Monday, January 7, 2013

Be Not Afraid of CBT

Cognitive Behavioral Therapy (CBT) is a psychotherapeutic approach based on the premise that our thoughts are the primary cause of our behaviors and feelings (vs. events, situtations, environments, other people, etc.)  CBT can help address a range of issues including how we recognize and react to pain.  We're seeing an increasing emphasis on CBT from our reviewing physicians as an alternative treatment pathway for chronic pain patients that are inappropriately utilizing prescription drugs. 

First, a few disclaimers.  I'm not a CBT expert.  I've never personally experienced it nor do I know anyone who has.  And while we've seen plenty of recommendations as of late for CBT, I'm not prepared to declare it a panacea for chronic pain or opioid dependence.  In fact, I'm not sure there is a panacea (and you should look upon anyone that claims to have discovered such a thing with great skepticism). 

That said, for those of us who have realized that long term chronic pain and opioid dependence are much more closely associated with psycho-social issues than with biological issues, CBT offers a potential alternative worthy of exploration.  CBT is goal-oriented, self-driven, and focused on correcting fundamental errors in thinking patterns (patterns like victimization, over-generalization, catastrophizing, focusing on the negative, etc... ever observed any of these in your legacy claim population?)  Several of PRIUM's physician reviewers feel strongly that CBT offers a compelling opportunity to change the course of a currently intractable claim. 

Plus, CBT generally runs anywhere from 6-12 sessions at a cost that ranges from $100-150/hour.  In some cases, the total investment in CBT might be less than you're spending on drugs in a single month. 

There are three significant barriers to CBT acceptance that we've observed:

1) Ignorance: the claims handler doesn't know what it is and would rather not find out... the path of least resistance appears to be continuation of (and payment for) ineffective pharmacotherapy.  This is the minority of cases we see, but still bears mentioning.  And if this is true in your claims organization, let us know.  We can set up an educational session to bring you up to speed (no marketing, we promise).

2) Fear of adding "psych" to the list of compensable diagnoses: Relax.  While CBT is a psychotherapeutic treatment, it is not equivalent to traditional psychotherapy and will not result in additional diagnoses.  CBT is a treatment tool, not a diagnostic tool. 

3) Lack of managed care coordination: Not only do PRIUM's reviewers recommend CBT, but we often find it's one of the few alternatives the treating physician will consider other than the drugs.  We all get excited because the CBT referral at least offers a new path, new potential to get the patient back on track... and then it gets denied through utilization review and the adjuster either isn't authorized to override the denial or doesn't bother to do so.  This is a classic example in work comp of snatching defeat from the jaws of potential victory.

To sum up: I can't offer PRIUM's highest recommendation on CBT.  We have lots of potential candidates and several engaged CBT providers and we're watching cases closely and compiling data where we can.  For now, I can tell you that CBT is relatively inexpensive, low risk treatment modality that's worth a shot for those patients dealing with the typical psycho-social issues that drive the costs and complexity of chronic pain claims.

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  1. Interesting. How we react to pain seems like something that would be very hard to "reprogram" in ourselves. It would be very hard to measure the impact. The people who would benefit most from the therapy would probably be the people who would have had good outcomes anyway.

  2. CBT is specifically being deployed on cases where "good outcomes" aren't happening... and don't even appear to be possible. Patients progressing in functionality and weaning prescription narcotics after short-term use aren't ideal candidates for CBT. Patients who have given up hope of improving, believe the world is out to get them, and would rather sit at home in a narcotic-induced stupor - these are candidates for CBT. Will CBT be successful for every patient that meets that description? Absolutely not. But like I said in the original post, it's a low risk, low cost alternative worthy of exploration.

    1. Thanks for the response. Claim handling is out of my area of expertise, but I am interested in the topic. I'm a WC actuary and I think the more I understand what is driving medical cost at the claim level the better predictions I can make ... maybe.