Pain & Opioid Issues

Pain causes stress, anger, depression, anxiety and hopelessness and so opioid use becomes opioid abuse which becomes addiction (and relapse).You self-medicate with opioids and sleeping pills and alcohol and then you get the anxiety and depression of a hangover and the pain and depression of opioid withdrawal symptoms… One merges with the next - pain, mental illness and addiction are completely interconnected - as if in a huge and tangled knot.

Here are some statistics which illustrate the interconnectedness of pain, addiction and mental illness.

• 32% of people with a chronic pain disorder also have an addictive disorder and 30.4% of pain patients misuse their opioids by taking more than they are prescribed.¹
• Between 29% and 60% (depending on the study) of people with an opioid addiction also report chronic pain.²

• People with a mental illness and a history of substance abuse are at higher risk of fatal opioid overdose.³ Recent studies indicate that 37% of chronic pain patients have co-occurring depression and 25% have co-occurring anxiety.

Interconnectedness – for Good and for Bad

But though pain, stress, mental illness and addiction can all exacerbate co-occurring problems, this interconnectedness also presents a fantastic opportunity – by reducing stress, anger, mental illness and substance abuse or addiction, you can also directly and immediately reduce pain.

Read on to learn more about:

• What kinds of people are more prone to opioid addiction.
• How a person in recovery should decide whether or not to use opioids.
• Checking yourself for signs of current opioid misuse or addiction.
• How your thinking habits affect your pain perception - and how changing your thinking with CBT can reduce pain.
• How to treat addiction while still managing pain.
• How to adopt more active pain management strategies.
  

Who’s Most at Risk of Addiction?

If you have a chronic pain condition, do you have to be overly worried about developing a co-occurring addiction?

Well, opioids are incredibly addictive and if you misuse them, addiction is likely. However, if you use opioids for legitimate pain relief and if you use them strictly as directed, your addiction risks are low.

That being said, at the epidemiological level, we can see that people with certain risk factors are more likely to misuse opioids and develop opioid addictions. If you have strong risk factors for opioid misuse and addiction, you should consider avoiding opioid therapy or enacting strict controls over your access and checks on your use.

Some examples of risk factors that may predict an increased addiction risk include:⁴

• Having a history of substance abuse.
• Having close family members with substance abuse problems.
• Having a mental illness.
• Being a male or a young adult (under 30).
• Having a pre-adolescent history of sexual abuse.⁵

Other, less obvious, signs that predict increased addiction risk include:⁶

• You smoke a cigarette within 5 minutes of waking.
• You have close friends with drug or alcohol problems.
• You are moody.
• You feel overwhelmed.
• People say you have a bad temper.

In Recovery and in Pain – Should You Use Opioids?

Opioids are dangerous for anyone with a substance abuse/addiction history, but on the other hand, uncontrolled pain is also a significant relapse trigger. Though people in recovery need to approach opioids with caution, in some situations, using opioids makes more sense than abstaining.⁷

• It has to be an individualized decision; you and your doctor have to weigh the potential risks against the potential benefits and proceed only if the likely benefits exceed the considerable known addiction risks.

If you and your doctor decide to trial opioids, you can reduce the risks of misuse by implementing control measures, such as:

• Asking for small prescriptions that need frequent refilling – this means you’ll never have an abundant supply on hand to tempt you. In some cases, you may even ask to pick up a one-day supply at the pharmacy each day.
• Agreeing to frequent office visits with your doctor and agreeing to bring in your medicines for pill counts.
  
• Agreeing to a drug testing program.
• Agreeing to have family members involved.

Checking Your Opioid Use

If you use opioids for pain, how can you know when you’re starting to slide toward addiction?

Use your opioids only as prescribed and you reduce your addiction risks. Use beyond the scope of your prescription (or use beyond a doctor’s care) and your addiction risks skyrocket.

If you ever take a higher dose than prescribed, take your medication more often than prescribed or supplement your prescription medication with other opioids, benzodiazepines, alcohol or other street drugs, then you are classified an opioid abuser/misuse, and at this point:

1. To prevent addiction, you should stop taking opioids differently from how they are prescribed to you (return to responsible use).
2. You should check yourself to make certain that you’re not already exhibiting signs of addiction.  

