According to research published in Pain Physician Journal as recently as 2006, 90 percent of people in the US receiving treatment for pain management were prescribed opiate medication. Of that number 9 to 41 percent had opiate abuse/addiction problems. The research also stated that 16 percent of pain management patients experienced illicit drug use along with their prescribed medication, and as high as 34 percent in other research they reviewed. These numbers illustrate the overall problem of chronic pain abuse/addiction problems in the general population. What is harder to quantify is the extent of this problem in the recovering community.
Whenever I asked the following question at trainings, “How many of you know someone in long-term recovery who has relapsed over pain management issues?” most of the audience raises their hands. The reasons vary, but more often than not they either take the wrong medication or too much. Others try to tough out the pain and end up relapsing back to their original drug of choice.
Living with chronic pain is difficult for anyone, but especially for someone with coexisting abuse, addiction or other psychological disorders. They can become severely depressed and discouraged. Healthcare providers often become confused and frustrated when their treatment interventions are ineffective and frequently blame their patients. The problem of managing pain and medication in recovery continues to grow and healthcare professionals are left with the challenge of how to effectively address it. Given the biopsychosocial nature of addiction and chronic pain, it is imperative to understand both conditions and implement a multidisciplinary treatment plan.
People in recovery living with chronic pain need to educate themselves about their particular type of pain and any research that supports currently available treatments. They need to be proactive in evaluating health practitioners’ pain management claims when they recommend only their particular treatment intervention to address pain, whether it’s medication management, psychotherapeutic techniques, chiropractic adjustments or acupuncture. True multidisciplinary pain management would probably include these if indicated for an individual’s pain disorder, but others as well. For example, physical therapy, massage, biofeedback, occupational therapy, exercise physiology, consulting an anesthesiologist or pharmacologist, and utilization of a case manager—ideally these would be offered all at one site. Some people have found it helpful to incorporate movement therapy such as Tai Chi, classes on spiritual wellness, yoga or meditation.
Anyone in recovery from an addictive disorder is at risk for a relapse episode, but for people also living with chronic pain that risk is much higher. Over the past 25 years I have seen far too many recovering people relapse because of poor medication management plans. This population needs a particular type of primary treatment that addresses coexisting psychological disorders including addiction, as well as relapse prevention protocols that include effective medication management. This is one of the reasons why I developed the Addiction-Free Pain Management® System and have taught it to treatment professionals around the country.
In my work I have found that many addiction treatment programs teach relapse prevention in one form or another, but almost nothing has been done to apply these protocols to pain management. I have also noticed that there continues to be confusion and misunderstanding about what relapse is, particularly related to pain management and what to do about it. To help provide some clarification, the remainder of this article offers a definition of relapse, how it happens and how to prevent people from entering the relapse cycle or stopping it quickly should it occur.
If you ask someone in recovery from an addictive disorder what “relapse” means, they will most likely say it means taking something or going back to using their drug of choice. When you ask someone in pain management, they might say they quit working an effective pain management program and their pain condition deteriorates. For someone with both an addictive disorder and chronic pain it can be either or both explanations. The most common meaning of relapse is that a person slips back into their addiction. While this definition is partially correct, the full explanation of relapse is much more complex.
What many people don’t realize is that the chemical use or self-defeating pain management behaviors are the final stage of a relapse process, not the beginning. In addition, relapse is a common symptom of chemical dependency—one-third to two-thirds of all recovering alcoholics/addicts relapse despite their best intentions not to.
For people in recovery with pain management issues, the relapse rate can be even higher because pain flare ups often become a relapse justification and can amplify Post Acute Withdrawal Symptoms. Fortunately, this stunning statistic can be lowered if people in recovery who also have chronic pain are exposed to education and training about relapse prevention and nonpharmacological pain flare up planning. Prevention is much easier than crisis management.
Relapse education must start with a new definition of relapse. The one I like to use is: Relapse is a progressive series of events that takes someone from stable recovery to a state of becoming dysfunctional in their recovery. When someone starts on the slide to relapse they undergo many changes.
The first change is a return to denial that often involves situations such as job stressors, arguments with significant others, financial or health issues. This leads to thinking problems. Now instead of responsible recovery-prone, positive thinking, there is relapse-prone negative thinking and even euphoric recall. Euphoric recall is remembering how good the pain medication used to work and how awful it is without it now. This negative thinking leads to uncomfortable and/or painful emotions. These feelings produce self-defeating urges which are often followed by self-destructive behaviors. Inappropriate medication use, including alcohol or other drugs, may not be an option in the early stages of relapse, but these self-destructive behaviors often set the person up to experience more problems and eventually a return to a chemical solution.
One of the biggest relapse triggers for someone in early recovery is their inability to recognize and/or cope with the serious symptoms of protracted or post-acute withdrawal (PAW). For someone in recovery with chronic pain and medication abuse/addiction problems these symptoms can be much worse. PAW is a series of biological and psychological symptoms that everyone in chemical recovery goes through. The brain chemistry is adapting and healing from the long term toxic affects of psychoactive substance use. There are six major symptoms of PAW:
- Thinking changes
- Emotional changes
- Sleep disturbances
- Short-term and long-term memory problems
- Coordination problems
- A sensitivity to stress
A great book that describes the symptoms of PAW and how to develop a strategic treatment plan to address them is Terence T. Gorski’s Staying Sober. The steps for managing PAW are also very useful for improving pain management. For example, stress management is a crucial component of a PAW treatment plan; and we know that if people living with chronic pain can lower their stress levels, it will also decrease their pain symptoms.
When a person is beginning to recover they need to learn new tools as they shift from an addiction centered life-style to a recovery-centered one. In the same way, when someone is trying to remain in recovery they need to learn all they can about the sobriety-based symptoms of an addictive disorder and begin using new recovery tools. One way to develop a new tool kit is through education. I believe that a recovering chronic pain person would benefit from and increase their chances of preventing relapse by reading the, Addiction-Free Pain Management Recovery Guide: A Guide to Managing Pain and Medication in Recovery, which describes how to develop a relapse prevention plan that addresses both a chronic pain condition and an addictive disorder.
There are some simple tools available to help improve the quality of recovery for someone living with chronic pain and lessen the risk of relapse such as learning how to develop a healthy, balanced life-style. This would include things like a healthy eating plan, exercising, identifying and managing uncomfortable emotions, challenging negative thinking, avoiding high risk people, places, and things, and developing a healthy spiritual connection.
Another important task is the ability to identify and manage high risk situations and relapse warning signs, as well as developing a relapse prevention network for both the addictive disorder and the pain condition. Often this can be done with the help of a 12-Step support group and/or a chronic pain support group, but may also include work with a relapse prevention specialist, who is also knowledgeable about chronic pain, in order to increase the chances of life-long sobriety and quality pain management.
Like many other things in recovery, relapse prevention is simple—but not easy. Although relapse prevention is an inside job, that does not mean you have to do it alone. Help is out there for those who want it. Please remember, Knowledge is Power, the more you know the more you grow.