The Need for Multidisciplinary Chronic Pain Treatment

Posted on Monday, June the 2nd at 8:59pm

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

For years the numbers of people experiencing chronic pain and coexisting psychological disorders including addiction have been increasing significantly. According to the International Association for the Study of Pain in 1999 there were approximately 86 million Americans suffering from chronic pain. In 2003, according to Peter D. Hart Research Associates, the number increased to over 117 million adults—about a 35 percent increase. 

According to researched published in Pain Physician Journal (2006), 90 percent of people in the US receiving treatment for pain management are prescribed opiate medication. Of that number 9 percent to 41 percent had opiate abuse/addiction problems. We also know that at least 80 billion dollars is spent for pain relief in the United States each year—a significant amount of that is for prescription medications. What is harder to quantify is the emotional cost to family systems when one or more members suffer with a chronic pain condition.

Living with chronic pain is very difficult. If a person also has a coexisting addiction or other psychological disorders it becomes even harder. Their self-esteem is practically non-existent and many of them lose the support of their significant others. People with chronic pain and coexisting disorders often become depressed and feel a deep sense of hopelessness. Healthcare providers often become confused and frustrated when their treatment interventions are ineffective, and often blame the patient. Given the biopsychosocial nature of chronic pain it is imperative to utilize a multidisciplinary treatment plan. 

But first a warning - chronic pain patients must be wary of any health practitioner who claims to treat pain, yet only recommends one thing, such as medication management, or chiropractic adjustments or acupuncture. True multidisciplinary pain management involves a host of interventions such as physical therapy, massage, medication management, counseling or therapy, biofeedback, occupational therapy, exercise physiology, an addictionologist, an anesthesiologist or pharmacologist, and a case manager. It may also include some type of movement therapy such as Tai Chi, classes on spiritual wellness, yoga or meditation.

The Addiction-Free Pain Management® (APM) System was developed to address the specific biopsychosocial needs of this under-served population. Historically, addictive disorders and pain disorders have been treated as separate issues. However, to effectively implement an APM approach, the addictive disorder, other coexisting psychological disorders and the chronic pain must be concurrently addressed. The APM™ System requires looking at the whole person, which means treatment plans for the biological, psychological, social, and spiritual domains. We need to work with patients—not on them. The whole person also includes that person’s family and significant others. This can best be accomplished by using a truly integrated multidisciplinary treatment team that teaches the patient how to be the Captain of their healthcare team.

APM™ treatment starts with a multidisciplinary assessment including medical, mental health and addiction.  In order for someone with chronic pain and coexisting disorders, including addiction to achieve effective pain management, the implementation of a multidisciplinary treatment plan is essential.  A collaborative multidisciplinary team is crucial in treating the synergistic problems people and their families’ face that have been severely impacted by chronic pain, addiction, and other psychological disorders. When these conditions coexist it creates a major challenge that must be addressed by utilizing a collaborative treatment approach. Effective treatment can be challenging and confusing for counselors, therapists and other healthcare providers, but especially for patients and their families. The APM™ strategic three-part approach can improve treatment outcomes and give families new hope.

For any healthcare provider to work effectively with this population, they need to understand and integrate the principals of the Addiction-Free Pain Management® (APM) system into their treatment protocols. The APM System consists of three major components: (1) A medication management plan—in consultation with an addiction medicine specialist; (2) A cognitive-behavioral treatment plan addressing pain versus suffering, treating family system issues and changing self-defeating behaviors, using eight Core Clinical Exercises from the Addiction-Free Pain Management® Workbook; and (3) A nonpharmacological pain management plan—developing safer medication-free ways to manage pain. Most pain patients need a strategic combination of all of the above.

Medication Management

Some pain disorders require pharmacological (prescription drug) interventions. Other conditions may respond to over-the-counter medications like aspirin or ibuprofen.  Still other conditions may need a combination of both. Some pain disorders can be effectively treated medication interventions as noted in the table below.