Warning Signs of Opioid Addiction

In the last month or so:⁸

• Have you felt worried about your opioid use?
• Have you used more opioids than you are prescribed?
• Have you ever asked to borrow opioids from another person?
• Has anyone you know expressed concern about your opioid use?
• Have you sourced opioids from anyone beyond your primary prescriber (friend, dentist, E.R. doctor, etc.)?
• Have you noticed memory or thinking problems?
• Have you felt quicker to anger than normal/gotten into more arguments than normal?
• Have you used opioids for reasons beyond what it is prescribed for – such as to boost mood?
• Have you had difficulty fulfilling your normal responsibilities?

How Thoughts and Attitudes Influence Pain

It’s surprising how much your attitude affects pain perception – in fact, your degree of pain catastrophizing is a better predictor of future pain and disability than current pain, disease type or the co-presence of a mental illness like anxiety or depression.⁹

Pain catastrophizing = a collection of negative beliefs about pain that affect your pain perception, for example:

1. An excessive focus on your pain and on the anticipation of future pain – ruminating on your pain.
2. Believing you are helpless to reduce or manage your pain.
3. Mentally exaggerating how much pain affects your ability to function.

Catastrophizing worsens pain in a number of ways, for example:

• We can see through MRI studies that people who hyper-focus on pain show greater activation in pain sensation areas of the brain after a painful stimulus.
  
• Pain catastrophizing is also linked to increased worry, stress, anxiety and low-mood – all of which are known to worsen pain.
  

If you live with pain and you catastrophize, there’s little doubt that your attitude worsens your pain. Fortunately, though it’s often hard to treat the underlying medical causes of chronic pain, learning to improve your attitude isn’t nearly as difficult. Cognitive behavioral therapy (CBT) is the most commonly recommended treatment for pain catastrophizing.

Cognitive Behavioral Therapy for Pain

Pain is pervasive; it affects all aspects of life. Though pain is usually physical in origin, it affects us physically, mentally, emotionally and spiritually. Persistent pain can change the way we think and feel and lead to mood disorders and maladaptive cognitive strategies (like pain catastrophizing) which can in turn further worsen the pain experience.

So though pain has physiological causes, you can often get significant pain reduction and quality of life improvements through time-limited, pain-focused therapies like CBT for pain.

CBT is an evidence based problem-solving-focused form of therapy - you look at what variables negatively affect your pain experience and then you learn and practice effective solutions to these problems. Some examples of problems you might seek to address with CBT techniques include:

• Reducing stress and anger in your life – learning effective relaxation and imagery strategies
• Learning more active coping strategies, such as activity pacing.
• Learning to combat irrational fears of re-injury that decrease activity and increase disability.
• Learning strategies to boost mood and to defeat maladaptive thinking patterns that increase anxiety and depressive symptoms.
• Learning better problem solving techniques.

CBT is a gold-standard psychological treatment for people with persistent pain, it gets you feeling better mentally, emotional and physically and it works in a hurry – typically providing results within 10 to 15 sessions.

Reduce Stress to Reduce Pain and Relapse

Stress increases pain and addiction relapse risks and worsens depression and anxiety, so if you live with persistent pain, learning stress management techniques can help you feel better across a number of domains.

1. Stress directly causes/increases pain in a number of ways, such as: by increasing muscle tension, increasing inflammation, reducing immune function and reducing digestive blood flow.
2. Stress also worsens your mood and outlook, and since psychological factors play a hugely influential role in pain perception – getting stressed out just makes pain feel worse.

To reduce the impact of stress in your life:

1. Reduce your stress exposure.
2. Learn to cope better with stress that you can’t avoid.

• Ideas to reduce stress exposure – learn to say no to excess commitments, find daily stressors and eliminate what you can, learn pacing strategies and get more organized.
• Ideas to cope better with stress – Learn relaxation, imagery or meditation exercises, stay social, stay healthy, avoid excessive alcohol, tobacco and drug use, get enough sleep and learn to communicate your feelings in a healthy assertive way.

