Effective Pain Management: Application to the Continuum

of AddictionEboni Winford, Ph.D.

Licensed Psychologist/Behavioral Health Consultant

Cherokee Health Systems

Addiction is a DiseaseNot a Sign of Weakness

Definition of Addiction (American Society of Addiction Medicine, 2014):

Addiction is a primary, chronic disease of brain reward, motivation, memory and related

circuitry. Dysfunction in these circuits leads to characteristic biological, psychological,

social, and spiritual manifestations. This is reflected in an individual pathologically

pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral

control, craving, diminished recognition of significant problems with one’s behaviors and

interpersonal relationships, and a dysfunctional emotional response. Like other chronic

diseases, addiction often involves cycles of relapse and remission. Without treatment or

engagement in recovery activities, addiction is progressive and can result in disability

or premature death.

Defining Pain

• International Association for the Study of Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

• A proposed definition: A distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive, and social components

Acute vs Chronic Pain

• Acute Pain: nociceptive pain associated with specific somatosensory stimuli, usually mechanical or inflammatory, and an identifiable peripheral injury or lesion; plays a functional role in body defenses

• Chronic Pain: transition from acute pain generally occurring at 12 weeks assuming the offending insult has healed; a shift to more prominent central sensitization and CNS mechanisms; no functional role

SUD – By The Numbers

• 30.5m individuals 12 years and older used an illicit drug(s) in the past 30 days

• 11.1m individuals experienced the misuse of a prescription pain reliever in the past

year

• 140.6m individuals use alcohol, 66.6m binge drink, and 16.7m are heavy drinkers

• 48.7m use cigarettes with 11.4m using one or more packs per day

• 19.7m individuals have a substance use disorder; only 12.7% needing care received

specialty addiction treatment

• 45.6% of SUD patients 18 years and older suffer from a co-morbid mental illness;

only 8.3% received care for both

www.samhsa.gov/data/report/2017-nsduh-annual-national-report

Pain and Addiction• Chronic pain affects more US adults than heart disease, cancer, and diabetes combined

• Gender, age, and socioeconomic status also affect the prevalence of chronic pain

• Health care costs for chronic pain are $261–$300 billion, while the indirect costs are $297–$336 billion annually

• In 1 large system, per-patient annual health care costs increased 40% following a diagnosis of a chronic pain condition

• In 2012, 55.7% of all adults reported some pain in the prior 3 months

• 31.7% reported moderate to severe pain

Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America. Washington, DC; 2011.

www.ncbi.nlm.nih.gov/books/NBK91497/pdf/Bookshelf_NBK91497.pdf. Published 2011. Accessed April 10, 2018; Schneiderhan J, et

al. JAMA. 2017;217(23):2367-2368; Park PW, et al. Pain Practice. 2016;16(8):1001-1011; Muneer S. American Health & Drug Benefits

website. www.ahdbonline.com/articles/2003-socioeconomic-burden-of-chronic-pain. Published October 26, 2015. Accessed April

11, 2018.

Pain and Addiction• In 2015, the estimated cost of the opioid crisis was $504 billion (2.8% of

GDP)

• $431.7 billion in fatality costs and $72.7 billion in non-fatality costs

• Some suggest the cost is up to $608 billion due to underestimation of fatalities

• An estimated 11.1 million people misused prescription opioids in 2017

• In 2017, there were an estimated 2.3 million people in the United States with an OUD

• 1.7 million related to prescription opioidsThe Council of Economic Advisers. The Underestimated Cost of the Opioid Crisis. Washington, DC; November 2017.

www.whitehouse.gov/sites/whitehouse.gov/files/images/The%20Underestimated%20Cost%20of%20the%20Opioid%20Crisis.pdf. Accessed April 11, 2018; SAMHSA. Key Substance Use and Mental Health Indicators in the United States. Rockville, MD: September 2017. www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-

FFR1-2016.htm. Accessed April 17, 2018; Huttman J. CEA reports underestimated costs of the opioid crisis. (2017) https://evolutionstreatment.com/cea-reports-

underestimated-costs-opioid-crisis/. Accessed May 3, 2018.

Pain and Addiction

• In 2016, opioid prescriptions were written at a rate of 66.5 per 100 persons, down from approximately 80 in 2012

• However, from 2006–2016, the days supply per prescription rose from 13.3 to 18.1

• From 1999–2015, opioid deaths increased 4-fold

• Within that category, heroin deaths increased x6 and deaths from synthetic opioids like fentanyl increased x10

• Opioid non-fatal overdoses accounted for approximately 145,000 emergency department visits and hospitalizations in 2014

• Prevalence of chronic pain in patients with OUD ranges from 37-60% (even 64% in one large EHR survey)

CDC. Annual Surveillance Report of Drug-Related Risks and Outcomes. www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf.

