New Rules for Treating Chronic Pain Addiction Free Solutions In The Era of Opioid Crisis
First Published in The California Therapist - January/February 2022
Prologue
This article outlines some of the overwhelming problems that led to what I am calling the Opioid and Chronic Pain Syndemic. Then I outline the need for implementing a synergistic solution that needs to include everyone. I am also including two case study examples to demonstrate the need and effectiveness of an Addiction-Free Pain Management® synergistic treatment solution.
Understanding the Problem is Crucial to Finding the Solution
I believe there is much more than an opioid crisis or epidemic. It is not an epidemic, rather it is a Syndemic. What I mean by that is it’s a perfect storm of over prescribing opioids, mismanaged chronic pain by depending only on the traditional bio-medical model and untreated mental health disorders. What we need to focus on is identifying the synergistic nature of the problem and the need to implement a synergistic treatment solution that helps heal the whole person – Biological, Psychological, Family/Social and Spiritual. A true Body-Mind-Spirit Approach. There is also a strong political and financial component to our current problem that Harry Nelson outlines so well in his book The United States of Opioids: A Prescription For Liberating A Nation In Pain.
Also, in his book Dreamland: The True Tale of America's Opiate Epidemic, Sam Quinones also covers some of the financial and political precursors to our current problem. In addition, many people believe what underlies this crisis is a severe deficit in coping skills for those who are suffering with chronic pain and coexisting mental health disorders including substance use disorders. Combine these poor coping skills with misinformation from leading medical prescribers using opioids for chronic pain, and we see addiction from prescription opioids has increased over 1,000 percent between 2012 and 2016.
The Center For Disease Control (CDC) posted an update on December 16, 2016 with some other staggering statistics:
- Over 1,000 people a day are being treated for prescription opioid overdose incidents with the three most common being Methadone, Oxycodone/OxyContin, and Hydrocodone.
- It stated that as many as 91 people a day are dying from prescription opioid overdose events.
- The report also stated that between 1999 and 2015 there were over 183,000 deaths directly related to prescription opiates. •
- Finally, in 2014 over 2 Million Americans experienced prescription medication misuse, abuse, pseudoaddiction or addiction. Many say this is an opioid epidemic.
The other coexisting epidemic noted is chronic pain. Chronic pain management is a serious health crisis facing the world today. In fact, in the well-publicized June 2011 White Paper The Institute of Medicine (IOM) stated that as many as 116 million people were experiencing chronic pain; the cost of managing it in the United States alone is over $635 Billion per year in direct medical costs and lost productivity. As I write this today the problem continues to worsen.
When a person who is undergoing chronic pain management, they are also experiencing other co-existing disorders, such as medication abuse or even addiction to prescription pain medication and psychological disorders, the problem reaches even more epidemic proportions. Every week in the media there are reports about the problematic use and/or abuse of prescription drugs being used in the treatment of chronic pain. The numbers of people impacted are staggering.
So what is the source of the so-called Opioid Epidemic and is there a link to chronic pain? A study posted in the New England Journal of Medicine in March of 2016, reported some interesting numbers in answer to this question. More than 30 percent of Americans have some form of acute or chronic pain and among older adults; the prevalence of chronic pain is more than 40 percent. In 2014 alone, U.S. retail pharmacies dispensed more than 245 million prescriptions for opioid pain relievers. Opioids are widely diverted and improperly used. In addition, many physicians admit that they are not confident about how to prescribe opioids safely.
This report went on to state that more than a third (37 percent) of the 44,000 drug-overdose deaths that were reported in 2013 were attributable to pharmaceutical opioids while Heroin accounted for an additional 19 percent. There was also a parallel increase in the rate of opioid addiction, affecting approximately 2.5 million adults in 2014.
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Exploring The Stress Pain Connection
Remember!
You Can’t Effectively Manage Your Pain Without Managing Your Stress
It is important to understand the connection between stress levels and pain symptoms, as well as how managing stress can decrease the perception of pain. Physically, chronic pain raises stress levels and drains physical energy, while psychologically it impacts the ability to think clearly, logically and rationally, as well as how effectively patients manage their feelings. Not only that, it can impact memory. In most cases when someone learns how to lower their stress levels, they will also experience a decrease in their perception of pain.
