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Comorbid addiction and chronic pain.

Those living with comorbid chronic pain and addictive disorders are a difficult and somewhat neglected population. Little research exists on which to base a standard of care or treatment guidelines. Yet clinical experience indicates that chronic pain patients who are comorbid for addictive disorders can have remarkably favorable outcomes.

The conundrum is that patients with chronic pain who also suffer from the disease of addiction often respond poorly to conventional chemical dependence treatment, although they may do very well when their chronic pain is addressed first. Unfortunately, pain management specialists often ignore the addictive disorder, while addictionologists may ignore the pain.

Physicians face enormous diagnostic challenges with this population. Patients' denial can be profound, and that in part serves to protect the self-esteem of those who already feel their self-worth to be diminished. For many, preserving their self-esteem may be more important than recovery or pain relief. This need may drive them to reject a stigmatized diagnosis in favor of a medical diagnosis. Physical suffering is honorable--addiction is not. Thus, they deny that anything is inappropriate about their substance use, and their denial may be supported by the illusion that their drug use is legitimate. Prescribing physicians may be unaware that their well-intentioned pain treatment plan has become part of the problem.

Ultimately, however, the diagnosis of addiction in pain patients is similar to that in recreational substance abusers--they have an impaired ability to control their use, experience drug preoccupation or craving, and continue to use the substance after it has clearly become a liability. A useful clue to the presence of addiction in a pain patient is that addicted pain patients use drugs to hide from life, rather than to become more functional. Many also exhibit a strong sense of entitlement to caretaking and drugs.

Treatment must begin with education and empathy, mixed with a healthy reality check. It may be clear to others that the patient's quality of life has deteriorated significantly, but this may not be at all clear to patients. Since their identity is that of pain patient and not that of addict, the clinician must "meet them where they are" to earn trust and form a working treatment alliance.

A 12-step program is likely to be rejected initially by these patients, and those prematurely coerced into such groups may actually become more treatment resistant. They may fear that, "If I go to 12-step meetings, then I'm not a pain patient, I'm just an addict." Timing their entry into recovery work is critical to their acceptance of the diagnosis and successful recovery.

These patients have typically felt dismissed by numerous physicians, since many of the causes of intractable pain are not associated with obvious tissue pathology. Additionally, both opioid and sedative withdrawal commonly produce transient hyperalgesia. The physician must be able to educate patients about physiologic causes of chronic pain, which presupposes that the physician has educated himself or herself in this area. Patients need to know that while pain is real and not imagined, it is not a gauge of damage--pain is the disease.

Addiction alters the body's reward and pleasure centers such that addicted patients come to require drugs (including alcohol) in order to feel normal. While the absence of drugs can cause dysphoria, prolonged sobriety will usually restore emotional equilibrium.

Paradoxically, it may be necessary to take away hope. Patients may devote years of their lives and all of their resources to the quest for a cure that medicine cannot provide. If they can acquire a degree of acceptance of the pain, a new hope can arise--the hope for a life that is productive, pleasurable, and sober. The false hope of pain elimination can keep a person active in his addiction in the same way that the false hope of riches keeps a person at the roulette wheel.

It is essential to educate patients about the ways in which addiction increases pain, impairs coping, and raises anxiety. They must believe (and must know that you believe) that addiction is not the result of a character flaw or weakness. For genetic and other reasons, some people on exposure to some chemicals will develop addiction as an idiosyncratic response, just as others will develop an allergy. Patients must understand that the alleviation of suffering and disability is contingent upon successful management of addiction.

It is important to address both self-pity and blame. In a study of 200 chronic pain patients, those who blamed their pain on others had increased mood distress and behavior disturbance, reduced past treatment response, and lower expectation of future benefit. In recovery, patients replace pity and blame with gratitude. They often say that they feel blessed and have a "sense of giving back." Patients remark that they no longer feel like "damaged goods."

A special treatment issue with this patient group is accountability. While they may insist that "I'm not like those addicts," they must be reminded that they have the same disease as those addicts, and thus must be accountable for the same recovery work as other addiction patients. Sponsors are essential, especially if the patient can be matched with someone who also has a comorbid addictive and pain disorder.

Family work is critical. The family must understand the meaning of the pain, what it signals, and the necessity of recovery work.

Addiction treatment alone is not enough, of course, for those with chronic pain. It is essential to optimize nonopioid (and nonbenzodiazepine) treatment methods, such as exercises, biofeedback/relaxation training, or yoga. Such interventions as nerve blocks, transcutaneous nerve stimulation, or even spinal cord stimulation may be helpful. Partial relief can usually be obtained through such other medications as NSAIDs, antidepressants, antiepileptic drugs, and antimigraine drugs. Many of these will simultaneously address the anxiety, depression, or sleep disturbances caused by pain or protracted withdrawal.

Relapse prevention is extremely important; many would say that the challenge of addiction treatment is not to achieve sobriety but to maintain it. One should expect and preempt protracted withdrawal symptoms. Patients must be taught that medical care may provoke relapse, since many physicians are unaware of analgesics beyond opioids and NSAIDs. Some physicians may not take addiction seriously, especially if the patient "doesn't look like an addict," or they may even assume that since the patient has "real pain" he could not have developed an addictive disorder.

It is important to prepare for future opioid use in this patient population. Alcoholics are encouraged to seek to maintain their sobriety for the rest of their lives, but patients addicted to prescription drugs can't do that, since almost everyone will at some time or other require opioids for acute pain. They should be taught strategies for future acute pain episodes and offered help in managing them.

The essential message is that even skillful treatment of pain or addiction in co-morbid patients will usually fail. Both conditions must be addressed.

The gift of sobriety combined with effective coping with pain usually leads to a life restored.

DR. KOTZ is an addiction psychiatrist at University Hospitals of Cleveland and Case Western Reserve University, Cleveland.

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Author:Kotz, Margaret M.
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:Oct 1, 2005
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