By – Peter Gannon, ARNP, MSN, BC – VP Medical Services – Board Certified Psychiatric Nurse Practitioner
The presence and treatment of pain in an individual suffering from substance abuse disorder presents a difficult and challenging situation for both the patient and health care provider. Concerns regarding giving narcotic medications to such a person out of fear of triggering cravings and relapse have generally dictated decisions regarding patient care for the past several decades. The need to review and rethink our beliefs, as well as our own prejudices regarding addiction, is vital if we are to effectively treat the problem while at the same time assure continued recovery for these individuals.
In recent years our understanding of addiction and its etiology has expanded significantly. The new DSM V diagnostic criteria reflect the concept that substance abuse occurs on a continuum ranging from mild to severe. We are beginning to realize that the idea of grouping all patients with substance abuse disorders (SAD) into the same category is generally unreasonable and ineffective. The use of narcotic medication is never without risk especially for someone with a history of a substance abuse disorder. There may be times however, when such medications are indicated. How then does this affect our concept of recovery and the treatment provided to the patient? If the patient requires certain medications for pain control does it necessarily mean that they have relapsed?
The impact of pain on the recovery process cannot be underestimated. Current research indicates that the presence of pain in individuals during the detoxification process is very common and is closely associated with continued long term substance abuse afterwards (Larson, et al, 2007). Pain affects the individual both physically and psychologically. A continuous low level stress response, as is associated with chronic pain, will have a negative effect on the body. Oftentimes, a decreased immune response and increased susceptibility to illness are are characteristic of these patients. Fatigue, malaise and sleeplessness are also commonplace. Emotionally, depression and anxiety can occur as a result of continued pain. Research shows that the presence of these can lead to increased perception of pain which in turn increases the already elevated levels of anxiety and depression (Kotz, et al., 2012). It is generally accepted that significant feelings of anxiety and depression, left untreated, lay a foundation for relapse and continued substance abuse.
There are three primary categories of pain: acute, chronic and end of life. Acute pain is an isolated situation which is usually a result of injury or surgery and is usually time limited in nature. Experts agree that this should be treated in the same manner for both addicts and non-addicts. If narcotics are required, special precautions should be taken by the individual with a substance abuse disorder. First, doctors and other practitioners providing care need to be made aware of the patient’s abuse history. Second, the patient should have a significant other in place that is willing and available to dispense medication when needed. Third, there should be a stop date arranged between the physician and prescriber at which time narcotic the medication will be discontinued and non-narcotic analgesics will be utilized if needed. Lastly, detoxification may be necessary for a brief period of time should symptoms of opiate withdrawal occur or if cravings for the drug are significant.
Patients who present with chronic pain usually report a 6 month history of pain which is generally unrelieved by medication, treatments or surgeries. Many also report a significant inability to function well in their activities or daily living. These patients are also very prone to both anxiety and depression. It is estimated that approximately 35% of patients suffering from chronic pain are also experiencing an addictive disorder (Chelminski et al., 2005). The goal of treatment for this group is the same whether they suffer from a substance abuse disorder or not, that is, the least amount of narcotic and non-narcotic medication should be utilized to obtain the greatest pain relief with associated level of functioning (Prater, et al., 2002). This does not necessarily mean the individual will be pain free however. Pain may become a part of the person’s life, but hopefully not to the degree where it will significantly impact their ability to work and be productive.
Treatment of pain issues should include a variety of medication and non-medication modalities. Therapies such as acupuncture, progressive muscle relaxation, guided visual imagery; meditation, etc. are all tools in the arsenal of pain relief available to the practitioner. Every effort should be made to focus on these complimentary techniques and less placed on medications which quickly stimulate the brain’s reward center. To a large degree, addiction is a learned response, especially in the patient experiencing acute or chronic pain. The positive reinforcement provided by opiate pain medications condition the patient to believe that pain relief cannot be achieved unless their brain feels the euphoric effects associated with the medication. This can be a very difficult obstacle for both the patient and practitioner to overcome. The health care worker must develop an environment of trust and caring before significant progress can be made in this area. With time and continued support, the patient will come to understand that their pain can be controlled, in many cases, without the use of narcotic medication.
For many practitioners, treatment decisions are influenced to a great degree by past personal experiences and exposure to addiction. Some may have been raised in an alcoholic family and have developed opinions and feelings regarding addiction based upon their years living in such a dysfunctional environment. Others may have been raised in a strong religious atmosphere where substance abuse is viewed as a personal and moral failing. The impact of past experiences and prejudices cannot be easily dismissed or overlooked when assessing and treating a patient with pain issues. Treatment for pain should never be withheld because of one’s personal beliefs or feelings regarding addiction or the addict. Treatment decisions need to be based on sound medical and scientific principles which focus primarily on the health and safety of the client. As our understanding of the disease of addiction grows, so should our willingness to treat it and all associated conditions in an ethical, humanistic fashion.
About the author:
Peter Gannon, ARNP, MSN, BC – VP Medical Services, New Beginnings Recovery Center/ Board Certified Psychiatric Nurse Practitioner. Peter oversee all medical services at NBRC. You can reach him at 888-840-5189. The NBRC website is www.newbeginningsrecoveryctr.com