Of course, before patients can manage stress, they first need to learn how to describe their level of stress at any given time. It’s important to remember that when someone reaches the upper moderate to severe levels of stress (6-10 range or what I call the “stress reaction”) thinking, emotions and behaviors are affected. The goal is to keep the level of stress at six or below as much as possible.
Since self-assessing levels of stress and learning how to implement simple but effective stress management tools is so important, we need an instrument, or tool, to help do that. I use the Gorski-CENAPS®Stress Thermometer below as a starting point to help patients accurately articulate their level of stress. In the next section I will take you through this exercise in the same way I do with patients.
Developing A Personal Stress Thermometer
Developing a personalized stress thermometer starts with the premise that there are ten levels of stress. As I continue to describe this tool, you can create and personalize your own stress thermometer which will help you internalize this process and enable you to be more successful at using it. Below is a starting example of a stress thermometer.
When describing the stress thermometer, I start at the bottom with the first zone which has Levels 1, 2 and 3. This zone is titled “Relaxation.” The description I use on the right for Level 1 is “Relaxed-Nearly Asleep.” This level is when you first wake up in the morning; your eyes aren’t even open yet, but you’re no longer asleep. At this level you aren’t functioning at all. Describe what a Level 1 might mean to you.
Level 2 is “Relaxed—But not Focused.” At this level you’re beginning to function, but it’s like being on auto pilot; fixing coffee, brushing your teeth, combing your hair, etc. You are not quite focused yet and are still at a low level of functioning. What does Level 2 look like for you?
Level three is titled “Relaxed-And Starting to Focus.” I call this “vacation” level. Yes, I’m focused, but my focus is on relaxing. This is the last level of the relaxation zone. If different, describe what Level 3 means to you.
The next zone is titled “Functional Stress” and contains Levels 4, 5 and 6. Level 4 are called “Focused and Active.” At this level I have energy and am starting to get things done. Level 5 is where you want to be most of the time if you want the best level of functioning and the most effective pain management. Level 5 is “Focused with No Effort.” This is the optimal level for getting things done. Write your own description for each of these levels.
Level 6, “Focused with Effort,” is the beginning of what I call the danger zone. I describe it like this: Have you ever had one of those days that even though you’re getting things done, it seems to take much more effort or push to make it happen? I know when I get to that point I’d better stop, rest and get centered or else I am setting myself up for trouble. What would a Level 6 look like for you?
The next zone is titled the “Stress Reaction” zone and it contains numbers 7, 8 and 9. When you are in this zone you start to lose some of your frontal lobe functioning and are transitioning into survival mode—fight, flight, freeze or the amygdala limbic system of the brain. This isn’t necessarily a bad thing.
Sometimes in emergency or crisis situations an active amygdala becomes a healthy survival tool – the fast track. But for someone living with chronic pain it can also raise their pain levels or at least their perception of pain.
Level 7 in the “Stress Reaction” zone is “Loss of Focus or Spacing Out.” At this level you aren’t able to really learn anything new and cannot be emotionally present with others. Many patients go in and out between levels 6 and 7. Often at Level 7, long-term memories are not being recorded. Can you think of a time when you were in a class or even a discussion and noticed you couldn’t remember what was just covered? Describe what Level 7 means to you.
If you don’t intervene at Level 7, you are at risk for moving on to level 8, “Getting Driven and Defensive.” When I’m at this level I tend to feel irritated or agitated and sometimes can’t sit still. What happens for you at a Level 8?
Not addressing Level 8 stress puts you at high risk for a Level 9 called “Over-React.” When I get to this level I experience foot in mouth reaction—I say or do something that I know I’m going to regret, but just can’t stop myself. Have you ever been at that point? What would a Level 9 mean for you?
The final zone titled “Trauma Reaction” is a Level 10 “loss of control.” At this point patients can’t function; they shut down and/or run away and escape. Some will go to bed and pull up the covers, while others are at high risk of using inappropriate pain medications that could include alcohol or other drugs to escape. Can you describe a Level 10 stress reaction for you?
Developing A Strategic Stress Management Plan is found in the remainder of the article that you can request below.
