Growing evidence indicates that many individuals struggling with chronic pain and, consequently, opiate or other substance dependence are underserved and have limited treatment options. Whether a person receives opiates prescribed by a physician or obtains them illegally, the physiological dependence is the same.
An increasing number of traditional addiction treatment centers with 12-Step approaches have recognized the need to provide effective treatment for chronic pain while simultaneously addressing a patient's dependence on pain medications. Treating only the chemical dependency while ignoring the chronic pain problems that paved the way for that dependency does not provide a favorable long-term prognosis.
In fact, many patients served only by traditional chemical dependency programs without a pain management component often will leave the treatment program early, signaling the ineffectiveness of such an approach. Only with a comprehensive approach-one that considers all the patient's comorbidities-can good quality of life be restored.
According to psychiatrist Murray H. Rosenthal, DO, FAPA, “Depression, anxiety, coping, somatization, sleeplessness and hypochondriasis, among other comorbidities, are prevalent in the chronic pain population and, left untreated, are associated with greater risk for poor outcomes.”1 Rosenthal believes that the symptoms of pain and common psychiatric conditions often overlap, so much so that pain itself could qualify as a psychiatric condition.
Given all this, how can we best serve patients suffering from chronic pain without becoming part of the problem? Do we encourage them to abstain from all drugs and go to meetings? Do we admit they are powerless over their pain? Do we take them off one drug while prescribing another that will only prolong their dependence? Are holistic treatment procedures and traditional cognitive-behavioral therapy sufficient without the use of psychopharmacology? And what about sleep? Since sleep poses a major concern with this population, how do we help these individuals achieve the sleep requirements they need without the use of medications?
Pain specialists have traditionally had to deal with the noncompliant patient, the addicted individual, or the patient who desires to rotate off opioids. These issues were largely responsible for the development of the Chronic Pain Management Program at Casa Palmera, an addiction treatment center based in the San Diego area. The goal was to bring together skilled, experienced professionals with state-of-the-art holistic resources for comprehensive, integrated treatment of chronic pain associated with problems of dependence on pain medication, other drugs, or alcohol.
This program utilizes the “Share the Risk” model of an interdisciplinary and holistic approach. The treatment team includes psychiatrists, psychologists, addiction specialists, primary care physicians, anesthesiologists, nutritionists, acupuncturists and physical therapists. Treatment includes music, art and massage therapy; neuro/biofeedback with brain mapping; and laser therapy.
Casa Palmera's treatment approach for pain patients is based on an understanding of the variable effects and manifestations that substances might have on a pain patient. Treatment is individualized and tailored, and a minimum of medications are used to achieve pain control, while incorporating complementary therapies whenever possible. Great care must be taken to assess properly for and differentiate among abuse, dependence, pseudo addiction (aberrant drug behaviors), addiction, tolerance and withdrawal.
It must be understood that dependence does not necessarily mean addiction. Tolerance and withdrawal are universal with prolonged opioid treatment. Therefore, to diagnose addiction requires observance of repetitive, self-endangering and/or destructive behaviors.
Joseph Shurman, MD, chairman of the Pain Management Program at Casa Palmera and Scripps Memorial Hospital in San Diego, explains it this way: “The key with pseudo addiction is that with proper pain management, retrospectively, the patient's behavior normalizes. However, with the disease of addiction, in the genetically sensitive individual, behavior deteriorates with pain management.”2
Addiction, psychopathology and pain are related, co-occurring, interdependent and compounding brain diseases. In addition, all areas of illness, including any medical comorbidity, must simultaneously be managed in the pain patient. Successful management of one without the others would be a recipe for failure in all.2 It is important to avoid treatment of one illness that is likely to exacerbate another.
Reimbursement for treatment constitutes another complicating factor in the treatment of patients suffering from chronic pain with comorbid disorders. The dilemma for those individuals who cannot afford to pay and who wish to use their healthcare benefits occurs when payment is denied for medical procedures used in pain treatment by behavioral health or addiction treatment facilities. While many facilities accept insurance reimbursement for addiction and/or behavioral health, they are not credentialed or licensed to receive reimbursement from medical insurance.