The Chemically Addicted Pain Patient

The patient with chronic benign pain represents a large population of people who suffer greatly, function less than optimally, experience severe impairment in family, social, sexual, and vocational functioning, and who impact the medical system in a highly costly manner. A subset within this population in the chemically addicted, chronic pain patient (CACPP) who represents anywhere between 3% and 18% of the chronic pain population (Fishbain, Rosomoff, & Rosomoff, 1992). This individual, to be differentiated from the patient who manifests a physical dependence only, meets the diagnostic criteria for addictive disorder as well as a pain disorder. The addiction typically includes overuse or abuse of prescription medications, such as, opioids, steroids, and sedative/hypnotics, but also includes over-the-counter aids and commonly used street drugs, such as, marijuana, cocaine, and amphetamines. Alcohol is often involved as well. Unlike the individual who has a physical dependence on prescription medications, the CACPP places a heavy financial burden on the health care system, utilizes medical services more extensively, repeatedly fail medical treatments, undergoes multiple surgeries, and are a source of extreme frustration for the primary care physician. The addicted pain patient has 1) more doctor visits per month, 2) more ER visits per month, 3) more than one dispensing pharmacy, and 4) more pain-related hospitalizations per year than patients who do not present with an addictive disorder. In this age of cost containment, the CACPP will receive extensive medical treatments with little or no long-lasting benefit.

For this sub set of patients, factors other than nociception, i.e., avoidance of responsibilities, financial rewards, attention and sympathy, and personality dynamics, serve to maintain not only pain but also pain behaviors, including medication usage. The need to communicate suffering to others seems to be important when exploring the dynamics of the CACPP. In a study exploring the interpersonal model of physical symptom presentation, Skenderian (1981) found that illness behavior, similar to the behavior of the CACPP, is designed for the purpose of controlling interpersonal behavior in order to avoid intimacy. Addicted pain patients show similar characteristics in that much of the pain experience is maintained by pain behaviors that serve to satisfy other unmet psychological and emotional needs. Intimacy is clearly avoided leaving the focus of interchange on the symptom itself.

The individual who is at high risk for becoming a CACPP usually has a preexisting addictive disorder, a positive family history of mental illness and/or chemical dependency (Maruta, Swanson, & Finlayson, 1979), a premorbid psychological disorder, such as, anxiety, depression, post-traumatic stress, or somatization, and/or personality characteristics that negatively modulate the experience of pain (Turner, Calsyn, Fordyce, & Ready, 1982). The CACPP medicates not only the physical pain but also any psychological discomfort that magnifies the pain experience, such as, anxiety, depression, etc. The addictive use of pain-relieving medications increases medication tolerance while at the same time lowers pain thresholds. He or she is in a self-defeating, destructive cyclical pattern that eventually leads to personal despair, family stress, occupational impairment, and overall frustration and anger for both patient and physician.
Moreover, cognitive impairment often accompanies medication abuse that, in turn, distorts the experience of pain. Consequently, the CACPP evaluates pain much more severely, believing even stronger that the need for medication is continually and increasingly justified. Interestingly, when the CACPP abstains from all medications or drugs of abuse, the subjective experience of pain decreases and a more realistic appraisal of sensory pain is then possible. The extent of this diminution of pain depends, of course, upon its organic nature and other influential cognitive, affective, and interpersonal factors.

In order to assess and treat the underlying pain condition, the addictive disorder must be concurrently treated. Medically supervised detoxification must be pursued followed by chemical dependency rehabilitation with a simultaneous focus on addiction and pain. Since the use of narcotics is no longer an option, the CACPP must rely on alternative avenues for pain management, such as, muscle relaxants, non-steroidals, physical therapy, acupuncture, hydrotherapy, exercise, social support, group therapy, psychological interventions, and, in some critical cases, surgery. Also, biofeedback and medical hypnosis are very effective treatment modalities especially during detoxification when there is high risk for rebound pain and emotional distress. Concurrent attendance at 12-step support groups, such as, AA or PPA (Pain and Pills Anonymous) will also help coping with the addictive disorder. This multimodal approach involving all aspects of the mind-body-spirit triad forms the basis of eventual healthier and happier living.

In my experience, the CACPP who follows the foregoing prescriptive measures takes fewer medications, utilizes the health care system in a more appropriate manner, and leads a more fulfilling, productive, and even spiritual life. The path is a very difficult one, requiring commitment, motivation, and family and social support. The outcome is remarkable, to say the least, for the patient, family, and physician. To date, unfortunately, outcome research is limited while anecdotal and theoretical reports are more common. Treatment programs exist, however, that focus on detoxifying and rehabilitating the CACPP, but are rare. Outcome data is preliminary but shows much promise for the effectiveness of rehabilitative care.