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Looking Below The Surface Of Chronic Pain
If you’re living with a chronic pain condition like I am you know how hard it is to explain what is going on for you to even close family and friends. It is also challenging to share with your healthcare providers what is really going on and often come away feeling like “they just don’t get it.” Even worse, some people come away stigmatized and accused of being histrionic or even worse “you’re just drug seeking.”
Other people, including healthcare providers, make judgements on what they are seeing and hearing from someone living, or suffering, with chronic pain. They see “exaggerated” pain behaviors. When people try to share what’s really going on they are perceived as complaining or maybe “malingering.” Friends and family members mistakenly believe their loved ones are just “making excuses” for not keeping commitments or completing projects.
When people live with chronic pain for a long time there are various mental health problems and emotional factors that complicate positive treatment outcomes for these people including those coexisting psychological (mental health) disorders including substance use disorders. These patients often become so overwhelmed that their levels of functioning and quality of life are significantly deteriorated.
When coexisting conditions occur, the family problems also increase synergistically. Effective treatment can be challenging and confusing for therapists and other healthcare providers who may be inexperienced with chronic pain disorders or addiction, but especially problematic for the patients and their families. That is another reason why a concurrent integrated treatment approach is crucial. In the next section we will look below the surface of the Chronic Pain Iceberg.
Understanding The Iceberg Principle – What Is Really Going On Under The Surface
So, if you are trying to be supportive of someone suffering with chronic pain it is crucial to know what’s really going on that most people don’t even realize. Below are some of the common problems going on below the surface.
Mental Health Conditions Under the Surface – What People Don’t See
- PTSD or other Unresolved Trauma
- Depression
- Anxiety Disorders
- Sleep Disorders
- Cognitive Distortions From Living with Constant Pain
- Medication management problems up to and including addiction
- Eating Disorders – Using food to cope
Pain Symptoms Under the Surface – What People Don’t See
- Aching, throbbing pulsing
- Irritating, nagging disturbing
- Spitting, piercing pounding
- Dreadful, severe awful
- Burning, stinging lacerating
- Irritated, sore, sensitive
- Excruciating, agonizing distressing
- Worrisome, saddening depressing
- Torturing, grueling punishing
- Exhausting, fatiguing debilitating
Understanding Spoonies
Several years ago one of my patients said she was a “Spoonie.” I told her I had never heard that term before and could she explain it to me. She told me that unless someone walked in her shoes, they could not understand her and gave me a website to check out. Then when I did some research, I found this on the Patient Rising website she gave me regarding the “Spoon” theory:
“Because we look healthy on the outside, one of the greatest challenges we have is explaining to others how a person who looks so good can actually feel sick or be in pain,” writes The Daily Migraine’s Lisa Jacobson. “They do not understand the freedoms many of us have lost.”
One term that helps explain the inexplicable: Spoonie.
“A spoonie can refer to any individual who suffers from a chronic illness or chronic pain,” explains chronic migraine patient Sophie Cowley. “These illnesses are often invisible; to most people, spoonies may appear healthy and able-bodied, especially when they are young. The daily feeling of being invisible can be one of the most challenging parts of being a spoonie.”
The term “Spoonie” was coined by Christine Miserandino, an award-winning blogger and patient advocate, when she was trying to explain to a friend what it’s like to live with lupus. “I thought she already knew the medical definition of Lupus,” Miserandino recalls at her website, But You Don’t Look Sick. “Then she looked at me with a face every sick person knows well, the face of pure curiosity about something no one healthy can truly understand. She asked what it felt like, not physically, but what it felt like to be me, to be sick.” “How do I answer a question I never was able to answer for myself?”
So, she laid out a handful of spoons on the table and explained that the spoons symbolize all of a patient’s daily energy reserves. Every activity, no matter how thoughtless and automatic, depletes from the energy supply. Getting out of bed, showering, getting dressed, eating, and any number of mundane tasks threaten to deplete energy at any given time.
When you run out of spoons, you can choose to borrow against the spoons of a future date, but there are consequences. When you deplete your spoons, you are bedridden. Unable to manage the simple activities of life.
This is clearly what many people with chronic pain, chronic illness or disabilities deal with day in and day out. And yet it is still very challenging for someone who has never had these challenges to understand and help someone who is suffering with chronic pain. There is so much going on under the surface.
