Exploring the notion of ‘chronic pain addiction’

It has been reported that over 90 million Americans struggle with chronic, noncancer pain every day. It is estimated that more than 4.7 million members of this population are addicted to prescription narcotic or opioid analgesics due to long-term prescription medication use. This growing trend in America has caused concern within the healthcare community, increased awareness in alternative treatment methods, and has led to numerous studies which address ways to get ahead of this epidemic and reduce the negative effects on individuals and society.

A common thread emerging in the research suggests that psychological and addiction issues may predate the medication addictions, and correlations have been found to support the theory that chronic pain is itself an addiction. The additional research produced to address these findings is showing growing support for the use of several psychological treatment modalities to obtain and sustain long-term sobriety. Among the most promising modalities are motivational interviewing (MI), progressive relaxation therapy (PRT), stress management, acceptance and commitment therapy (ACT), mindfulness-based cognitive therapy (MBCT), guided imagery (GI), cognitive behavioral therapy (CBT), and a 12-step group process.

In the workers’ compensation and disability arenas, narcotic use, abuse and/or dependence can have far-reaching consequences, including stay-at-work (SAW), return-to-work (RTW), and start-back-to-work (SBTW) struggles which may result in both negative effects on the individual’s experience and a drain on society through increased instances of need and dependence on social support programs like Medicaid, food stamps, early Social Security Disability (SSDI) benefits, and the list goes on. In light of these negative effects, it is vital that the healthcare industry, workers’ compensation industry, and disability industry start working together to take a proactive, rather than the historically reactive, role in addressing these issues early in a treatment plan.

 

When the System BecomeS a Problem

As a workers’ compensation adjuster, over the years I have seen my fair share of injured workers who have developed medication addictions as a result of opioid use for chronic noncancer pain. It saddens me to know that the system, which was designed to protect the patient, in fact places them at increased risk in a potentially harmful situation. As a mental health counseling student, I have developed a desire to learn how to assist these individuals so they are able to avoid the potential harm and/or return to satisfying, productive lives. In my research of this subject, I have found several psychological modalities that have produced very encouraging outcomes, yet the first step is in identifying the problem, which should be done as early in the treatment of chronic pain as possible. In research findings, it has been discussed that chronic pain is an addiction and, as such, psychological treatment should be included in the pain management treatment protocol.

In the clinical setting, most chronic pain patients present with persistent pain, during which the patient may or may not voice the need for pain medication. The current medical approach is to use narcotic medications to address the pain issues. It is suggested that in addition, or possibly in place of, narcotic medications, a referral to a qualified pain management psychologist should be made to address potential barriers to recovery or secondary gain issues. Mandatory participation, while the narcotic medication is in use, seems to be an effective way in addressing these issues before, rather than after, a narcotic condition becomes a problem.

A qualified clinician should be well versed in motivational interviewing, progressive relaxation therapy, stress management, acceptance and commitment therapy, mindfulness-based cognitive therapy, cognitive behavioral therapy, and guided imagery. In addition, the clinician should also either personally conduct a group or have a referral list for the patient to attend a 12-step pain management program. The clinician should also be familiar with and able to administer assessments that can address malingering, such as the Miller Forensic Assessment of Symptoms (M-FAST), the Structured Interview of Reported Symptoms (SIRS), the Minnesota Multiphasic Personality Inventory 2 (MMPI 2), and the Substance Abuse Subtle Screening Inventory 3rd Ed., or any other assessments deemed necessary in order to adequately identify, diagnose and treat substance abuse and dependence issues.

Another critical part of the treatment regimen should also include a stay-at-work plan to keep the patient involved and prevent isolation. Another study, published by the Society of Personality and Social Psychology in August 2011, finds that individuals who experience an injury and are then isolated from society through off-work status or unaccommodated modified duty resulted in lack of motivation, increased sadness, and lack of desire to return to social behaviors which may include the work environment.

It is important to note that, if at any time during the treatment process, the clinician suspects the patient is noncompliant with treatment and/or is developing an addiction cycle or loss of interest in social functions, they can employ the M-FAST, which is a brief assessment, to address possible malingering. If the M-FAST suggests malingering, then it should be followed up with the more specific SIRS assessment to pinpoint the malingering. If the M-FAST does not suggest malingering, then other assessments, such as the MMPI 2 and/or the Substance Abuse Subtle Screening Inventory 3rd Ed., may be administered to either confirm or rule-out a potential substance abuse condition.

When trying to locate a suitable clinician, the case manager, adjuster, physician or decision maker should ask a potential provider if they are familiar with these modalities and assessments. They should also be able to convey how they would address these items in a comprehensive treatment plan and they should have clear objective goals with appropriate timelines and set reporting periods, such as after each visit, with an acceptable period between visits. The clinician should also be well versed in medical conditions, drug interactions and potential barriers to recovery, and they should be willing to actively participate with the treatment team and communicate regularly with other treating providers, including but not limited to the orthopedic surgeon, the physiatrist, the physical therapist, the chiropractor, and so on.

All and all, the end goal is to prevent needless lost time from work, medication addictions, and long-term care. It is in the best interest of the patient, society and healthcare to achieve these goals. Most important, all discipline’s ethical guidelines include a regulation much like the American Counseling Association’s (ACA) ethical code A.4, Avoiding Harm and Imposing Values, which states, “Counselors act to avoid harming their clients, trainees, and research participants and to minimize or to remedy unavoidable or unanticipated harm.” Therefore, to borrow a phrase from our forefathers as they so eloquently stated in the Constitution of the United States, it is incumbent upon those who are able to act, to do so in the best interests of the greater good.

 

Kelli Pacicco is a third year clinical mental health counseling student at Argosy University in Phoenix. She has experience as an indemnity workers’ compensation adjuster in Arizona, New Mexico and Utah. Contact: kpacicco@cox.net