Walking the Tightrope of Pain Management and Addiction

When you live with chronic pain, it can be very frustrating when you aren’t getting the pain relief you want. I know that when I experience a pain flare-up, my first reaction is I want it to stop — now! Because many pain medications were developed for acute pain conditions, problems can arise when you use them for chronic conditions. When people are in pain, they often have a need for instant gratification (I want it, and I want it now). While acute pain medication can give them the relief they are looking for, it can also lead them down the path to the quick fix.

Being able to tell the difference between appropriate and effective use of pain medication and the beginning of abuse is sometimes difficult to determine. There are progressive stages of problems that include medication dependency, medication abuse, pseudo-addiction and, finally, addiction. The confusion and uncertainty of this progression can be a challenge for both you and your treatment provider.

Some people living with chronic pain are afraid to take their narcotic (opiates, etc.) medication because they have heard horror stories of people getting hooked on pain pills. This leads to a decision to under-medicate, to live in pain and suffer. If you happen to be in recovery for alcoholism or any other drug addiction, the problem is even worse. If you under-medicate, it could trigger a relapse when you try to manage your pain. Or you could overmedicate, which may lead to a rapid tolerance buildup and, finally, reactivation of your addiction.

Understanding Addiction

In this section, I will use the terms addictive disorders and addiction to discuss what the DSM-IV-TR™ (Diagnostic and Statistical Manual of Mental Disorders; Fourth Edition, Text Revision) classifies as substance use disorders and is also referred to as chemical dependency, orpsychological dependence.

I define an addictive disorder as: A collection of symptoms (i.e., a syndrome) that is caused by a pathological response to the ingestion of mood-altering substances and has 10 major characteristics that I have listed below.

Common Addictive Disorder Symptoms

  1. Euphoria
  2. Craving
  3. Tolerance
  4. Loss of Control
  5. Withdrawal
  6. Inability to Abstain
  7. Addiction-Centered Lifestyle
  8. Addictive Lifestyle Losses
  9. Continued Use Despite Problems
  10. Substance-Induced Organic Mental Disorders

Differentiating Between Addiction and Pseudo-Addiction

No one who is in treatment for chronic pain starts out with the goal of becoming addicted to their pain medication; nevertheless it happens at least 10 percent of the time. If someone has a family member with addiction or mental health conditions, or if they have a personal history of addiction or mental health problems, they are at high risk for racing through the progression of addiction.

People at risk for addiction react differently from the very first experience of taking pain medication. With ongoing exposure, they experience the seeking/reaching stage, at which time they begin to doctor shop. There are many questions to be addressed when treating someone who has chronic pain and coexisting substance use disorders. The three most important ones I talk about at my Addiction-Free Pain Management® trainings are these:

1.    Are we managing pain but fueling the addiction?
2.    Are we treating the addiction but sabotaging the pain management?
3.    Is it addiction or pseudo-addiction?

The term pseudo-addiction is fairly new to the addiction treatment field, but has been used in pain management for quite a while now. The point to remember is that even though pseudo-addiction looks like addiction, it is actually caused by an undertreated or mistreated chronic pain condition. However, the treatment plan for pseudo-addiction and addiction is identical. The major danger of pseudoaddiction is that if it is not adequately addressed, it can turn into full-blown addiction — sometimes quickly, sometimes slowly.

I have worked with many patients over the years who were labeled “prescription drug addicts”, but who were actually suffering with pseudo-addiction. A client, Sharon, was an example of how damaging a misdiagnosis can be. Sharon was in her early forties and came from a fairly normal and religious upbringing. She had never used alcohol or any other drugs, including nicotine, and, up until her chronic pain condition, had never used psychoactive prescription medications either.

Sharon began having infrequent migraine headaches and went to her general practitioner who gave her Vicodin, which worked for a time. As the Vicodin began losing its effectiveness, her doctor prescribed OxyContin, but she also used Vicodin for breakthrough pain. Sharon later found out that she would have been better off using migraine-specific medication from the start.

Although barbiturates and opioids are sometimes considered effective for short-term migraine relief, many doctors are now recommending against prescribing this type of medication for long-term use. The risks for potential dependence and abuse are too high, and there is a real danger of developing medication overuse headaches (sometimes called pain rebound or transformed migraines).

