It can be challenging to manage chronic pain, even more so when our patients suffer from addiction. We can find ourselves walking a tightrope between the risk of relapse due to the inadequate treatment of pain, and the risk of relapse due to the use of opioid analgesics.
Since our mission is to minimize suffering and optimize functioning while helping our patients stay in recovery, this article will outline the general principles for achieving these goals in a pain management setting.
Nature of chronic pain
There are three types of pain: nociceptive, neuropathic, and mixed. In acute pain, nociceptors send pain signals upon tissue injury. Neuropathic pain arises from dysfunction of the sensory nervous system, often due to sensory nerve injury. Mixed pain is a combination of nociceptive and neuropathic pain.
Chronic nociceptive pain can persist long after the healing of tissues. This appears to be due to autonomous neural signaling of sensitized nerve fibers. Alteration of inhibitory pain signaling may also play a role. For example, after suffering severe burns, some patients develop complex neuropathic pain syndromes.
Pain signals can be altered in the peripheral nerves, the spinal cord, the thalamus, and the cerebral cortex (Compton P et al. Principles of Addiction Medicine, 5th ed. Chevy Chase, MD: American Society of Addiction Medicine; 2014). This makes an accurate diagnosis of the chronic pain’s source potentially important for treatment. For example, pain originating in peripheral nerves may respond best to electrical stimulation or acupuncture, while post-stroke pain that originates in the cerebral cortex will respond better to cortical interventions and cortex stimulation (Zaghi S et al, J Pain Manag 2009;2(3):339–352).
Psychosocial factors influence the perception and impact of chronic pain. For example, a positive outlook and family support can reduce both pain and disability (Flor H and Turk DC, J Behav Med 1988;11(3):251–265). Low self-efficacy is associated with greater depression, pain, and disability (Turk DC and Okifuji A, J Consult Clin Psychol 2002;70(3):678– 690). Reinforcing pain behaviors—providing secondary gain—can also worsen a patient’s symptoms and functioning. The benefits of pain (eg, relief from family obligations, medico-legal rewards) can both perpetuate disability and impede recovery (Dersh J et al, J Occup Rehabil 2004;14(4):267–279).
Preexisting psychiatric illnesses, including depression, anxiety, and PTSD, increase suffering due to pain and impair coping ability. (See https://bit.ly/2FUxIVu for a pain treatment improvement protocol.) Conversely, chronic pain often worsens psychiatric illness, creating a vicious cycle.
Additionally, chronic pain often causes depression, anxiety, insomnia, or impaired functioning. Like any stressor, chronic pain can also trigger relapse to addiction (Gourlay GL et al, Pain Medicine 2005;6(2):107–112). The interplay of addiction, other psychiatric illnesses, and chronic pain can make it challenging to assess and treat these conditions.
Assessment of patients with chronic pain
Since chronic pain is multifaceted, its assessment should be too. Be sure to obtain consent to speak to collateral providers and supports. You’ll want to gather the findings of other clinicians and the observations and concerns of loved ones. Be sure to also check your state electronic prescription monitoring program to see whether the patient is being prescribed controlled substances. Ideally, you should try to obtain medical, psychiatric, and addiction treatment records from other clinicians. After doing these things, you should assess the following:
• Assess the nature of the pain. Ask questions about onset, what the pain feels like, its severity, and what makes the pain worse.
• Assess how the pain impacts functioning. Ask how the patient copes with it. How does the pain affect daily activities, including work, household responsibilities, socializing with friends, sex, and having fun?
• Further explore how the pain makes the patient feel. Does the patient feel irritable, frustrated, or hopeless? Be sure to ask how the pain is affecting sleep and mood. Listen for underlying negative beliefs about the pain, such as the idea that life is not worth living or that there is nothing that can be done about the situation. Is the patient willing to accept the pain and pursue a fulfilling life? Is there a sense that the pain can be addressed through the help of others? Degrees of acceptance and self-efficacy will inform and impact the treatment.
• Ask about the impact of pain on a patient’s recovery. Is the patient sober? Having cravings? Is the patient adhering to a recovery program, or is pain getting in the way? Is the patient continuing to reach out to recovery supports, or retreating into isolation? If the patient is new to you, conduct a thorough substance use assessment, including details of current and past use, treatment history, and recovery history. Pay attention to factors that have sustained the patient’s recovery and examine relapse history, taking note of factors that triggered relapse to addiction.
• Assess all other co-occurring conditions and disorders. Include other psychiatric illnesses, medical conditions, and neuropsychiatric impairments.
• Assess environmental contingencies. Does the family reinforce wellness behavior or illness behavior? Are there vocational, financial, or insurance/legal incentives or disincentives for being in pain? What will be the consequences of resuming healthy functioning? These factors can significantly impact pain severity and associated disability. Is the family concerned about the medication, opioids or otherwise, being prescribed to the patient?