Recently I conducted a consultation and treatment planning session for a therapist whose patient has been on prescription opiates and benzodiazepines for over ten years. My colleague’s concern increased after her patient, who was significantly over-medicated, drove herself to therapy. My colleague’s patient didn’t seek out this problem. But after ten years of using only medication to address her chronic pain, as well as for emotional and stress management, the situation finally became too much for her—she became caught in a prescription drug trap.
According to researched published in Pain Physician Journal (2006), 90 percent of people in the US receiving treatment for pain management are prescribed opiate medication. Of that number 9 percent to 41 percent had opiate abuse/addiction problems. We also know that at least 80 billion dollars is spent for pain relief in the United States each year—a significant amount of that is for prescription medications. What is harder to quantify is the emotional cost to family systems when one or more members suffer with a chronic pain condition.
Peter Hart Research Associates report that in 2009 over 57% of all U.S. adults experience chronic pain—which translates to about 117 million people. While the vast majority of people with chronic pain may safely use pain medication, what may not be evident is that as many as 8.6 million to 11.7 million people taking prescription drugs also suffer from coexisting medication abuse or addiction problems.
The problem of abuse and addiction to pain medication has been gaining national attention as more and more recognized personalities admit to having difficulties. So how do intelligent, high functioning people get ensnared in a prescription drug trap and how can it be avoided? In my work with chronic pain and addiction over the last 25 years, I have found the leading cause is an under-treated or a mismanaged chronic pain condition.
In many cases the chronic pain patient has become a passive recipient of treatment and is unable to articulate his or her concerns about the course of treatment. They lack knowledge about effective pain management, the addiction potential of the medication they are using and how to foresee problems that may arise when taking potentially addictive medications. These patients are at a much higher risk for problems when they do not receive sufficient information and education about the medications they are being given.
In other situations the patient has had an addiction or there is a family history of addictive disorders which makes them significantly more vulnerable to abuse or addiction to their prescription medications. Or patients may have a pre-existing trauma history that makes them more susceptible to addiction. They often have a greater physical sensitivity to pain than the “normal” population. No matter what the underlying issues, non-pharmacological pain management tools are invaluable to help reduce the amount of pain medication patients need in order to effectively manage their pain.
Another major risk factor for patients is not identifying and managing the psychological or emotional components of their pain. Patients in denial about this risk factor often use their pain medication to cover up these symptoms. Negative thinking patterns often lead to uncomfortable emotions and the patient shifts from the physical experience of pain—“ouch this hurts”—to emotional suffering—“this is horrible, awful, terrible, and I can’t take it anymore.” The thinking and emotional components of pain often act like an amplifier circuit that boosts the intensity of the original pain signal.
When patients do not understand all of the components of a chronic pain syndrome they can experience increased use, abuse or addiction of their pain medications. It’s important for them to comprehend that Pain is a total biopsychosocial experience. They hurt physically. They psychologically respond to the pain by thinking, feeling, and acting. They obsess about the pain and try to figure out what is causing it and why they’re hurting. They also experience emotional reactions to their pain. They may get angry, frightened, or frustrated by their pain. They talk about their pain with family, friends, and coworkers who help them to develop a social and cultural context for assigning meaning to their personal pain experience and hopefully take appropriate action.
There are several warning signs or red flags for someone who may be at risk of abuse or addiction to their pain medication. Some of these indicators include the following:
- Frequently taking more medication than prescribed
- Using medications in physically dangerous situations, i.e., driving, childcare, etc.
- Experiencing problems with thinking, feelings and/or behavior due to medication use
- Quality of life and/or relationships are impacted by the use of medication
- History—or family history—of alcoholism or other drug addiction
- Using medication to manage psychological/emotional pain or to cope with stress
- Family members or friends report concerns about medication use/abuse
- Having considerable urges or cravings for the medication
It may be difficult to accurately determine the extent of some of these risk factors from the patient as they could be in denial, which is why obtaining information from significant others becomes so essential. A collaborative effort should be made that includes the patient, their support network, other healthcare providers, and any other sources that could more accurately determine the reality of the situation. If two or more of the Red Flag areas are present, it is time to seek a referral to an appropriate addiction specialist who can make a more accurate assessment to determine the presence of a potential medication abuse/addiction problem.
As mentioned above, patients may be in denial about their pain management which can become a major obstacle to effective treatment. If patients don’t recognize they have a problem it can be extremely difficult to find a solution. Many of the patients I have worked with had a mistaken belief that “I can’t be addicted because I’m in pain and a doctor gave me the medication.” This can be a type of denial if in fact they have been abusing or are addicted to their medication and experiencing life-damaging consequences. My colleague’s patient was stuck in this trap—despite the objective evidence of having ALL of the red flags mentioned above, along with her husband’s concern; she still didn’t believe she had a problem.
Effective pain management includes three core components that work together to systematically approach the treatment of pain at all three levels—biological-psychological-social—simultaneously.
The first component looks at physical treatments, including appropriate medication to reduce the intensity of the physical pain, as well as an effective medication management plan. The second component involves using psychological treatments to identify the thoughts, feelings, and behaviors that are making the pain more intense. Patients need to learn how to replace the negative thinking patterns with positive ones, as well as feeling and behavior management skills that work together to reduce the intensity of the pain. The third component of a truly effective chronic pain management plan is to support patients to develop non-pharmacological pain management interventions such as biofeedback, massage therapy, physical therapy, hydrotherapy, etc.
Effective pain management is possible if someone is willing to do the footwork and follow a strategic treatment plan using a collaborative multi-disciplinary treatment team. With the proper treatment planning and support, patients with chronic pain can have successful treatment outcomes. They can move from being a passive recipient (i.e., victim) to being an active participant in their healing process, so they can feel empowered and experience a higher quality of life.