Because transformed migraines are difficult to diagnose, many people are not being treated appropriately. Treatment is further complicated by the chronic nature of migraine headaches. People with transformed migraines may overuse pain relievers, both prescription and over-the-counter, on a daily basis with or without having a headache. This puts them at risk for building a tolerance to the drugs. Additionally, taking too many pain relievers containing caffeine can also lead to rebound headaches.
As Sharon’s migraines became more frequent, she began taking more and more medication to get any relief. As the dose increased, her family and then her doctor became concerned that she had become addicted to the OxyContin and Vicodin. Sharon’s doctor told her he couldn’t help her anymore unless she went into an addiction treatment program.

Sharon’s family found an addiction treatment program that said they treated pain and prescription drug addiction, which is when her nightmare began. While undergoing detoxification from the OxyContin and Vicodin, Sharon was forced to stand up in front of groups and identify herself as a drug addict. She was not even allowed to say she was a prescription drug addict, which was humiliating for this very conservative woman.

After Sharon stopped all of her medications, the migraines kept coming back. To add insult to injury, when she asked for help with the migraines, the program staff said she was “drug seeking” and all she needed to do was “turn it over” and work the steps. Even though I’m a big advocate of a 12-Step approach for people with addictive disorders, it can be dangerous to label or advise chronic pain patients in this manner.

Sharon was discharged from this program with a letter to her doctor stating she was an addict and should not be given opiates anymore. She became depressed and attempted suicide. Sharon’s family finally sent Sharon to the pain clinic where I was consulting. I met with her several times, assessed her case and discovered that her diagnosis was not addiction, but pseudo-addiction.

Addressing Pseudo-Addiction

As mentioned above, pseudo-addiction describes patient behaviors that may occur when pain is under-treated. People with unrelieved pain may become focused on obtaining medications, clock watch or otherwise seem to be inappropriately drug-seeking. Even such behaviors as illicit drug use and deception can occur in the person’s efforts to obtain relief. Pseudo-addiction can be distinguished from true addiction in that the behaviors will resolve once the pain is effectively treated.

  • Pseudo-addiction looks a lot like addiction
  • Patients may appear to be “drug-seeking”
  • Patients may need frequent early refills
  • Behaviors are caused by under-treatment
  • Problematic behaviors resolve when the patient’s pain is adequately treated

As this was the case for Sharon, the pain clinic prescribed migraine-specific medications, since opiates are contra-indicated for ongoing migraine treatment. There are seven triptans (Imitrex, Maxalt, Zomig, Amerge, Axert, Frova and Relpax) that were developed for and FDA approved as migraine abortive (management) medications. These medications work to stop the migrainous process in the brain and stop an attack with its associated symptoms.

Sharon responded well to Maxalt, but she also was put on a preventative medication called Migranal. Ergotamine medications, such as DHE and Migranal, are used as vasoconstrictors for migraine prevention and sometimes mixed with caffeine. They are also FDA approved for migraine treatment, as is Midrin (a combination of acetaminophen, dichloralphenazone, and isometheptene). Because of these two medications, her migraines were now effectively managed.

Sharon was also prescribed an SSRI antidepressant as we began to implement a cognitive behavioral therapy treatment plan for the depression and pain-focused psychotherapy for pain management. Today Sharon is experiencing a great quality of life, but still has nightmares about her time at the treatment program. Getting back to my original three questions: Sharon’s general practitioner risked fueling an addiction, and the addiction treatment program definitely sabotaged her pain management.
It is important to work with a multidisciplinary team and get assessments to determine if you are experiencing addiction or pseudo-addiction when you have chronic pain and coexisting addictive disorders. Sharon experienced pseudo-addiction — not addiction as everyone thought. Once she was placed on an appropriate migraine medication management plan, along with cognitive behavioral therapy to address the psychological pain symptoms, Sharon’s quality of life improved dramatically and her migraine episodes lessened both in frequency and intensity.

Understanding and Addressing Chronic Pain and Addiction

Pain is the reason many people start using potentially addictive substances. Jeanie is an excellent example of what can happen when a pain condition is not managed appropriately and treatment depends only on medication.

We know that regular use of psychoactive medication, plus a genetic or environmental susceptibility can lead from pain relief to increased tolerance. Both of Jeanie’s parents were alcoholics, and she was in an abusive marriage. She developed a chronic pain condition and was prescribed opiate medication to treat her pain. Jeanie soon discovered that her pain medication also helped her escape from painful childhood memories and the trauma of an abusive relationship.

Eventually Jeanie’s medication no longer helped with the physical pain symptoms or her emotional distress, so she started taking much more than was prescribed. She eventually went to several different doctors to get the amount she believed she needed, but her pain continued to get worse. In fact, Jeanie’s medication started to increase or amplify her pain signals — this is called the pain-rebound effect.