Medication Management Approaches

• Acetaminophen and nonsteroidal anti-inflammatory medications used alone to treat mild to moderate pain symptoms.
• Acetaminophen and nonsteroidal anti-inflammatory medications used with opioids to treat more severe pain.
• SSRIs like Prozac, Effexor, Lexapro, or Celexa, improve mood as well as help relieve pain, reduce fatigue and improve sleep problems.  There have been reports about SSRIs being helpful for some types of neuropathic pain symptoms.  Using an SSRI and a tricyclic antidepressant (such as Amitriptyline) together may be more successful at breaking the cycle of pain, depression, and sleep problems caused by chronic pain than using just either one alone.
• Adjuvant medication, such as antidepressants, anticonvulsants, steroids, anxiolytics, and muscle relaxants, can also be considered for pain relief to boost and/or assist other pain medication.

It is important to remember that for people with a genetic or personal history of an addictive disorder, any psychoactive medication could be problematic. Unfortunately, there may be times when opiate (or opioid) medication management is needed, but there are risks. (See table below)

Efficacy and Risks of Opioid Medication Management

• Opioids have been shown to effectively reduce cancer and acute pain conditions and they can also share a role in the management of chronic pain.
• Opioids may be inappropriate for patients with substance use disorders or a history of those problems.  If any psychoactive medications are used, providers must take special precautions.
• Concerns about side effects, such as functional impairment and physical inactivity, as well as concerns about physical or psychological dependence, must be taken into consideration when using Opioids for chronic pain management.
• Physical dependence is a physiological adaptation to a substance, defined by a growing tolerance for its effects and/or withdrawal symptoms when use is reduced or ends. 
• Psychological dependence (often called addiction) is a primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. 
• Psychological dependence may occur with or without physical dependence and is conceptually characterized by impaired control over drug use, compulsive use, continued use despite harm, and craving for the psychic effects of the drug.
• What appears to be psychological dependence may be due to pain that is under treated.  This is also known as Pseudoaddiction. 

Cognitive Behavioral Treatment

This component consists of the eight Core Clinical Exercises from the Addiction-Free Pain Management® Workbook. The major purpose of each of the workbook exercises is not for the patient to just “fill out the forms;” the goal is to increase their understanding about their condition and show them what it takes to heal all of the biopsychosocial areas of their lives. For patients to obtain the most benefit they need to process each of these exercises with a clinician who uses a combination of Cognitive Behavioral and Rational Emotive therapy interventions.  What follows is a brief description of each of these eight exercises. 

Exercise One: Understanding Your Pain—Many chronic pain patients don’t have the words necessary to accurately describe the symptoms they are experiencing. Therefore in this exercise patients review and analyze a list of common symptoms that people who live with chronic pain experience and then they are asked to identify the ones that affect their own lives. Next they learn to differentiate between their physical (ascending) pain symptoms and their psychological/emotional (descending) pain symptoms. They also examine their TFUARs (Thinking, Feelings, Urges, Actions, and the Reactions of others) and how they change when they experience a bad pain day.

Exercise Two: The Effects of Prescription and/or Other Drugs—Often chronic pain patients use a variety of different medications to treat chronic pain and the underlying medical disorders that are causing the pain. In Exercise Two patients explore the benefits they experienced from using problematic pain medication (including alcohol) and other drugs and what they wanted to get from using the chemicals. They also identify the problems that they experienced as a result of problematic pain medication (including alcohol) and other drug use.  

Exercise Three: Decision Making About Pain Medication—In this exercise patients look at the reasons why they started using problematic pain medication (including alcohol) and other drugs, make an assessment of life damaging problems they experienced as a result of using chemicals, and explore reasons for deciding to do something different.  

Exercise Four: Finding the Solution—In this exercise patients define what their medication management and recovery plan will include. They complete and sign a medication management agreement that details their adherence to this commitment. Next they develop a relapse prevention intervention plan that describes the responsibilities for themselves, their counselor, and three significant others to stop a relapse process quickly should it occur. Finally they develop a personal craving management plan and a pain flare up plan to support them if they feel tempted to deviate from their medication management agreement.