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Moving Beyond Anticipatory Pain for Effective Pain Management
If you’re living with a chronic pain condition like I am you may have noticed that sometimes you are so fearful about doing even the most basic tasks of daily living, that you become immobilized. It can also manifest as overwhelming anxiety, so much so, that a phenomenon gets triggered which amplifies your perception of pain. I call this Anticipatory Pain.
Because you believe you are going to hurt by doing a certain activity, you can activate the physical pain system. Just by thinking about doing something that you believe will cause you to hurt, you will start to feel pain. This can happen before you even do whatever it is you already believe will cause physical pain. All you have to do is to start thinking about doing that thing.
Once the physical pain system is activated, the anticipatory pain reaction can make your perception of chronic pain symptoms worse.
Whenever you feel the pain, you interpret it in a way that makes it feel worse, and you think about it in a way that actually does make it worse. You tell yourself that “this pain is awful and terrible,” and “I can’t handle it.” You convince yourself that “it’s hopeless, I’ll always hurt, and there’s nothing I can do about it.”
This way of thinking contributes to the development of emotional reactions that further intensify or amplify the pain response. The increased perception of pain causes you to keep changing your behavior in ways that create even more unnecessary limitations and mounting emotional discomfort. These reactions can make you believe you are trapped in a progressive cycle of disability.
Coping and Moving Beyond Anticipatory Pain
One of the most requested articles I wrote was titled “Coping with Anticipatory Pain. I believe it’s vital for us to support people to not just cope with anticipatory pain, but to move beyond it.
I learned a long time ago that what we expect is usually what we get which can sometimes be both helpful and harmful. When it comes to feeling pain and developing an effective chronic pain management plan, it’s crucial to understand the role of anticipatory pain. It has both biological and psychological components.
On the biological side, the cascade of effects from a pain sensation occurs on many levels and involves a variety of different areas within the nervous system. As a result, a wide variety of nervous system chemicals are produced and dumped into the blood while other brain chemicals are rapidly absorbed or depleted. Pain doesn’t just hurt — it changes the most basic neurophysiologic processes in the human body.
On the psychological side, anticipation of an expected pain level can influence the degree to which you experience your pain. In some cases, when your anticipatory level of pain expectation is lowered, your brain responds by influencing special neurons. This renders your brain less responsive to an incoming pain signal and your sensation of pain decreases. In any event, both ascending (pain signals coming from the point of injury to the brain) and descending nerve pathways (signals from the brain to the point of injury) will influence or modify the effects on your body.
Fortunately, you can learn how to change your anticipatory pain response. You can lower the amount—or perception—of pain that you anticipate by changing what you believe will happen when you start to hurt. You can also change your thinking, or your self-talk, and learn how to better manage your emotions. You can learn new ways of responding to old situations that used to cause or intensify your pain. As you come to believe that you really can do things that will make your pain sensations bearable and manageable, your brain responds by influencing special neurons that reduce the intensity of your pain. Your brain becomes less responsive to an incoming pain signal.
There are things you can do that will make you habitually less responsive to incoming pain signals. Herein lays the rationale for including biofeedback, positive self-talk, meditation, and relaxation response training as part of your pain management treatment plan. In any event, both ascending (pain signals coming from the point of injury to the brain) and descending nerve pathways (signals from the brain to the point of injury) influence or modify the effects of pain on your body.
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Chronic Pain Management and the Impact on Family and Friends
The Family Also Needs A Bio-Psycho-Social-Spiritual Approach To Heal
I’m writing this for people who are living with someone—or care for someone—who is suffering with a chronic pain condition and they are having a hard time coping because they’re not sure how to help. Unless someone’s been in your place they have no idea how challenging this can really be.
I’ve seen many marriages and partnerships end due to one of the partners living with an undertreated or mistreated chronic pain condition. Sometimes family members and significant others develop their own healthcare problems while trying to help someone they love cope with chronic pain. Family and significant others often get burned out, or they become frustrated and resentful towards the person living with chronic pain. A spouse can become just as hopeless and helpless as their family member who is suffering with pain and may even develop a severe depression or sleep problem.
For those of you helping someone living with a chronic pain condition who don’t have a personal experience of living with chronic pain I want to ask you to follow the steps below to see if you can develop a better understanding of what it must be like to live with chronic pain. To get the most out of this following exercise please make sure to do it when you have the time and space where you won’t be interrupted. It’s also helpful if you journal your reactions to this as soon as you’ve completed the four steps below.