Physical pain is the reason many people like Jeanie start using potentially addictive substances. Chronic medication use, plus genetic or environmental susceptibility can lead to increased tolerance as a result of searching for pain relief. Eventually, the addictive substance no longer manages the pain symptoms. Not only will it increase or amplify the pain signals, it can also cause an extreme sensitivity to pain, a condition called hyperalgesia. The end result is severe biopsychosocial pain and problems.

Jeanie did become addicted to her medication, which increased her pain and created problems in every area of her life: physically, psychologically and socially (biopsychosocial). Because Jeanie was experiencing both chronic pain and substance dependency problems, she needed a specialized, concurrent treatment plan for both conditions.

An effective synergistic treatment protocol for Jeanie’s chronic pain and substance addiction condition included the three following components:

  • Appropriate Medication Management
  • Core Clinical Processes
  • Nonpharmacological Interventions

Appropriate Medication Management: Jeanie’s medication management plan included collaborating with an addiction medicine practitioner/specialist. This person made sure that her medication was needed, was recovery-friendly and was the right type, as well as the appropriate quantity and frequency, so it would not trigger relapse.
Core Clinical Processes: Jeanie also needed to deal with her irrational thinking, uncomfortable emotions and self-defeating urges and behaviors, as well as the isolation tendencies that can develop with co-existing pain and addiction. I used a cognitive behavioral therapy approach using the eight clinical processes in the Addiction-Free Pain Management® Workbook as a starting point, which worked well since her health care provider was experienced in the concurrent treatment of chronic pain and substance dependency.

Nonpharmacological (Holistic) Interventions: I supported Jeanie to search out alternative non-pharmacological/holistic pain management modalities such as hydrotherapy, physical therapy, acupuncture, chiropractic, prayer, meditation, hypnosis, self-hypnosis and so on. I also suggested she read Managing Pain Before It Manages You (2001), a book by Margaret Caudill, which was very helpful for her. Jeanie also used both a 12-Step group and a chronic pain support group, which greatly enhanced her recovery.

Knowledge Is Power

Developing an effective treatment plan also required that Jeanie understand which stage of the addiction process she was in. It was also important for her to know how much damage had been done by her inappropriate use of pain medication. As Jeanie progressed, she learned how to identify which stage of the developmental recovery process she was in, and then implemented appropriate treatment interventions.

As you can see, the road to recovery can be a difficult one for someone with both chronic pain and a coexisting addictive disorder. However, most of the chronic pain research I have reviewed over the past two decades has been very clear about treatment outcomes. The best prognosis is when people are proactive in their own treatment and recovery process. One way they can do this is to learn as much about their pain and effective pain management as they can.

As the title of this section stated, knowledge is power. Once people understand what is really going on with their body and mind, they can take action to effectively manage their pain. In fact, the most important shift they can make is to stop believing that pain is their enemy and accept it as their friend.

Jeanie looked at me like I was crazy when I suggested that she make peace with her pain and that pain is her friend; she had a very difficult time accepting that. Even so, it is true. It was very important for Jeanie to stop seeing herself a victim of her pain condition and empower herself by developing a pain management and chemical dependency recovery program. Fortunately, Jeanie adhered to her treatment plan and remains clean and sober, as well as effectively managing her chronic pain.

The Relapse Intervention Plan

While walking the tightrope of pain management and addiction, it’s important to make sure patients have a safety net in case they fall. I call this the relapse intervention plan, which must be developed with the patient before moving into the three-part treatment process explained above.
This is their insurance policy. People don’t buy auto insurance because they plan to crash into other vehicles. They have it just in case. The relapse intervention plan should be a mandatory component of a treatment plan for anyone with chronic pain and coexisting disorders; especially addiction.

In its simplest form, developing a relapse intervention plan consists of writing out a specific plan for the following three questions.

  1. What is your healthcare provider supposed to do if you relapse, stop coming to sessions or fail to honor your treatment or medication management contract?
  2. What are you going to do to get back in recovery if you start inappropriately using pain medication (including alcohol) or other drugs or other ineffective pain management so that you can stop using before you hit bottom?
  3. Who are three significant others who have an investment in your recovery? What is each of them supposed to do if relapse occurs? Make sure you have their day and night phone numbers accessible and they have a copy of this plan.

The premise here is simple: Those who fail to plan, plan to fail. I believe that positive treatment outcomes are possible if people have a three-part, multidisciplinary treatment plan, are committed to being active participants in their treatment process, and they develop a relapse intervention insurance policy — especially when walking the tightrope of pain management and addiction.

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