Exercise Five: Identifying and Personalizing High Risk Situations—It is important for patients to learn how to identify the immediate high risk situations that can cause chemical use and ineffective pain management in spite of their commitment not to. In this exercise they are instructed to review a list of common High Risk Situations that can activate the urge to use/abuse problematic pain medication (including alcohol or other drugs) and/or sabotage their effective pain management program. Next they are asked to identify and personalize their own most important (critical) High Risk Situation and write a personal title and description for use in self-monitoring. 

Exercise Six: High Risk Situation Mapping—Patients are asked to describe one past situation in which they experienced their immediate high risk situation in recovery and managed it poorly.  This situation map is used to help them identify the pattern of self-defeating behaviors that drive their relapse process. Next they identify one past situation in which they experienced their immediate high risk situation in recovery and managed it effectively. This situation is used to identify new and more effective ways of coping with their high risk situation. These new behaviors become the foundation for Future High Risk Situation management and recovery planning. 

Exercise Seven: Analyzing and Managing High Risk Situations—In this exercise patients are asked to analyze the immediate high risk situation they are learning to manage. Here they identify the irrational (addictive) thoughts, unmanageable feelings, self-destructive urges, self-defeating (addictive) actions, and reactions of others (TFUARs), that drive their high risk situation. They learn how to manage this kind of high-risk situation more appropriately by identifying three points where they can use more effective ways of thinking, feeling, and acting to avoid relapse. They are encouraged to apply these new ways of coping to future high-risk situations. 

Exercise Eight: Recovery Planning—Patients develop a schedule of recovery activities that support the ongoing identification and effective management of their high risk situations. They are instructed to write a schedule of recovery activities and explore how each activity can be adapted to help them identify and manage their high risk situations.

Summarizing the Core Clinical Exercises—The first two exercises in the workbook are data gathering or assessment instruments focusing on pain. Exercises three and four are motivational with a goal to help patients make better choices with their pain management and develop a plan to implement more effective pain management strategies. Exercises five, six, seven, and eight are relapse prevention counseling exercises, and the goal of exercise eight is to develop a recovery plan to address future high risk situations for pain and addiction.

Nonpharmacological Interventions

Nonpharmacological treatments have proven effective for some pain conditions. Studies have shown that endorphins mediate the analgesic effects of acupuncture and placebos as well. Still to be discovered is the mechanism by which hypnosis accomplishes its analgesic effects. 

For optimal effectiveness, an Addiction-Free Pain Management® treatment plan uses both Medication Management and Cognitive Behavioral interventions described above along with the Nonpharmacological Processes. Since each patient has problems and needs that are unique to them, different combinations of the above interventions will be necessary. The treatment team collaborates with the patient to decide how to strategically combine these three components.

Below is a brief list of some the nonpharmacological interventions that can be utilized.  It’s important to remember that the only limitation to the types of interventions possible is the clinician or patient’s imagination

• Exercise and Stretching
• Cognitive Restructuring
• Diet/Nutrition
• TENS Unit
• Physical Therapy
• Reflexology
• Yoga
• PA / AA /NA-type 12-Step Meetings
• Meditation
• Cranial Sacral Therapy
• Hydrotherapy
• Acupuncture
• Talking Circles
• Rolfing or Heller Work
• Sweat Lodges
• Tai Chi or Qui Gong
• Hydrotherapy
• Biofeedback
• Hypnosis and Self-Hypnosis
• Neuro Linguistic Programming ( NLP)
• Family/Couples Therapy
• Art Therapy i.e., collage, pottery
• Sleep Therapy
• Traditional Native
• Tribal Healing
• Volunteer Work

Chronic pain patients have a much better chance of quality recovery when their healthcare providers use a combination of Medication Management Components, the APM™ Core Clinical Exercises, and appropriate Nonpharmacological Treatment Processes. It is the healthcare providers’ responsibility to be aware of all potential resources in their communities.  For more information about Addiction-Free Pain Management® please check out the remainder of our website www.addiction-free.com.or feel free to contact us at (916) 575-9961.