Chronic Pain Management with Addiction: It’s a Tightrope Act (Part II)

Addressing Pseudoaddiction

An important point to remember is that, even though pseudoaddiction looks like addiction, it is actually caused by an undertreated or mistreated chronic pain condition. However, the treatment plan for pseudoaddiction 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.

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

Sharon responded well to Maxalt, but she was also put on a preventative medication called Migranal. Ergotamine medications such as DHE and Migranal are used as vasoconstrictors for migraine prevention and are 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, Sharon’s migraines were now being effectively managed.

As we began to implement a cognitive behavioral therapy treatment plan for Sharon’s depression, and pain-focused psychotherapy for pain management, her pain management doctor also prescribed Lexapro, an SSRI antidepressant. 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. The lack of a team member who understood family system dynamics was also a big part of Sharon’s suicide attempt.

It Takes a Multidisciplinary Team

As we see from Sharon’s experience, it is very important to work with an integrated multidisciplinary team and perform assessments to determine if a patient is experiencing addiction or pseudoaddiction when chronic pain and coexisting addictive disorders are present. Sharon’s correct diagnosis was pseudoaddiction — not addiction, as everyone thought.

My work with Sharon’s family included educating them about the differences between pseudoaddiction and addiction, as well as the impact Sharon’s attempted suicide had on them. Once Sharon was placed on an appropriate migraine medication management plan, along with cognitive behavioral therapy to address her psychological pain symptoms, her quality of life improved dramatically; her migraine episodes lessened both in frequency and intensity.

When coexisting conditions occur, the family problems increase synergistically. Effective treatment can be challenging and confusing for therapists and healthcare providers inexperienced with pain disorders or addiction, but especially for patients and their families. That is why Sharon’s treatment plan included several family sessions in order to ensure that everyone’s issues were adequately addressed.

Effective treatment can be challenging and confusing for therapists and healthcare providers inexperienced with pain disorders or addiction, but especially for patients and their families.-Stephen Grinstead

Collaboration Not Competition

However, there is a systemic problem that can sabotage effective treatment for anyone with an addiction problem, but especially people with chronic pain and coexisting disorders. It’s called Competition! In my experience of working with this population, an integrated, multidisciplinary treatment approach is essential to the success and effectiveness of pain management recovery. But everywhere throughout society, competition reigns supreme: in politics, sports, and relationships.

It’s fundamental to our American economy and the foundation for every reality program on TV today. Regrettably, in the treatment field, it often develops into “Turf Wars” between healthcare disciplines. Unfortunately, one by-product of this mentality is the conclusion held by pain management specialists that there is no need for family systems trained psychotherapists to be included on a multidisciplinary pain treatment team.

This is not only shortsighted, it can also sabotage effective treatment for patients who are working with a therapist.

Let’s Move Out of the Problem and Into the Solution

The Addiction-Free Pain Management® (APM) Treatment System addresses the whole person, which means treatment plans that include the biological, psychological, social, and spiritual domains, as well as family members and significant others. We need to work with patients — not on them. We need to teach them how to be the Captain of their own healthcare team that includes integrated multidisciplinary treatment members. APM™ treatment starts with a multidisciplinary assessment including medical, mental health and addiction. These three disciplines are necessary to implement the three core components of the APM™ Treatment System.

For integrated multidisciplinary teams to work effectively with this population, I believe that they need to understand and assimilate the principals of the APM™ Treatment System into their treatment protocols, which consists of three major components:

• A medication management plan
• A cognitive-behavioral treatment plan using eight Core Clinical Exercises from the Addiction-Free Pain Management® Workbook
• A proactive nonpharmacological pain management plan. (Most pain patients need a strategic combination of all of the above.)

Understanding and Addressing Chronic Pain with Coexisting Addiction

Another former patient of mine, 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 ultimately 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 physical or psychological pain symptoms. Not only will it increase or amplify the pain signals (the pain-rebound effect), it can also cause an extreme sensitivity to pain, a condition called opioid induced hyperalgesia. The end result is severe biopsychosocial pain and increased problems.

Jeanie eventually became addicted to her medication and the long term use of opioids increased her pain (opioid-induced hyperalgesia). Her medication use 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 that addressed both conditions.

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

• 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 to decrease the risk of triggering a relapse.
• Core Clinical Processes: Jeanie also needed to learn how to deal with her irrational thinking, uncomfortable emotions, and self-defeating urges and behaviors, as well as the isolation tendencies that often 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 as her other 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, etc. I also suggested that she obtain and read Managing Pain Before it Manages You (2001), a book by Dr. Margaret Caudill, which Jeanie found very helpful. Jeanie also used both 12-Step and chronic pain support groups, which greatly enhanced her recovery.

Developing an effective treatment plan meant making sure that Jeanie understood which stage of the addiction process she was in. It was also important for her to understand how much damage had been done through her inappropriate use of pain medication. And as she progressed in treatment,Jeanie learned how to identify which stage of the developmental recovery process she was in, and how to implement the appropriate treatment interventions.