Support And Caring For The Addicted Person With Chronic Pain

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Working With The Addicted Person With Chronic
Pain (APCWP)
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Support And Caring For The Addicted Person With
Chronic Pain
A/D PSYCHOTHERAPY AND CLINICAL CONSULTING INC.
Presented By Michael E. Dusoe, PhD, LCSW
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The Problem, The Solution, And The Barriers
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Goals

• Open A Dialogue
• Initiate Some Common Themes
• Provide A General Overview
• Nature Of The Problem
• Common Approaches
• Discuss Treatment Complications
• Avoid Providing Specific Philosophical
  Underpinnings Which Restrict This Dialogue

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PAIN TOLERANCE
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Some Clients Have Low Pain Tolerance
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Some Clients Tolerate Pain Much Better Than Others
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The New OrderTres Diagnosis

• Axis I Major Dx
• Axis II Personality
• Axis III Related Physical Disorder

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Definition Of Pain

• An unpleasant sensory and emotional experience
  associated with actual or potential tissue damage
  or described in terms of such damage.
• International Association For The Study Of
  Pain, 1979

Pain is a multidisciplinary and subjective
experience. Its subjectivity is influenced by
behavioral, physiological, sensory, cognitive,
and cultural factors. Drug Topics, 2001
Chronic Pain occurs when an injury damages the
pain system itself, clients develop long term
pain which frequently occurs even without a
stimulus.
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Working Definition Of Chronic Pain

• Chronic Pain Is Pain That Lasts For 6 Months Or
  More And Does Not Respond Well To Conventional
  Medical Treatment. Frequently, but not always,
  chronic pain is the result of permanent
  structural damage to the neurological and/or
  muscular-skeletal systems.

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Dependency vs.

• Physical dependence is often associated with
  addiction but it is NOT the same thing as
  addiction.
• Physical dependence is the occurrence of
  withdrawal symptoms following the abrupt
  discontinuation of narcotics. Dependence is
  nearly universal among patients receiving
  continual opioid therapy for a week or more.

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Addiction!

• A primary, chronic, neurobiological disease,
  with genetic, psychosocial, and environmental
  factors influencing its developments and
  manifestations. It is characterized by behaviors
  that include one or more of the following,
  impaired control over drug use, compulsive use,
  continued use despite harm, and craving.
• Asam

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The Chemical Coper (FDA)

• Bears resemblance to addiction with regard to the
  centrality of the drug and drug procurement to
  the patient
• CCs need structure, psych input, and drug
  treatments that decentralize the pain medicine to
  their coping
• Decentralize pain medication reduce its meaning,
  undo conditioning, undo socialization
  accomplished through pain-related psychotherapy
  and prudent drug selection

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Pseudoaddiction

• Drug Seeking
• Must be seen ASAP
• Feigns Physical/Emotional Problems
• Loses Prescriptions
• States specific request and/or states they have
  allergies to non-narcotics
• Resists collateral information efforts.
• Embraces medication escalation.
• Dependent Addicted

• Seeking Relief
• Specific complaints, can objectively report
  quality and intensity of pain.
• Encourages collateral information.
• As likely to lose a prescription as to lose a
  young child.
• Maintains a reliable relationship with MD.
• Appointments
• Medication Compliance
• Overall cooperation
• Fears Medication escalation.
• Dependent, not addicted.

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Aberrant Drug-taking Behaviors The Model

• Probably more predictive
• Selling prescription drugs
• Prescription forgery
• Stealing or borrowing another patients drugs
• Injecting oral formulation
• Obtaining prescription drugs from non-medical
  sources
• Concurrent abuse of related illicit drugs
• Multiple unsanctioned dose escalations
• Recurrent prescription losses

• Probably less predictive
• Aggressive complaining about need for higher
  doses
• Drug hoarding during periods of reduced symptoms
• Requesting specific drugs
• Acquisition of similar drugs from other medical
  sources
• Unsanctioned dose escalation 1 2 times
• Unapproved use of the drug to treat another
  symptom
• Reporting psychic effects not intended by the
  clinician

Passik and Portenoy, 1998
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Pain Injury Numbers

• 50 Million Chronic Pain Sufferers Nationwide
• 65 Billion In Lost Productivity
• 4 Billion In Lost Workdays
• 40 Million MD Visits Annually (2)
• 55 To PCP or Dentist
• 12 To Pharmacist
• 5 To Podiatrist
• 3 To Pain Management Specialist
• Currently More Than 8 Million People Are Disabled
  with Back Pain (65,000 cases every year)