Published 2016. Accessed April 10, 2018.

Barry DT, et al. An evaluation of the feasibility, acceptability, and preliminary efficacy of cognitive behavioral therapy for opioid use disorder and chronic pain. https://doi.org/10.1016/j.drugalcdep.2018.10.015

Where Does This Leave Us?

Concerns: Patients

• Individuals with SUDs (both active addiction and in recovery) report concerns when presenting for pain management:• Fear of discrimination—”they’ll think I’m drug seeking”

• Fear of relapse—”I’ve been clean for 6 months, and I don’t want to relapse”

• Fear of withdrawal—”they’ll give me meds, and then they will stop prescribing, and I hate withdrawal.”

• Fear of inadequate pain management—”they know I use drugs so they probably won’t take me seriously.”

Concerns: Providers

• Individuals who provide care to those with SUDs also report concerns:• General distrust of those who have SUDs

• Fear of overtreating pain that may increase need for ventilation

• Concerns that pain reports are not true

• Fear of diversion

• Fear that patients will not complete course of recommended treatment

Current States of Pain and Addiction• Treatment of Pain

• Societal/cultural expectation that pain should be eliminated

• Frequent silo approach

• Medication focused

• Lack of provider education/practice guidelines

• Limited access to non-pharmacological treatment (e.g., behavioral therapy, interventional options, exercise/PT, CAM modalities)

Current Status of Pain and Addiction

• Treatment of Pain

• Yes, there is still a role for opioids, although the evidence is weak for reduction of chronic, non-cancer pain

• A graduated, structured approach to pain management is recommended: treat locally, behavioral intervention, sleep restoration, non-opioid pain medications, treatment of co-morbid psychiatric illness, and then consider opioids

• Use of practice guidelines such as the CDC prescribing guideline to improve risk profile and effectiveness of opioid therapy

What Do We Do About It?

Treating Chronic Pain in Individuals with Addiction

• Addiction and pain are interrelated• One often exacerbates the other

• Alleviating one often alleviates the other

• Individuals with SUDs are less likely to receive adequate pain management compared to those in the general population

• Inadequate pain relief is a risk for relapse

Chronic Pain: Treatment Goals

• Improved functioning & quality of life NOT elimination of pain

• More effective medical

visits

• Increased behavioral

activation & paced

activity

• Decreased avoidance

Chronic Pain: BH Interventions

• Assess the following:• Health behaviors

• Physical activity, avoidance behaviors, medication adherence

• Emotional & cognitive factors• Stress/anxiety, trauma history, depression, hopelessness, patterns in & triggers to

pain intensity, current vs. acceptable level of pain

• Social & environmental factors• Others’ responses to pain behaviors, social support

Chronic Pain: BH Interventions

• Explore goals

• Ask questions such as• How does the pain limit you?

• What would you be doing differently if your pain were reduced?

• What people and things does your pain cause you to avoid?

• What are your own goals for pain management?

• What, if anything, do you want to change?

Chronic Pain: BH Interventions

• Specific interventions• Address comorbid mental health diagnoses (e.g., depression, anxiety)

• Educate on gate-control theory of pain, mind-body connection, perceived benefits of pain

• Assess values

• Monitor changes in pain including exacerbating & alleviating factors

• Increased access to medical & behavioral health providers via frequently scheduled, regular visits

• Reinforce plan established with patient & PCP

Chronic Pain: BH Interventions

• Specific interventions• Pleasant activity scheduling

• Paced activity

• Anger management

• Sleep hygiene

• CBT strategies

• Values clarification

• Relaxation training

• Progressive muscle relaxation• Pursed lip breathing• Belly breathing• Guided imagery• Distraction

H E A L T H S Y S T E M S

Cherokee Together…ENHANCING LIFE

Sleep Hygiene

CBT Interventions

Cognitive distortions about

pain and its meaning

Relationship between mood

and pain (both ways)

Avoidance, aggressive

behaviors

ACT Interventions Can you have the pain and do what matters

to you anyway?

How has pain limited your ability to do the

things that are important to you?

If your pain was better controlled, what

would you be able to do that you’re not able

to do now?

What things have you tried that have

improved your functioning, mood, pain even

a little bit?

Wrapping It Up

Don’t Forget Compassion

• Repeatedly being exposed to individuals requesting opioids can reduce compassion and empathy and increase burnout and suspicion

• Also reinforces implicit bias and stereotypes about individuals who live with SUDs

Perspective