There are many questions to be addressed when treating someone who has chronic pain and coexisting substance use disorders.  I start most of my Addiction-Free Pain Management™ trainings with three questions:

1. Are we managing pain but fueling the addiction?
2. Are we treating the addiction but sabotaging the pain management?
3. Is it addiction or pseudoaddiction?

The term pseudoaddiction is fairly new to the addiction treatment field but has been used in pain management for quite a while now.  I’ve worked with many patients who where labeled as prescription drug addicts when in fact it was pseudoaddiction.  One patient, Sharon is a great example of how damaging a misdiagnosis can be.  Sharon was in her early forties and came from a fairly normal and religious upbringing.  She had never used alcohol or any other drugs and up until a few years ago she had never used any psychoactive prescription medications either.

About three years ago Sharon began having infrequent migraine headaches.  She went to her general practitioner and was given Vicodin to help her cope.  This worked for her at the time, but we now know that she would have been better off on migraine specific medication.  Although barbiturates and opioids are sometimes considered effective for short-term migraine relief, many doctors recommend against prescribing them for long-term use because of the potential for dependence and abuse and the very real danger of developing medication overuse headaches (this is sometimes called pain rebound).

Sharon’s migraines started coming more frequently and she eventually needed to take more and more to get any relief.  As the dose increased her family and then her doctor became concerned that she had become “addicted” to the Vicodin.  Her doctor told her he couldn’t help her anymore unless she went into an addiction treatment program.  Her family found a program that advertised treating pain and prescription drug addiction.  That’s when Sharon’s nightmare began.  As she was detoxing from the Vicodin, the treatment center made her stand up in front of groups and identify herself as a drug addict.  They wouldn’t even let her say she was a prescription drug addict, which was humiliating for this very conservative woman.  

Unfortunately her migraines kept coming back after she was off all her medications.  To add insult to injury, when she asked for help they said she was just “drug seeking” and needed to “turn it over” and work the steps.  Even though I’m a big advocate of 12-Step support for people with addictive disorders, it can be dangerous for support groups, or treatment programs based in the 12-Step program to either label or advise chronic pain patients. 

Sharon was discharged from this program and with a letter to her doctor stating she was an addict and shouldn’t be given opiates anymore.  She became extremely depressed and near suicidal.  That’s when her family entered her into the pain clinic I was consulting for.  I met with Sharon several times and assessed her case.  I discovered her diagnosis never was an addictive disorder; she suffered from pseudoaddiction.

Pseudoaddiction is a term which has been used to describe patient behaviors that may occur when pain is under-treated.  Patients with unrelieved pain may become focused on obtaining medications, clock watch, or otherwise seem to be inappropriately drug seeking.  Even such behaviors as illicit drug use and deception can occur in the patient’s efforts to obtain relief.  Pseudoaddiction can be distinguished from true addiction in that the behaviors will resolve when the pain is effectively treated.

This was the case for Sharon. The clinic decided to use migraine specific medications as opiates are contra indicated for ongoing migraine treatment.  There are seven triptans (Imitrex, Maxalt, Zomig, Amerge, Axert, Frova, and Relpax) that were developed for and FDA approved as migraine abortive (management) medications. These medications work to actually stop the Migrainous process in the brain and stop the Migraine attack and its associated symptoms. 

Sharon responded well to Maxalt, but she also was put on preventative medication.  Ergotamine medications (used as vasoconstrictors for migraine prevention and are sometimes mixed with caffeine) such as DHE and Migranal; they are also FDA approved for Migraine treatment as is Midrin (a combination of acetaminophen, dichloralphenazone, and isometheptene).  Sharon was also prescribed Migranal.  Because of these two medications, her migraines were now being effectively managed.

Sharon was also prescribed an SSRI antidepressant as I implemented a cognitive behavioral therapy plan for the depression and pain-focused psychotherapy for pain management. Today Sharon is once again experiencing a great quality of life but still has nightmares about being in the treatment program.