Step One: Think back to a time when you hurt yourself or had a painful condition such as a surgery, toothache, broken bone, or headache etc.
Step Two: Try to remember what that felt like and what you wanted to do to stop the pain.
Step Three: Now imagine that you have that level of pain right now and have had it for the past six months without any relief. Every day when you woke up it was there. Every night you wonder if you’ll be able to sleep because the pain is so disturbing.
Step Four: Now imagine trying to explain this to your family and friends or your healthcare provider. What would you say? What would you want from them? Please make sure write down your reactions to this brief exercise.
What kind of healthy support can friends and family provide if a loved one is undergoing chronic pain management, experiencing significant quality of life problems and a decreased level of functioning? The most important thing is to understand what it must be like; if you answered the four questions above and reflected on what you learned, you should have a much better idea.
Here are six additional starting points.
1. Make sure that you are practicing good self-care; take time to relax, sleep, play, eat healthy, etc.
2. Develop compassion and even empathy for your significant other—but never sympathy as that can cause even more problems. Remember the old saying “Sympathy Kills” that is often heard at Al-Anon meetings.
3. Do NOT do things for your significant other that they can and should be doing for themselves.
4. Don’t keep secrets from your significant other. This is especially true concerning medication use or abuse issues.
5. Remember the three (3) Cs of Al-Anon: You didn’t CAUSE it, you can’t CONTROL it, and you can’t CURE it.
6. Seek out a professional with experience in chronic pain and any coexisting problems for you and your family.
However, these are just starting points. In order to help someone else, you first must make sure to take care of yourself. You also need to be aware of the two major traps—enabling and resentment. Enabling is when you find yourself doing something for your friend or loved one that they can and should be doing for themselves.
When supporting someone living with chronic pain for long periods of time many people are at risk of burnout. What started as loving care and support sometimes turns into a major chore and the helper becomes angry and resentful of the person living with chronic pain. Just like many people who are living with chronic pain become isolated and depressed; many helpers also fall into these problems.
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Spirituality in Chronic Pain Management Is Crucial
Chronic pain is often misunderstood and under-treated. In addition to the biopsychosocial impact a chronic pain condition frequently has on a person, a spiritual crisis often accompanies the situation as well. Long-term chronic pain is a body-mind-spiritual problem that requires a multifaceted solution. I believe that complementary spiritual practices are necessary components of any effective chronic pain management plan.
Many people have found spiritual interventions like the traditions of prayer and meditation to contribute to the reduction of the sense of suffering. Unfortunately, in our fast-paced world and the secular treatment modality, adding a spiritual component to chronic pain management does not get enough attention.
The concept of spiritual pain requires healthcare providers to go beyond the bounds of traditional clinical treatments and be prepared to devote the time required to give supportive and understanding care. It is crucial to explore spirituality and its impact on a person’s pain in a multidimensional assessment.
It’s Time To Think Outside The Box
Spirituality is vital aspect of being human which is difficult to fully understand or measure using scientific methods; yet convincing evidence in medical literature supports its beneficial role in the practice of medicine. It will take many more years of study to understand exactly which aspects of spirituality hold the most benefit for health and well-being.
Many of the world's great wisdom traditions suggest that some of the most important aspects of spirituality lie in the sense of connection, inner strength, comfort, love and peace that individuals derive from their relationship with self, others, nature and the transcendent.
I believe that spiritual healing is an important component of a multifaceted chronic pain treatment plan. One goal of spiritual healing is to help patients improve their well-being and quality of life, rather than to cure specific diseases or in this case eliminate pain. Spirituality as part of a treatment plan may include encouraging patients to use visualization, prayer and positive thinking.
The Difference Between Religion and Spirituality
Over the years I have found it important to have a discussion with my patients regarding spirituality and effective pain management, as a common understanding of terminology is essential as is an understanding of what their beliefs are.
One concept that rang true was the simple saying: “Religion prepares people for the next life while spirituality helps them live this life to their fullest potential.” Many of my colleagues also recommend clarifying the difference between the terms “spirituality” and “religion.” They advocate developing a broad-based definition of spirituality that encompasses religious and nonreligious perspectives.
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