On the one hand, we repeatedly hear of people in recovery relapsing on prescribed pain medication. On the other hand, people in recovery get cancer, have surgeries, experience trauma, and break bones. In other words, they experience very real, very severe, and very legitimate pain.
This month’s column will explore the human costs of failing to manage a person’s pain, some of the barriers to pain management, and ways to approach pain management for those in recovery.
Human Costs of Unmanaged Pain Cross Multiple Dimensions
Spiritually, a person in intense pain can feel separated from their God or Higher Power. It’s easy for them to feel as though God has abandoned them, or worse yet, is testing or punishing them. Substance abuse is a disease of isolation and loneliness, and the last thing we want is for the person in recovery to feel alone and separated from a primary source of support, comfort, strength, and sustenance.
Emotionally, untreated pain can increase anxiety, fear, distress, despair, depression, hopelessness, and suicidal ideation. It can also interfere with focus, concentration and memory, and lead to a decreased sense of control and/or quality of life.
Socially, pain can limit people’s ability to get to 12-Step meetings, to maintain their Fellowship, and to be of service. It can also increase the burden on their caregivers, and cause their own universe to get smaller and smaller.
Physically, pain can lead to disturbances in appetite and sleep, self-care deficits, disruption in ability to perform sexually, and an inability to participate in rehabilitative procedures. Pain can also lead to fatigue and falls, and other problems.
Barriers to Pain Management
On the prescriber [physician] side, there are:
- Regulatory fears (“If I prescribe too many opioids, the DEA will take away my license.”)
- Fears of being lied to by substance abusers (“The dog ate my morphine; can I get some more?”)
- Fears of creating addiction or causing a relapse
- Lack of training on pain assessment and pain management in general, and specifically in the recovering substance abuser
On the consumer [patient] side, there are:
- Fears that taking any opioid will mean I’ve lost my sobriety
- Failure to take pain medication as prescribed (either “If one is good, three will be great” or “I know it says every four hours, but I’m gonna see if I can make it to six or seven hours“)
- Fears of getting addicted
- Lack of knowledge about how to report one’s pain in a way that is useful
Of course there are cultural and language barriers that may also serve to impede effective pain management.
It is important for recovering persons to remember that pain is one of the most treatable symptoms we experience. This means that in the vast majority of cases, we should be able to eliminate the pain or reduce it to a tolerable level. However, the recovering person with pain must also be aware of some basic reporting techniques that empower the healthcare provider to help them.
It is important for recovering persons to remember that pain is one of the most treatable symptoms we experience.-Jay Westbrook
Keep in Mind:
- You are not “bothering” the doctor or nurse by reporting your pain.
- You’ll need to tell your doctor or nurse:What makes the pain worse?What makes the pain better?What medicine(s) are you taking and do they relieve your pain?
Utilizing a Pain Journal
- It helps to keep a pain journal – a day-to-day record of your pain score using a 0-10 scale.
- Be sure to bring your pain journal along when you have a doctor’s appointment. The information you’ve written in it can be very useful.
- Your pain journal should contain the following information:Where you hurtThe location of your painThe type of pain
How the pain feels
Whether or not the pain “travels” or stays in one spot
How much pain you have (using a rating scale between zero and ten (0-10), with 0 = no pain and 10 = worst pain possible)
Pain Journal Tip:
When keeping a pain journal, you must describe your pain in detail. For example, common descriptors might include:
Sharp and stabbing – Dull, aching and throbbing – Electric, burning and stinging
Pain Management Basics
Some of the most basic principles of pain management include:
- Pain is whatever the patient says it is.
- Recovering substance abusers typically need higher, rather than lower, starting doses to get on top of the pain.
- When pain is inadequately treated, patients will often start self-medicating – taking more of a medication, taking it more often than prescribed, and/or seeing multiple prescribers.
- It is essential for the recovering person to be aware of what the Big Book says on page 133: God has wrought miracles in our physical & mental health, but has also gifted us with wonderful practitioners – the doctor, psychologist, psychiatrist, who can be invaluable to the alcoholic. [paraphrased]
- There are multiple non-opioid approaches to pain that work wonderfully – alone or in concert with one another – for many types of pain, and these should always be the first line approach for recovering substance abusers.
Non-Opioid Pain Treatment Therapies
Recovering substance abusers don’t have to languish in pain. In fact, most can successfully utilize a number of non-opioid pain treatment therapies.
Some of the most commonly utilized alternative pain therapies include: prayer, hypnosis, guided meditation, bio-feedback, acupressure, acupuncture, reiki, visualization, massage, physical therapy, hydrotherapy, ice, heat, topical treatments (lidocaine or capsaicin creams), and non-opioid analgesic and anti-inflammatory medications (oral or injections).
- In cases where opioids are to be prescribed, it is much safer to use extended-release opioids, than to use immediate-release opioids. This is because the extended-release opioids leak a very small amount of medication into the bloodstream every hour for multiple hours, and the patient rarely feels high or altered. With the immediate-release opioid, all of the medication is released at once, and the patient feels high, and the “beast” may well be awakened.
- When opioids are part of the pain management plan, the parents, spouse, and/or sponsor should always be informed of the plan, and may need to hold and dole out the medication.
- When the pain resolves, all pain medication should be immediately disposed of, and not kept of hand “just in case.”
- Anticipate side effects and incorporate a prophylactic approach to their treatment. All opioids cause constipation, and stool softeners and/or laxatives should probably be commenced at the same time as the opioid.
- Stay focused on the primary purpose of pain management – patient comfort and function.
…[recovering patients] should be able to cautiously navigate a bout with pain in which opioids are required – and do so without losing their sober time or their recovery.-Jay WestbrookWhenever possible, opioids should be avoided in the recovering substance abuser, and should certainly be used only after considering non-opioid interventions (see #5, above) to treat the pain. That being said, there are illnesses and situations accompanied by pain so profound that the only way to address it is with opioids.
Employing solid pain management principles can make tremendous differences in patients’ lives. Pain management not only leads to comfort and alleviates suffering, but can restore a degree of function which allows a person to engage in those activities, including recovery-based activities, which give their lives joy and a sense of value, worth, meaning, and purpose.
As long as recovering patients remember and live their primary purpose – to stay sober and carry the message – they should be able to cautiously navigate a bout with pain in which opioids are required – and do so without losing their sober time or their recovery.