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Pharmaceutical Numbers

• 50 Of Non-Cancer CP Patients Are On Opioids
• Estimated 16,500 Deaths Annually From
  Anti-Inflammatory Drugs and Complications (26
  Billion Pills, 100 Million Prescriptions)
• Oxycontin In 2000 Broke Into The Top 20 In
  Pharmaceutical Sales Generating More Than 1
  Billion Dollars In Sales

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Comparative Sales
Total Retail Dollars (000)
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Point Of ConfusionAddiction Or Dependence

• The prevalence of addiction among patients with
  chronic, non-cancer pain is unknownthe rates of
  drug abuse and addiction with chronic, non-cancer
  pain have been estimated between 3.2 and 18.9.
• Dickinson, et al (2000) Western Journal Of
  Medicine

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Types of Pain

• Transient Pain
• Acute Pain
• Chronic Pain
• Initially Nociceptive Pain..Typical Response
  Sensory Receptors Signals The Potential For
  Tissue Injury And Evokes The Escape Response
• If The Sensory Nerve(s) Are Damaged, A New
  Process Neuropathic Or Persistent Pain Occurs.

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Neuropathic Pain(Allodynia)

• In General
• Neuropathic pain is relieved not at all, or
  poorly by conventional analgesics. It is likely a
  reflection of nervous system dysfunction, not
  merely a symptom of the initial injury. NP pain
  is often agonizing and untreatable. These
  patients will never likely be pain free.

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Three Components of Pain

• Biological
• Nerves signal injury and discomfort.
• Psychological
• The meaning an individual assigns to pain.
  Expectations of the pain experience.
• Social/Cultural
• The societally approved sick role assigned to
  the person in pain.

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Treatment Populations
APWCP
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Six Stages Of Treatment

• Assessment
• Reconceptualization Of Nature Of Pain
• Skills Development
• Rehearsal Application Of Skills Developed
• Generalizing Of Skills To Situations
• Follow-up To Maintain Progress Skills

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Identification Assessment

• Utilize Multi-Axis Approach
• Establish Traditional Diagnosis With Appropriate
  Techniques
• Do A Pain Assessment
• What specifically is the diagnosis?
• Collateral Info From Doctor?
• Collateral Info From Medication Database?
• Listen. when is it worse, when is it better. what
  is the clients goal?
• Do A Specialized Threshold Assessment (e.g.
  McGill, CSQ-R)
• Collate stress with pain whenever it occurs.
• Establish is it relief or craving?
• Document Findings Obtain Release For Collateral
  Care Providers (PCP, etc).
• Refer For Psychopharmacological Care If Evidence
  Of Underlying Emotional Factors

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Assessment Measuring Pain

• Behavioral Observation
• Observed Outward Manifestations including
  distorted posture, distorted ambulation,
  avoidance of activity, and distressful facial
  expressions.
• Subjective Reports
• Pain Assessment Grid
• Journaling Assignments Documentation

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Traditional Non-TraditionalApproaches To Care

• Massage Physical Therapy
• Biofeedback
• Hypnosis Meditation
• Stress Management Emotional Care
• Acupuncture
• Chiropractic Intervention
• Nutrition
• Exercise
• Relaxation Training
• Herbal Supplement Care

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Theories of Pain

• Specificity Theory
• IntensityAmount of Damage
• Conditioning Theories
• Nervous system retains the memory of pain.
  Pathways are built and repeatedly used.
• Pain Pathways
• Going Up To Brain-Fast (A-Beta) Slow (A-Delta
  C Nerve Fibers)

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Gate Control Theory

• 1965 (Melzak Wall)
• Proposed That There Were Gates On The Bundles Of
  Nerve Fibers
• Proposed That A Sufficient Amount Of Stimuli
  Can Close The Gate To Pain Sensation
• Specifically Large Diameter Nerve Fibers
  (A-Beta) Can Close The Gate On A-Delta C Fibers
  Superseding The Pain.

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The Paradigm Of The Coconut Or Monkey Trap!
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Questions Comments
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Some Resources

• Eimer, BN, Freeman, A. 1998 Pain management
  psychotherapy a practical guide. New York John
  Wiley Sons.
• Robinson, JL. 1997 CSQ Five factors or fiction?
  The clinical journal of pain. 13(2), 156-162.
• Thomas, R. 1999 Alternative answers to pain. New
  YorkReaders Digest Association
• www.mindfulnesstapes.com

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Working With The Addicted Person With Chronic Pain