Chronic Pain, Addiction and Healing

1. Chronic Pain, Addiction and Healing

2. Addiction Often Starts with A Prescription • 259 million prescriptions were written in the United States in 2016. (Rate of 66.5 prescriptions per 100 people) • 4 out of 5 heroin users report that their addiction started with a prescription • In 2017 more then 1/3 of all adults prescribed Opioidsfor chronic pain Centers for Disease Control and Prevention. US drug overdose deaths continue to rise; increase fueled by synthetic opioids. Updated March 29, 2018. Accessed July 26, 2018.

3. Commonly Abused Pain Drugs • Alcohol • Hydrocodone (Vicodin, Loratab, etc.) • OxyContin & Oxycodone • Demerol & Dilaudid • Morphine & Codeine • Methamphetamine • Methadone

4. Commonly Abused Prescribed Pain Meds Sleep Medication such as Ambien, Lunesta “Non-Addictive” Pain Meds • Ultram/Tramadol • Soma Benzodiazepines

5. Tolerance, Dependence and Addiction Definitions developed by the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine. (Savage, Covington, Heit, et al., 2004) • Tolerance • Physical Dependence • Addiction • Pseudo Addiction

6. Tolerance Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time. (Over time, we need more)

7. Physical Dependence Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. (We experience Withdrawal)

8. Addiction Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environ-mental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

9. Pseudo Addiction Patient behaviors that may occur when pain is under-treated. Patients with unrelieved pain may become focused on obtaining medications, may "clock watch," and may otherwise seem inappropriately "drug seeking." Even such behaviors as illicit drug use and deception can occur in the patient's efforts to obtain relief.

10. Addiction vs Pseudoaddiction Pseudoaddiction Looks A Lot Like Addiction Patients May Appear To Be “Drug-Seeking” Patients May Need Frequent Early Refills Behaviors Are Caused By Under-Treatment Problematic Behaviors Resolve When The Patient’s Pain Is Adequately Treated

11. How Did We Get Here Trick or Treat

12. How did we get here? When doctors began prescribing opioids more liberally in the 1980s, they thought only a small fraction of patients would become addicted. We know otherwise today. (JAMA)

15. National Opioid Overdose Epidemic Drug overdose is the leading cause of accidental death in the US, with 52,404 lethal drug overdoses in 2015. Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015. From 1999 to 2008, overdose death rates, sales and substance use disorder treatment admissions related to prescription pain relievers increased in parallel. The overdose death rate in 2008 was nearly four times the 1999 rate. With more than 130 million individuals who suffer chronic pain, it is imperative we look at treating pain and addiction together as a seamless pain recovery program. ASAM - Opioid Addiction 2016 Facts & Figures

16. The Charleston Gazette reported that opioid wholesalers shipped 780 million oxycodone and hydrocodone pills into West Virginia over a six-year period — enough for 433 pills for every person in the state. Meanwhile, 1,728 West Virginians died from overdoses of those two drugs. Achenbach, Joel, The Washington Post, Dec. 23, 2016, An Opioid Epidemic is What Happens When Pain is Treated Only With Pills

17. Classification of Pain Types

18. PAIN: An unpleasant sensory and emotional experience associated with the stimulation of specialized nerve endings that signal actual or potential tissue damage. PAIN is always subjective. If one regards their experience as PAIN and if they report it as PAIN, who are we to judge another's physical feeling….It should be accepted as PAIN!

19. Acute vs Chronic Pain

20. Transition from Chronic Pain to a Chronic Pain Syndrome • Likelihood of developing a Chronic Pain Syndrome is unrelatedto pain intensity • Psychological variables (e.g., depression, anxiety, anger, somatic focus) and self-perceived disability consistently have been found to be the most accurate predictors of subsequent pain syndrome development

21. Recurrent Acute Pain Patients Experience Acute Pain Episodes Episodes Are Usually Brief Low Or Pain Free Periods Between Episodes Associated With Identifiable Precursors Needs A Separate Treatment Plan

22. Anticipatory Pain • Conditioned Pain Responses (Felt Sense Experiences of Pain) • Activated By • Environmental Triggers • Internal Psychological/Emotional Triggers • Associated With Previous Episodes of Pain

23. Three Components of Pain • Biological • A nerve signal that something is wrong • Psychological • We assign meanings to pain signals • Social/Cultural • Role assigned to the person in pain • Family & cultural beliefs about pain

24. Typical Psychological Conditions that Result from a Chronic Pain Syndrome • provides help for: • Addictive Disorders • Other Substance Use Disorders • Depressive Disorders • Sleep Disorders • Anxiety Disorders • PTSD & Other Trauma-Related Disorders • Bi-Polar & Other Mood Disorders

26. Pain and Stress = Toxins in Your Body Limits thinking Narrows problem solving Interferes with memory Increases heart rate, breath rate, and Increases blood pressure Increases aging Increases obesity Decreases absorption of nutrients Associated with depression Increases blood sugar and cholesterol Increases sticky platelets High muscle tension and decreased bone density Decreases Immune function Infertility

29. Pain Perception • Is it all in my head? • Why see a mental health professional? • Pain is medical! • Not psychological!! • Cultural factors

30. DEPRESSION and Chronic Pain • RATE of depression about 4 times higher among those with chronic pain than in the general population • Depression repeatedly found to be one of the best predictors of pain intensity and pain‑related impairment • COURSE: Risk highest within 2 years following pain onset • CAUSE OR EFFECT? Contradictory results thus far