Treating Addiction While Controlling Pain

When persistent pain leads to opioid addiction, how do you treat the addiction while still managing the pain?

The 2 primary options are:

1. Medical detoxification followed by abstinence based addiction treatment.
2. Medication assisted treatment (MAT) with methadone or buprenorphine (Suboxone).

Abstinence Based Treatment

Though the idea of detoxing from opioids while in chronic pain sounds scary, addiction-level opioid use often worsens pain, so eliminating opioids can actually reduce baseline pain levels. After detox, ongoing addiction treatment is combined with non-opioid-based pain management strategies.

Caution*** Under-treated pain can provoke opioid relapse, and since even short periods of abstinence can reset opioid tolerance to zero, relapsing to the same dose you used prior to your break can be deadly.

MAT (Methadone or Suboxone)

Alternatively, you can treat opioid addiction with methadone or buprenorphine. At appropriate addiction-treatment-level daily doses, both drugs:

1. Reduce or eliminate drug cravings
2. Provide a full day’s relief from opioid withdrawal symptoms
3. Offer some analgesia

Pain Relief with Methadone or Buprenorphine?

At typical addiction treatment doses, methadone and buprenorphine will offer some pain relief. Unfortunately, though the withdrawal and craving suppression half-life of these medications provides for a full-day of addiction related relief, both drugs only offer between 6 to 8 hours of analgesic potential.¹⁰

• In some cases, the analgesic window can be expanded to provide sufficient pain relief through split dosing – instead of taking your methadone or Suboxone once a day, you would take it 2 or 3 times daily.
• Since getting addiction under control reduces pain (reduced stress, reduced peak and valley opioid bloodstream levels, etc.) methadone or buprenorphine alone, when combined with non opioid based forms of pain control, may provide sufficient pain relief.

Supplementing MAT with Short Acting Opioids

Some people will not get sufficient pain relief from methadone or Suboxone alone. Fortunately, people on methadone can still take supplementary short acting opioids for pain control without excessive addiction risk.

1. At sufficient daily doses, methadone will block the euphoria potential of additional opioids.
2. This means that you can take additional opioids for pain as needed, without getting high.
3. Since additional opioids won’t get you high, you aren’t likely to misuse them.¹¹

Non Opioid Pain Management

Opioids work well to reduce pain, but when you need chronic analgesia you have to weigh the potential benefits against the serious potential risks, like serious side effects, decreasing effectiveness, addiction risks and more.

So when you need persistent pain relief, you can avoid many of these negative opioid effects by reducing your opioid need with alternative forms of pain management.

Some examples of alternative forms of pain management include:

• Non opioid based medications
• Heat or cold therapy
• TENS machine therapy
• Occupational or physical therapy
• Stretching and exercise
• Cognitive behavioral therapy and other forms of psychological therapies
• Nerve blocks
• Acupuncture

Learning to Live with Pain (Active Coping)

There are 2 basic forms of pain management:

1. Passive pain control (listening to your doctor’s advice, taking medicines, etc.)
2. Active pain control (learning to pace yourself, controlling stress, staying socially active, etc.)

Though you’ll probably need to use of a combination of strategies, research shows that people who take an active role in pain management have less disability, less pain, a better sense of control over life, less healthcare costs, better sleep and more!¹²

So rather than waiting for a pain-cure that might never come and rather than relying solely on outside experts and medicines for relief – take a turn in the driver’s seat and get active with pain management strategies that really work.

Some examples of active pain management techniques include:

• Learning effective distraction, relaxation and imagery techniques.
• Learning pacing strategies.
• Learning to control stress, anger and other negative emotions that can increase pain.
• Learning to improve your mood (depression increases pain and pain increases depression).
• Learning how to stay socially active without overdoing it.
• Learning to become a more active user of healthcare services.
• Making full use of ergonomic solutions to ease discomfort

If you can’t eliminate pain, you can at least learn to live with it so that it doesn’t derail your quality of life.