Walking the Tightrope of Pain Management and Addiction

Understanding and Addressing Chronic Pain and Addiction

Pain is the reason many people start using potentially
addictive substances. We also know that regular use of
psychoactive medication plus a genetic or environmental
susceptibility can lead someone from experiencing
pain relief to increased tolerance.

Jeanie is an excellent example of what can happen
when a pain condition is not managed appropriately
and treatment depends only on medication. Both of
Jeanie’s parents were alcoholics and she was also in an
abusive marriage. She developed a chronic pain condition
and was prescribed opiate medication to treat
that pain. At an unconscious level Jeanie found that
her pain medication also helped her escape from painful
childhood memories and the trauma of an abusive

Over the course of a few months Jeanie’s medication
no longer helped with the physical pain symptoms
or her emotional distress, so she started taking much
more than was prescribed. She eventually went to several
different doctors to get the amount she believed
she needed, but her pain continued to get worse. What
Jeanie didn’t realize is that the opiate medication was
increasing or amplifying her pain signals—this is called
the pain-rebound effect.

Physical pain is the reason many people like Jeanie start
to use potentially addictive substances. As I mentioned
above, long term use of opiate medication, plus genetic
or environmental susceptibility, can lead to increased
tolerance as a result of searching for pain relief. Eventually
the addictive substance no longer manages the
pain symptoms. Not only will it increase or amplify the
pain signals, it can also cause an extreme sensitivity to
pain, a condition called hyperalgesia. The end result is
severe biopsychosocial pain and problems.

Eventually Jeanie did develop an addiction to the medication
which increased her pain and created problems
in every area of her life; physically, psychologically, and
socially (biopsychosocial). Because Jeanie was experiencing
both chronic pain and substance dependency
problems, she needed a specialized concurrent treatment
plan for both conditions.

An effective synergistic treatment protocol for Jeanie’s
chronic pain and substance addiction condition included
the three following components. Before thisprotocol was
put into place, I helped Jeanie develop a
relapse intervention plan which was a vital part of her
treatment and is explained in more detail later in this

• Appropriate Medication Management

• Core Clinical Processes

• Nonpharmacological Interventions

Appropriate Medication Management: Jeanie’s
medication management plan incorporated collaboration
with an addiction medicine practitioner/specialist.
This person made sure that the medication prescribed
was needed, was recovery friendly and was the right
type, as well as the appropriate quantity and frequency,
in order to avoid triggering a relapse.

Core Clinical Processes: Jeanie also needed to learn
how to manage her irrational thinking, uncomfortable
emotions, and self-defeating urges and behaviors, as
well as the isolation tendencies that can develop with
co-existing pain and addiction. I used a cognitive behavioral
therapy approach using the eight clinical
processes in the Addiction-Free Pain Management®
Workbook as a starting point which worked well as her
health care provider was experienced in the concurrent
treatment of chronic pain and substance dependency.

Nonpharmacological (Holistic) Interventions: I
supported Jeanie to search out alternative non-pharmacological/
holistic pain management modalities
such as hydrotherapy, physical therapy, acupuncture,
chiropractic, prayer, meditation, hypnosis, self-hypnosis,
etc. I also suggested she read Managing Pain Before
it Manages You (2001), a book by Margaret Caudill,
which she found very helpful. Jeanie also used both a
12-Step group and a chronic pain support group which
greatly enhanced her recovery.

Knowledge is Power

Developing an effective treatment plan required that
Jeanie understand which stage of the addiction process
she was in. It was also important for her to know how
much damage had been done by her inappropriate use
of pain medication. As Jeanie progressed, she learned
how to identify which stage of the developmental recovery
process she was in, and then implement appropriate
treatment interventions.

As you can see, the road to recovery can be a difficult
one for someone with both chronic pain and a coexisting
addictive disorder. However, most of the chronic
pain research I have reviewed over the past two decades
has been very clear about treatment outcomes.

The best prognosis is afforded to people who are proactive
in their own treatment and recovery process.

How they can do this is by learning as much as possible
about their pain condition and implementing an effective
pain management plan.

As the title of this section states, knowledge is power.
Once people understand what is really going on with
their body and mind, they can take action to effectively
manage their pain. In fact, the most important shift
they can make is to stop believing that pain is their enemy
and accept it as their friend.

Jeanie, like most of my patients, had a very difficult time
accepting the suggestion that she make peace with her
pain and consider pain her friend. Even so, I have found
it to be true for myself and the patients I work with.
It was very important for Jeanie to stop seeing herself
a victim of her pain condition and empower herself
through the development of an appropriate pain
management plan and chemical dependency recovery
program. Fortunately, Jeanie adhered to her treatment
plan and remains clean and sober, as well as effectively
managing her chronic pain.

The Relapse Intervention Plan

While walking the tightrope of pain management and
addiction, it’s important to make sure you have a safety
net in case you fall; I call this the relapse intervention
plan. As I mentioned above, this must be developed
before moving on to the three-part treatment process.

This is your insurance policy. People don’t buy auto insurance
because they plan to crash into other vehicles.
They have it just in case. The relapse intervention plan
should be a mandatory component of a treatment plan
for anyone with chronic pain and coexisting disorders;
but especially for addiction.

In its simplest form, developing a relapse intervention
plan consists of writing out a specific plan that answers
the following three questions.

1. What is your healthcare provider supposed
to do if you relapse, stop coming to
sessions, or fail to honor your treatment or
medication management contract?

2. What are you going to do to get back in
recovery if you start inappropriately using
pain medication (including alcohol) or other
drugs, or other ineffective pain management,
so that you can stop using before you
hit bottom?

3. Who are three significant others who have
an investment in your recovery? What do
you want each of them supposed to do if
a relapse occurs? Make sure you have their
day and night phone numbers accessible
and that you give them a copy of this plan.
The premise here is simple—those who fail to plan,
plan to fail. I believe that positive treatment outcomes
are possible if you are committed to being an active
participant in your treatment process, develop a relapse
intervention insurance policy, and you follow a
three part multidisciplinary treatment plan—especially
as you walk the tightrope of pain management and addiction.