Chronic Pain, Addiction and Trauma: The Troubling Trifecta

Posted on Wednesday, May the 19th at 6:49pm

By Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

The Impact of Coexisting Disorders

Historically pain, psychological and addictive disorders have been treated as separate issues. Pain clinics have had great success in treating chronic pain conditions. Addiction treatment programs have had success in treating addictive disorders. If the addiction program also treats coexisting disorders their success rate with the coexisting psychological disorders increases as well. However, the effectiveness the pain clinics or addiction treatment programs often fail when the person is suffering with both chronic pain and other coexisting conditions.

Within addiction and/or mental health treatment centers, specific issues need to be addressed in order to obtain positive treatment outcomes for those disorders. The same holds true for pain clinics when striving for effective pain management. But for people who are dealing with coexisting disorders, finding appropriate treatment can be difficult as well as frustrating for them and their healthcare providers—unless their unique treatment needs are adequately addressed.

Dealing with Grief/Loss and Trauma

Another major obstacle facing people living with chronic pain is grief and loss over their prior level of functioning, so you need to evaluate this and develop a treatment plan to address it. Many people with chronic pain and a coexisting addictive disorder also have a pre-existing moderate to severe trauma history that they need to be assessed for and helped with.

If you’re treating an addictive disorder and the person is not yet fully stabilized, exploring their trauma history could trigger a relapse. It’s been my experience that past trauma tends to make a person respond to painful stimulus differently, so we need to look at a trauma precursor for both ineffective pain management and an increased sensitivity to pain signals.

If you do notice unresolved problems it’s important to make sure you resolve any grief caused by their chronic pain condition and they are moving into acceptance by beginning to reintegrate back into life. At this point the person should be able to say, and mean it, “today my life is better than ever—it may be different, but it is better and I have hope where before I had none.” But what happens if you are dealing with an unresolved trauma history?

The Role of PTSD in Chronic Pain Management

Coping with chronic pain is a difficult struggle that requires a lifestyle management approach focused on caring for body, mind and spirit. This struggle can be even more difficult when the cause of the pain involves a trauma, such as a motor vehicle accident, work-related injury, combat-related injury, assault or even complications from a surgical procedure. In some cases, a person who is exposed to a traumatic event can develop an intense fear response to the trauma — a psychological syndrome called post-traumatic stress disorder (PTSD). Given the high rates of co-morbidity between chronic pain and PTSD, and evidence suggesting that these two disorders interact in some way, efforts to develop more effective treatments for this population are greatly needed.

It is important to recognize that certain types of chronic pain are more common in individuals who have experienced specific traumas. For example, adult survivors of physical, psychological, or sexual abuse tend to be more at risk for developing certain types of chronic pain later in their lives. The most common forms of chronic pain for survivors of these kinds of trauma involve: pain in the pelvis, lower back, face, and bladder; fibromyalgia; interstitial cystitis; and non-remitting whiplash syndromes.

Some of the theories as to why this relationship occurs relate to personality development, neurobiology or neurophysiology, memory, behavior, and personal coping styles. If you have a history of any type of trauma it is essential that healthcare providers have accurate information about your experiences.

The prevalence of PTSD has been estimated to be between 20 to 34 percent in patients referred for the treatment of pain. The prevalence of pain has been estimated to be between 45 to 87 percent in patients referred for the treatment of PTSD. Data obtained from VA Boston Psychology Pain Management indicate that 50 percent of patients assessed met criteria for PTSD based on PTSD Checklist scores.

Patients with co-morbid pain and PTSD experience more intense pain, more emotional distress, higher levels of life interference, and greater disability than pain patients without PTSD. Due to the interaction of these conditions, these patients can also be more complex and challenging to treat.

Determining if a person with injury-related pain has PTSD is very important because research shows that individuals with PTSD who develop chronic pain experience greater difficulty coping with the pain, higher levels of pain and distress, and greater interference of pain in their lives than people who have no PTSD symptoms.

Pain often results from injuries related to events such as occupational injuries, motor vehicle accidents, or military combat. This has led to a growing interest in the interaction between pain and Posttraumatic Stress Disorder (PTSD), as research and clinical practice indicate that they frequently co-occur and can interact in such a way to negatively impact the course of treatment for either disorder.