31. Anxiety and Chronic Pain • Lifetime prevalence higher for Chronic LBP than for general medical population • Which Came First? Anxiety may predate Pain • Anxiety exacerbates pain and increases muscle tension

32. ANGER and Chronic Pain • Clinicians typically see chronic back pain patients as very angry • However, anger levels are no higher for individuals with CLBP than for the general population • When anger is present, it may exacerbate depression,intensify pain, and increase emotional distress • ACCEPT the patient’s report of pain. Much of their anger stems from past caregivers indicating that the pain was “all in their head”, or that it “had no physical basis”

33. What I see, I will be Fear & Avoidance(Vlaeyen, Kole-Snijders, Boeren et al.,1995; McCracken & Gross, 1993) Beliefs are more disabling than pain itself(Crombez, Vlaeyen, Heuts et al.,1999; Vlaeyen & Linton, 2000) Catastrophizing(Sullivan, Bishop & Pivik, 1995)

34. Accepting Persons Perception of Pain is Important

35. Catastrophizing • Strong relationships between catastrophizing and most indices of functioning: Pain intensity, disabilty and distress (Severeijins et al., 2001) • An exaggerated mental set, rumination on pain sensations, past, future & consequences, magnification, perceptions of self as helpless. (Sullivan et al., 2001)

36. Catastrophizing Cont…. Pain patients’ behavioral functioning is compromised Pain patients’ emotional functioning is also affected Beliefs & appraisals are strongly associated with behavioral and emotional functioning Acceptance also appears to play an important role in emotional and behavioural functioning

37. Other Life Problems • Sleeplessness • LEGAL • Lack of Intimacy • Reduced Activity-Isolation • Somatic Issues • Children Act Out • Memory Issues • Poor Self Esteem • Helplessness • Kineisophia

38. Treating Chronic Pain Syndromes • The presence of a chronic pain syndrome strongly suggests that medical interventions (including surgery) will not be effective. Therefore, accurately distinguishing between chronic pain and a chronic pain syndrome is critical for effective treatment. • Early treatment of pain syndromes may improve employment-related outcomes, but even those with longstanding syndromes generally improve dramatically with mindfulness class training within the context of a CPP.

39. Moving From Passive :Cure me Doctor to Being an ACTIVE PARTICIPANT Paradigm Shift

40. Pain Treatment Obstacles • Failure To Recognize Coexisting Disorders • Judgmental Healthcare Providers • Minimize The Seriousness Of The Pain • It’s All Their Fault • Imply That “It’s All In Their Head” • Patients’ Self Defeating Reactions • Noncompliance • Grief/Loss & Feeling Ashamed/Guilty • Treatment Resistance & Denial

41. Assessment • Complete Medical and Psychiatric Assessment with Blood Panel and DNA • Functional Capacity Evaluation • Psychological Testing, Clinical Pain Assessment • Psychosocial Assessment • Addiction History and Assessment • Nutritional Assessment

42. Types of Pain Medical Procedures Spinal Cord Stimulation Lumbar Sympathetic Blocks Peripheral Nerve Injections Facet Joint Injections Epidural & Trigger Point Injections Nerve Blocks Radio Frequency (RF) Procedures

43. Treatment • Medically Supervised Detox • Residential, PHP, IOP, Extended Care • Medical and Psychological Evaluation • Individual and Group Therapy • Family Work

44. Treatment Components • Interventions • Group & Individual Psychotherapy • Medication Education • CD Education • Psycho-Education Groups • Biofeedback/Relaxation-Response • Cognitive-Behavioral Techniques • Dialectical Behavioral Therapy • Visual Guided Imagery • Trauma Work: EMDR, SE • Hypnosis & Self-Hypnosis

45. Treatment Components • Active Therapy • Physical therapy • Occupational therapy (as needed) • Adaptive exercise classes • Hydrotherapy and Aquatic Therapy Programs • Body mechanics training • Manual therapies • Yoga & Tai Chi • Experiential Therapies

46. Non-Pharmacological Approaches Meditation And Relaxation Emotional Management Massage Therapy Physical Therapy Chiropractic Treatment Acupuncture Biofeedback Hypnosis

47. Other Non-Pharmacological Approaches Passive Proactive • Practice Yoga/Tai Chi • Follow Diet/Nutrition Plan • Practice Sleep Hygiene • Participate In Aerobics • Swimming Regularly • Frequent Nature Walks • Walking A Labyrinth • Learn & Use Self-Hypnosis TENS/RS Stim Units DBT, CBT, ACT Trauma Work through SE Life Coaching Hydrotherapy Aquatic Therapy Havening Rolfing/Hellar Physical Therapy Equine Therapy Hypnosis

48. Treatment Services Providing referral sources with comprehensive pre-admission assessments Comprehensive Multidisciplinary Diagnostic Assessments Residential rehabilitation treatment estimated to be a 4-6 week length of stay

49. Modalities Used • Acceptance and Commitment therapy (ACT) • Cognitive and Behavioral Therapy (CBT) • Dialectical Behavior Therapy (DBT) • Motivational Interviewing (MI) • Solution Focused Therapy (SFT) • Adventure Based • 12 Step Facilitation

50. Modalities Used • Chiropractic • Massage • Acupuncture • Somatic Experiencing • EDMR-Havening • Physical Therapy/Exercise • Adventure Based Interventions