Chronic Pain Management with Addiction: It’s a Tightrope Act
People living with chronic pain can get very frustrated when they aren’t receiving the pain relief they want and deserve. I know because I’ve lived with chronic pain for a long time and when I experience a pain flare up, I want the pain to stop – now!
An Instant Relief Culture
People in pain have come to expect instant relief through pharmaceutical advertising or TV commercials – they want it and they want it now! But when pain medications, which were developed for acute pain, are used for chronic conditions, people frequently run into trouble. While acute pain medication can give them the relief they are looking for, it can also set them up to expect a quick fix and experience potential problems in the future.
Knowing the difference between appropriate and effective use of pain medication, as well as the beginning stages of abuse, is sometimes difficult to determine. Even so, there are some things to look out for that include:
- Medication dependency
- Medication abuse
The confusion and uncertainty of this progression can be a challenge for the person in pain, but it’s also challenging – and sometimes frustrating – for their treatment providers.
Some people living with chronic pain are afraid to take their psychoactive pain medication (opiates, benzodiazepines etc.) because they have heard horror stories of people becoming addicted to their pain medication. This leads to a decision to under-medicate, live in pain, and suffer. If someone is in recovery for alcoholism or any other drug addiction, the problem is even worse. If they under-medicate, it could trigger a relapse when they end up suffering and then try to manage their pain with inappropriate interventions. Or they overmedicate which could lead to a rapid tolerance buildup and finally a reactivation of their addiction and relapse.
An addictive disorder can be defined as a collection of symptoms (i.e., a syndrome) that is caused by a pathological response to the ingestion of mood-altering substances with the following ten major characteristics:
- Inability to Abstain
- Addiction Centered Lifestyle
- Addictive Lifestyle Losses
- Loss of Control
- Continued Despite Problems
- Substance Induced Organic Mental Disorders
Major Changes in the DSM-V
Some long awaited changes occurred under the Substance Use Disorder Category in the new edition of the Diagnostic and Statistical Manual of Mental Disorders. The latest DSM-V eliminates the disease categories for “Substance Abuse and Dependence” and replaces it with a new “Addictions and Related Disorders” classification.
Like many other addiction professionals, I believe that eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and the normal responses of tolerance and withdrawal that some chronic pain patients experience when using prescribed medications which affect the central nervous system.
Charles O’Brien, M.D., Ph.D., chair of the APA’s DSM Substance-Related Disorders Work Group says the following in regards to the new DSM-V:
“The term dependence is misleading, especially for people on chronic medication management, because people confuse it with addiction, when in fact the tolerance and withdrawal that patients experience are very normal responses to prescribed medications which affect the central nervous system.”
Dr. O’Brien also states:
“On the other hand, addiction is compulsive drug-seeking behavior which is quite different. We hope that this new classification will help end this wide-spread misunderstanding.”
Differentiating Between Addiction and Pseudoaddiction
No one currently in treatment for chronic pain has an intention of becoming addicted to their pain medication; nevertheless, it happens at least ten 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, then they are at much 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 doctor shopping can begin.
Many questions need to be addressed when assessing chronic pain and coexisting substance use disorders. At my Addiction-Free Pain Management® trainings, there are three very important questions I pose to participants:
- Are we managing pain but fueling the addiction?
- Are we treating the addiction but sabotaging the pain management?
- Is it addiction or pseudoaddiction?
The first two questions highlight the biases of treatment disciplines, specifically the Medical and Addiction communities. I have long advocated for collaboration that concurrently treats both the substance use disorder and chronic pain disorder. In fact, I have found that it takes a multidisciplinary integrated treatment team to address the complex nature of pain and coexisting disorders.
The term pseudoaddiction is fairly new to the addiction treatment field, but has been used in pain management treatment for quite some time. It describes patient behaviors that may occur when pain is under-treated or mistreated. People with unrelieved chronic 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. Pseudoaddiction can be distinguished from true addiction, in that the behaviors will resolve once the pain is effectively treated.
- Pseudoaddiction 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
Working With Those Labeled Prescription Drug Addicts
I have worked with many patients over the years that were labeled prescription drug addicts, but what I found after working with them is that the appropriate diagnosis was actually pseudoaddiction. One of the assessment tools I developed helps in making this differentiation. APM Module One:Understanding and Evaluating Your Chronic Pain Symptoms, evaluates the ratio of physiological to psychological pain symptoms a patient is experiencing.
This instrument has been one of the most requested by treatment providers when there is a question about whether addiction versus pseudoaddiction is present. Another indication of possible pseudoaddiction is co-existing disorders such as depression and a trauma history. In fact, 100 percent of the patients I see with a chronic pain condition and an addictive disorder also have preexisting trauma which must be addressed concurrently.
Following is an example of how damaging an “addiction versus pseudoaddiction” misdiagnosis can be:
A previous patient of mine, 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. Up until her chronic pain condition, she had never used any psychoactive prescription medications, either.
Sharon began having infrequent migraine headaches and went to her general practitioner who gave her Vicodin (hydrocodone with acetaminophen) which worked for a time. As the Vicodin began losing its effectiveness, her doctor prescribed OxyContin (extended release oxycodone), but she also used Vicodin for breakthrough pain. As Sharon found out later, she would have been better off using migraine specific medication when she was first diagnosed.
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 receiving appropriate treatment, which 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 kind pain 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 and she needed to check into an addiction treatment program.
Sharon’s family found a program that said they treated pain and prescription drug addiction, which is when her nightmare began. While in detox treatment 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 religious woman.
After Sharon stopped all of her medications, the migraines kept coming back. When she asked for help with them, the program staff accused her of “drug seeking” and suggested that all she needed to do was “turn it over” and work the steps.-Stephen Grinstead
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. In addition, when her family participated in their component of the program, they were not educated about the disease concept as it relates to chronic pain and addiction, nor what their role would be to support Sharon post discharge.
After discharge Sharon was sent home with a letter to her doctor stating that she was an addict and should not be prescribed any opiates. She became depressed and attempted suicide. Sharon’s family finally sent her to a pain clinic I consulted with and wanted her “fixed.” I met with Sharon several times, assessed her case and determined that her diagnosis was not addiction, but pseudoaddiction and developed an appropriate treatment plan. As a Licensed Marriage and Family Therapist I also understood the importance of getting Sharon’s family immediately involved in this treatment plan.
In Part II of the Chronic Pain Management with Addiction: It’s a Tightrope Act series, we’ll talk about addressing pseudoaddiction.
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