Here are some symptoms of PTSD

• A person is exposed to a traumatic event that involves experiencing or witnessing an actual or threat of death or serious injury.
• They may begin to re-experience the event with reoccurring dreams and/or intrusive thoughts or "flashbacks" that can be very stressful.
• They may avoid thoughts, feelings, activities, people and places that remind him or her of the trauma. She or he may even avoid talking about the trauma or steer clear of the site of the accident or incident because it is too upsetting.
• They may have symptoms of arousal such as having difficulty falling or staying asleep, irritability and anger, difficulty concentrating, an exaggerated response to sudden loud noises or movements, and extreme watchfulness.

Individuals may begin to experience these symptoms immediately after a trauma or even months afterward (called delayed onset). Additionally, while some people who develop these symptoms recover within a few weeks or months, a number of people may continue to experience these symptoms for longer than three months and even years later (chronic PTSD).

Relationship between Chronic Pain and PTSD

While chronic pain and PTSD are conditions that may occur together, their relationship to one another is not always obvious and is often overlooked. PTSD can be overlooked because the health care provider, the patient and the family may be focusing on the pain disorder. At times, the patient's level of disability may be attributed solely to pain. Because there is such a close relationship between PTSD and chronic pain, they have been referred to as mutually maintaining conditions. This is because the presence of both PTSD and chronic pain can increase the symptom severity of either condition.

For example, people with chronic pain may avoid activity because they fear the pain—avoiding activity can lead to physical de-conditioning and greater disability and pain over time. Similarly, people with PTSD may avoid reminders of the trauma. This avoidance of activity can lead to the continuation of PTSD symptoms while also contributing to greater physical disability.

People with chronic pain may also focus their attention toward their pain while individuals with PTSD may unknowingly focus on things that remind them of the trauma. Consequently, people with both PTSD and chronic pain may have less time and energy to focus on more adaptive ways of coping with both their pain and fear. Furthermore, people with PTSD often experience symptoms of arousal and tension, which may decrease their tolerance for handling pain and increase their perception of pain.

The Role of Stress in Chronic Pain Management

Stress management and teaching relaxation response techniques are crucial components of a PTSD treatment plan. In addition, it is important to educate people about the connection between stress levels and pain symptoms, as well as understanding that stress management can also decrease suffering. Physically, chronic pain raises stress levels and drains physical energy, while psychologically it affects the ability to think clearly, logically and rationally, as well as to effectively manage feelings or emotions. Remember that in most cases if people can learn to lower their stress levels, they will also experience a decrease in their perception of pain.

It is important to learn how to self-assess your levels of stress and then learn how to develop some simple but effective stress management tools. I like to use the Gorski-CENAPS® Stress Thermometer concept. This concept proposes that there are ten levels of stress and when you get to the moderate to higher levels of stress your thinking and behavior are impacted.

Managing Your Stress Helps You Manage Your Pain

Another step in stress management is to learn how to identify and challenge irrational thinking that leads to uncomfortable emotions. For example if you’re under high stress the thought might be “I can’t stand this… I need to escape.” This in turn could lead to, fear, anger, anxiety, or even cravings to use self-defeating behaviors or even inappropriate pain medication for stress relief.

The next step is to be aware of and learn how to manage those uncomfortable feelings before they lead to self-defeating urges. Developing healthy feeling management skills is very important. Learning to share with trustworthy people is one way to deal with uncomfortable emotions. If the feelings are too intense or overwhelming, counseling or therapy may be necessary.

If those negative self-defeating urges do surface, it is important to learn how to make healthier decisions before indulging in self-destructive behaviors. There is a decision point between the urge and the behavior that is almost non-existent when people are under high stress. If people keep reacting to their impulses instead of thinking and responding they very well could indulge is self-defeating behaviors. That is why learning impulse control and delayed gratification is so important.

When you are more aware of your stress levels, you can then take action to reduce your stress, which in turn leads to a decrease in your pain symptoms. A very effective stress management strategy is exercise. In addition to lowering your stress levels regular exercise can also be an important part component of your pain management program. It is also important to reduce, or even eliminate, nicotine, caffeine, and sugar, and have a healthy eating plan.

Other stress management tools could include breathing and relaxation exercises, meditation, Yoga, Tai Chi, listening to soothing music, being in nature, soaking in a hot bath (or Jacuzzi), etc. Sometimes a good stress management plan includes appropriate activity pacing and taking time for leisure and recreational activities. An additional intervention is massage therapy, which also helps you with your pain management goals.

The major point to remember is failure to recognize and treat all of the coexisting disorders in crucial for successful treatment outcomes.  That is why it requires a collaborative multidisciplinary treatment team, with the patient being the captain of the team, to ensure helping people improve their quality of life and relieve their pain and suffering.  This Troubling Trifecta is in fact very treatable when the right treatment plan is put in place.