I want to add that it is crucial to conduct multidisciplinary assessments and keep an open mind to discover whether a patient is experiencing addiction or pseudoaddiction.  Going back to my original three questions; Sharon’s general practitioner was at risk of fueling addiction and the addiction treatment program definitely sabotaged her pain management.  Sharon was experiencing pseudoaddiction—not addiction as everyone thought.  All of her addiction symptoms disappeared when she followed an appropriate and effective medication management plan, which enabled her to manage her migraines appropriately.

I often get calls or emails from people who have been diagnosed with Fibromyalgia and are very confused and frustrated.  The frustration comes from some medical providers not believing that the diagnosis of Fibromyalgia is a real condition.  I ran across an article “New Approaches to Treating Fibromyalgia” by Katherine Hobson - U.S. NEWS AND WORLD REPORT – Updated: 01/22/08. To go to this article please go to http://www.buffalonews.com/185/story/257658.html. I also want to highlight some of this article and comment on Ms. Hobon’s insightful perspective.

Sufferers of fibromyalgia experience a suite of symptoms: chronic pain throughout the body, sleep problems and fatigue. In some, this syndrome starts with no warning; others get it after a traumatic physical injury, a viral infection, or stressful life event. Symptoms can come and go.

For years, doctors thought the problem must be at the tissues or nerve endings — that is, at the places where it hurt. When they couldn’t find hallmarks of injury such as inflammation or nerve damage, many threw up their hands and chalked up symptoms to depression, anxiety, or that all purpose grab bag for female complaints: hysteria. Over the past decade or so, doctors have come to understand that fibromyalgia is actually a problem of the central nervous system — the brain and the spinal cord — not the peripheral nerves that branch into organs, limbs and skin.More recently, researchers using functional MRI scans have found that people with fibromyalgia have increased activity in areas of the brain dealing with where and how much it hurts. In other words, far from being whiners, they are wired to be exquisitely sensitive to pain. What also happens for many people suffering with this condition is they are prescribed opiates by well meaning doctors who want to help.  Unfortunately, due to the type of pain opiates don’t really address the real problem.  In fact most of the pain symptoms with this condition are neuropathic or burning type pain.  One of my patients described it like a lava flow going through different parts of her body.  I was very happy that in June of 2007 the FDA approved Lyrica for treatment of Fibromyalgia.  Several of my medical colleagues had been using it off label before but most insurance companies wouldn’t cover it and now many of them will.

Another problem is that many people do not realize that medication alone is not the answer either.  The best outcomes in fact are when the patient has a multidisciplinary approach.  This includes diet, nutrition, exercise, yoga or stretching, dealing with the psychological/emotional symptoms and an effective medication management plan.  For some people this may be Lyrica and for others one of the SSRI Antidepressants or the new SSNRI Antidepressant Cymbalta, which is also approved for some types of neuropathic pain management.

To learn more about Fibromyalgia please go to http://www.fibromyalgia.com.

Throughout my professional addiction treatment career I have been an advocate for people stopping all addictions when they decide to get into recovery. This includes smoking and chewing tobacco. Unfortunately, many of my colleagues do not agree—in fact, many of them are using nicotine addictively themselves.

I am writing this paper in an attempt to present objective reasons why people in recovery from alcohol and other drugs should also be in recovery for their nicotine addiction—and that nicotine recovery is possible and preferable. Part of my motivation is because I cannot stay silent when people I care about are dying from this addiction and they do not yet see that they have other choices. Fortunately, many addiction treatment programs are now starting to address this problem and have began to initiate nicotine addiction treatment plans.

Unfortunately, many programs—including some of the biggest and best—are afraid to go nicotine free. The rational is that people will not come to the program. I remember this same argument being used by Bar and Restaurant owners in California when people were trying to make those establishment smoking free. Many cried that they would lose their businesses. What actually happened was more people started going to restaurants and the business at bars was not impacted at all. Many addiction treatment programs that went nicotine free discovered the same thing.

A recent Alcohol Alert from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) stated that until recently, alcoholism treatment professionals have generally not addressed the issue of smoking cessation, largely because of the belief that the added stress of quitting smoking would jeopardize an alcoholic’s recovery. This report goes on to state that research has not confirmed this belief.

To read the remainder of the article please click here.