A blog by Araminta Jonsson

The best approach to chronic pain treatment is multidimensional. Especially for someone who also has a problem with substance misuse. ‘Similar to other chronic conditions such as diabetes, hypertension, or asthma, both pain and addictive disease often have biological as well psychobehavioral contributors that may shape clinical expression. [1]’

When there is no way to kill the pain, because it is chronic, because addiction will eventually put the individual at a greater risk, we can only attempt to alleviate its cause or learn how to live with it through acceptance and healthy pain reduction techniques. Currently there here are no definite optimal solutions - only ongoing pain mediation ones.

When helping someone who is suffering with chronic pain, but also has a substance abuse problem, it is imperative that they are encouraged to look after themselves properly. A routine of self care is vital. Self care differs for everyone, but when someone is suffering from chronic pain and addiction there are certain self care ideas that may be helpful to suggest. For example: engaging in an addiction recovery group; meditating a couple of times a day; exercising - especially focussing on stretching before and after; working one to one with an addictions counsellor; attending a chronic pain peer support group if there is one available locally and positive distraction techniques such as engaging in pleasurable activities like art, crafts, gardening, outdoor activities, or volunteer work. There are also some very efficient evidence-based mindful meditation specific techniques focused on pain relief. These will help take the focus off the pain. Involving many specialists and disciplines when dealing with chronic pain and addiction is the best way to achieve positive outcomes. Both chronic pain and addiction are not usually able to be treated and cured in the same way as some diseases - they require treatment over a long period of time.

When someone with chronic pain is also addicted, it will further complicate the recovery process for both issues. When a person is in pain they will feel the need to frequently use medication that offers them some relief, further exacerbating the addiction to the drug. Equally when addicted, the addict will feel pain more intensely and use the pain to justify use of the drug. This creates a perpetual cycle of pain and addiction.

When treating an individual with chronic pain, it’s important to understand that there are certain characteristics of the illness that are also visible in someone with a substance use disorder. These can include high levels of stress, anxiety, anger and mood swings, irregular sleep patterns, unhealthy appearance and losses of certain functions.

There are many reasons that individuals who suffer with chronic pain may abuse alcohol, street drugs together with or in addition with their prescribed medications. Often they are attempting to self medicate their pain, they may also be using them to try to help themselves sleep, control their moods or simply numb negative and painful memories. When helping someone on their recovery journey, it is important to try and identify the individual’s reasons for using each substance and then seek to address the root of the issue. ‘Research suggests that there is a ‘high prevalence of chronic pain in patients seeking treatment for drug abuse.[2]’ There are many factors that may contribute to pain among those with addictions, including injuries and adverse childhood experiences. As we saw in an earlier blog: Early Childhood Experiences Cast Long Shadows, ACEs can increase an individual’s risk both of becoming addicted in later life, and also developing illnesses such as chronic pain as an adult.

Multidimensional Treatment Approach

When treating people with chronic pain and addiction, ultimately we want to help reduce their pain and any symptoms they believe to be associated with it. Ideally we want to stop all harmful use and abuse of substances and help them return to a physical, emotional and spiritual wellbeing and a life of quality that has meaning and purpose. The best way to achieve this is by using an interdisciplinary approach.

Ideal treatment would involve support from a GP, a psychologist or counsellor as well as local addiction providers who can help educate on self care such as nutrition, exercise and holistic therapies. It could also be useful to explore other personal issues such as relationships and financial issues. If personal issues are also a problem in your clients life, referring them for legal advice, accountancy consultations or relationship counselling will also help achieve the end goal of physical, emotional and spiritual wellbeing. Often however, we fail to join the dots and connect all of our services together. Ultimately doing clients a great disservice. More often than not, instead of exploring the services of other specialists with clients, and highlighting the importance of resolving presenting issues such stress, poor diet, lack of exercise and sleep, we resort to the easiest and quickest solution - increasing medication. While those without substance use disorders, may be aided by this approach, maybe even returning to a better quality of life, free from pain. Those with co-occurring chronic pain and addiction with simply form a further dependance on other medication.

Different Treatment Approaches

‘Effective treatment of chronic pain may draw from 4 broad categories: psychobehavioral, physical therapeutic, and interventionalist approaches, as well as medications.[3]’ There are a number of treatment modalities that have proved themselves to be successful both in the treatment of pain management and addiction. Among these are: cognitive-behavioral therapy, meditation,12-step programs, and exercise.

CBT can be used to help change thought patterns and behaviours, relating to both the chronic pain and addiction. For example, when people thinks that their chronic pain means that they will no longer be able to work, CBT can help them see that perhaps their work might change, but it may lead them to do something more meaningful and that they enjoy more. Equally when thinking about their inability to manage their pain without the harmful use of substances, they can be encouraged to think of other more beneficial ways to manage their pain, such as exercise and meditation. CBT can help reframe negative thinking such as “I can’t go through my whole life without another drink”, and changing it to “I can manage today without a drink”.

There have been studies conducted on the benefits of meditation for both pain and addiction[4]. 12 step programmes have been around for over 70 years helping people manage addictions, they are free and benefit individuals in a number of ways, including encouraging them to practice acceptance, find gratitude and instigate connection through peer to peer support. More recently 12 step programmes for chronic pain have come into existence, although currently face to face meetings aren’t available in the UK, there are online and phone meetings which people can attend.

There is plenty of research on the benefit of exercise for chronic pain management. ‘Exercise activates central endorphin release and descending pain inhibition. Aerobic exercise, such as cycling, using an elliptical machine, or walking, may improve circulation and tissue oxygenation, which in turn can improve healing.[5]’ There are also studies that ‘suggest exercise can improve outcomes in addiction treatment.[6]’ A study exploring exercise as a preventative strategy against relapse found that ‘those who attended at least 75% of the exercise sessions had significantly better substance use outcomes than those who did not.[7]’

Opioid Treatment for Addicts with Chronic Pain

When treating an addict with chronic pain, opioids should never be the first port of call. However, there are times when other treatment modalities and self management has not had the desired result and opioids are necessary. If this is the case, then extreme care must be taken. There is obviously an extremely high risk for a heroin addict or someone with a history of abusing prescriptions drugs to misuse opioids if prescribed them for pain. However, there is also a higher potential risk for an alcoholic or someone who has been addicted to another substance to also misuse opioids.

If opioids need to be prescribed working with the full multidisciplinary team is really important. It also may help to become stricter around their structure of care. This may include[8]:

  • Providing a smaller supply of medications at more frequent intervals;
  • Increasing supports for recovery from pain, addiction, and co-occurring disorders;
  • Increasing supervision including office visits, urine drug screens, and pill counts;
  • Selecting treatments carefully to limit reward (euphoria) when possible, as reward can trigger misuse
  • Assuring that the setting of care can provide optimal care coordination.

When pain and addiction cohabit, rarely is the journey to recovery a smooth one. It is important that everyone around the suffering individual, including family which can play a central role there, works together, communicates, is flexible and non judgemental. Supporting the individual throughout this process will be tough and patience and empathy will be necessary. Remember to celebrate the small victories because they are often massive stepping stones for those with co-occurring chronic pain and addiction.

Living with chronic pain is an awful, individual journey of loneliness, creating even more pain: no one is, nor can be, in anyone’s painful experience. Togetherness against pain, through understanding, compassion and support is crucial - from family, colleagues and of course professionals.