The Stages & Phases of Concurrent Treatment

Posted on Monday, April the 7th at 11:13pm

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

When discussing Addiction-Free Pain Management® (APM) Stages and Phases of Concurrent Treatment for patients with chronic pain and coexisting addiction, I’m often asked when someone has chronic pain and addiction, which condition do we treat first?  Many people think it’s one or the other.  But it’s not really that simple. 

For example if you have an arbitrary 100 units of treatment available, it doesn’t mean you use 50 for pain and 50 for addiction.  Instead I believe that a multidisciplinary assessment is necessary in order to see which condition needs the most intervention first; but you never ignore the other condition.  Sometimes that means 80-90 percent of the treatment focus is on pain management, but you still pay attention to the addiction with the remaining 10-20 percent of your effort—it can also be the other way. 

When I teach health care professionals how to implement the Addiction-Free Management® system in their agency we first address addiction treatment issues and then pain management.  However, in the real world it wouldn’t work this way.  In trainings I break them apart artificially so team members can understand what each of the components are and how they all work together. 

For the purposes of this article we’ll begin with pain management, but remember if the addiction is out of control you would start there.  The most important part of the process is conducting a multidisciplinary assessment—in real world treatment you would be assessing both pain and addiction concurrently.  This would be the time to implement a medication detoxification or taper as well as other safer interventions if needed. 

It is vitally important that patients learn how to differentiate between the physical and psychological-emotional symptoms of pain which is described in the first exercise of my APM™ Workbook.  The patient must also understand what denial is and be taught how to identify and manage it.  They need to see how it undermines an effective pain management program, as well as supporting them to look at the payoffs or secondary gains they may have for being in pain. 

Now is the time to begin teaching patients non-pharmacological pain management interventions.  The APM™ system supports them to build their nonpharmacological pain management plan—in fact this is an ongoing process, after which they develop relapse and pain flare up plans for pain management.  In the real world this happens concurrently with the addiction relapse intervention plan.  This pain plan also includes craving management to help ensure that the patient adheres to their medication management agreement.

One of the major obstacles facing patients with chronic pain is grief and loss over their prior level of functioning, so we evaluate this and develop a treatment plan to address it.  Many patients 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. 

If patients are not yet fully stabilized with their addictive disorder, 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. 

It’s important to make sure patients resolve any grief caused by their chronic pain condition and 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.” 

During this stage patients also need to resolve other core-psychological issues—this is of course contingent upon them being stable in their addiction recovery.  The same holds true for deeper work and the resolution of any trauma history. 
Another important component is reviewing and refining the patients’ activity pacing plan.  Some patients are at one end of a spectrum where they have been immobilized and need to step up their pace; while others are major over-achievers and need to slow down.

Now that we’ve seen how Addiction-Free Pain Management® addresses pain management, let’s switch to addiction treatment; also known as the Developmental Model of Recovery Transition and Stabilization.  As with pain management, we conduct a multidisciplinary assessment.  The addiction professional needs to assess the potential level of the addictive disorder and differentiate between prescription drug dependency, abuse, addiction and pseudoaddiction. 
Then they need to identify and begin developing a treatment plan for denial management and treatment resistance.  Patients need to learn the crucial skill of stress and craving management for two important reasons.  First, stress turns on or exacerbates Post Acute or Protracted withdrawal symptoms; and second stress also amplifies or intensifies the level of pain the patient is experiencing.

Next is the development of a collaborative biopsychosocial treatment plan while keeping in mind the recovery skills needed in each stage of the Developmental Model of Recovery.  Many patients with addictive disorders isolate, which happens even more when they also have a chronic pain condition.  Therefore, it’s important to introduce appropriate social support at this stage, keeping in mind however that traditional 12-Step groups like AA or NA might be dangerous because of “don’t take nothin’ no matter what” attitudes.  Pills Anonymous or chronic pain support groups may be a better intervention here. 

In the next phase, which is also known as the Developmental Model Stage of Early Recovery, we continue to monitor and manage denial—remember denial is always the first stage of a relapse.  The major task here is to teach patients to recognize and manage high risk situations that could lead them to deviate from their medication management contract or to choose ineffective pain management strategies.  We also want to help patients explore and develop a management plan for their relapse justification.  The most common one might be “I have to take something or I’ll suffer forever” or words to that effect. 

As on the pain management side, we need to assess for and put a treatment plan in place if a trauma history is uncovered.  Unresolved trauma can lead to relapse or to an intensified pain perception.  We want to look at trauma as a possible precursor to the addictive disorder or other psychological conditions, including a psychologically based pain disorder. 

The final phase of addiction treatment also known as the Middle to Late Stage of Recovery, patients need to shift from externally motivated recovery to internal motivation where they begin to demonstrate a willingness to access social support groups.   When patients are internally motivated toward recovery, they are stable enough and ready to work on core psychological issues and unresolved trauma.  Unfortunately many patients relapse in this phase because they continue to use early recovery tools on late stage recovery problems. 

The last treatment intervention is to finalize and fine tune the patients’ relapse prevention plans that include high risk situation management and core psychological/trauma issues. 

To learn more about the phases and stages of treatment for someone with chronic pain and a coexisting addictive disorder please check out the publications page for my new book Managing Pain and Coexisting Disorders; sign up for my free E-Newsletter to receive monthly updates on the Contact page, read my latest Blogs, or check out the Services page to see how we might be able to work together.