stability in your recovery process, action plans can especially helpful.⁵

CBT and Medication Management

Many people who go through treatment for opioid addiction require medical oversight and treatment in the recovery process. Medications used in opioid addiction treatment include:⁴

• Methadone: mimics the action of illicit opioids, making withdrawal less painful and getting high on opioids less intense. If stopped abruptly, it can also cause withdrawal and pose a risk for opioid overdose, especially in the first few weeks of treatment.
• Buprenorphine: partially mimics the action of opioids so that, like methadone, it improves withdrawal symptoms and weakens cravings. Because it is only a partial effect, it has a lower risk of overdose. It is often combined with Narcan, as the hybrid medication Suboxone, to discourage opioid use.
• Naltrexone: completely blocks the emotional high and pain-killing effects of opioids. It can trigger withdrawal so you need to finish medically supervised withdrawal before starting this medication.

It is important to understand medication management for opioid addiction in relation to CBT because often medication-assisted treatment alone is not sufficient. Research shows that you will probably need therapeutic support to maintain abstinence and consistency with your treatment.⁵ In fact, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) recommends psychosocial treatments like CBT in its guidelines for the treatment of opioid and other substance use disorders.⁵

According to SAMHSA, adding CBT and other psychosocial treatments to your addiction recovery program can:⁵

• Improve your overall commitment and participation in recovery
• Help you to maintain sobriety
• Assist you in coping with cravings
• Help you develop healthy coping skills

Where CBT is Used for Opioid Addiction

Cognitive behavioral therapy techniques are used in a variety of settings to treat opioid use disorder. Each facility has policies about if and how CBT is implemented to aid in your treatment. In general, CBT is offered in the following recovery treatment settings:^(3,5)

• During inpatient treatment
• As part of partial hospitalization programs
• Individually during intensive outpatient programs
• As part of medically managed outpatient treatment
• Individually with a private therapist
• As group therapy in outpatient settings
• Through peer group support forums such as SMART recovery

CBT for Groups

CBT for opioid addiction is offered both on an individual and group basis. The group format allows for members to share experiences and insights as they apply cognitive behavioral therapy techniques and live without opioids.³ This is facilitated by a CBT-specialized therapist.

How to Find a Treatment Center that Offers CBT

CBT is increasingly offered as a standard component of care during substance use treatment programs. If you are struggling with opioid addiction and need help, look for a treatment center or recovery program that offers CBT.  For help in finding a treatment center that offers cognitive behavioral therapy techniques, call 800-934-1582(Who Answers?) .

References

1. YouTube. (2018). Beck Institute for Cognitive Behavioral Therapy.
2. Beck, A. T., & Dozois, D. J. A. (2011). Cognitive Therapy: Current Status and Future Directions. Annual Review of Medicine, 62(1), 397–409.
3. Pan, S., Jiang, H., Du, J., Chen, H., Li, Z., Ling, W., & Zhao, M. (2015). Efficacy of Cognitive Behavioral Therapy on Opioid Use and Retention in Methadone Maintenance Treatment in China: A Randomised Trial. PloS One, 10(6).
4. National Academies of Sciences, E., Mancher, M., & Leshner, A. I. (2019). Medications for Opioid Use Disorder Save Lives. National Academies Press.
5. Lent, M. R., Callahan, H. R., Womer, P., Mullen, P. M., Shook, C. B., DiTomasso, R. A., Felgoise, S. H., & Festinger, D. S. (2021, May 10). A mental health professional survey of cognitive‐behavioral therapy for the treatment of opioid use disorder. Journal of Clinical Psychology, 77(7), 1607–1613.