February 13, 2017  | 

Dr. A’s Blog – Recovery: Managing Chronic Pain

A Blog By Dr. Gregory Acampora, Addiction Psychiatrist & MD

Today I want to answer the question: How can we manage chronic pain during addiction recovery?

It is not uncommon in the treatment of Substance Use Disorder to have the subject of pain come up.

Now we all have aches and pains, but I’ll be talking about chronic pain.

Pain is universal and everybody experiences pain at one time or another – we have to cope with it and adjust.  One defining dimension of pain is how long has it lasted? Anything lasting up to a month is considered as acute pain. Longer than that is sub-acute however if it lasts longer than three to six months it is called chronic pain.  It is also important to clarify that pain can have physical (broken wrist) or psychological (death of a loved one) dimensions; the wringer is that these are often intertwined!

Remember that pain is a very important and protective survival sensation.  Our bodies have any number of sensors in place to guard us from harmful stimuli.  Luckily, when the harmful provocation goes away the body usually cuts back on signaling caution.  Sometimes there is a residual “ache” that lasts which promotes the formation of memories so we can learn to anticipate pain and avoid it. This is when body is repairing and it gives warnings – just as there are flashing lights and a bright sign to grab your attention around road work or other dangers, the body uses inflammation that can be red and pulsing to get your attention. We now know that any number of psychological conditions including grief and anticipation can involve inflammation pathways!

As with any body system that uses complex signaling to get its work done, sometimes the signals get crossed. Unfortunately, the body can get into a feedback loop where what is meant as a cry for help turns into the problem. One of the most dramatic examples is something called phantom limb; this is when somebody looses a body part but during the healing process, the brain has all kinds of memories and associations that makes a person “feel” like that part is still there and moving around! The worst part is that the person can feel pain from that ghost part of the body. There are many conditions that defy normal signaling and result in abnormal pain.

To make matters worse, we know that pain is very subjective, meaning individuals who experience the same stimulus, report different numbers for subjective pain when everyone is given the same scale to measure that pain. Some of that subjectivity comes from memories of pain (physical or psychological) that we have experienced.
Remember also, there is both a time component and origin component (mechanical/neuropathic) to pain. These are going to greatly influence what is chosen for medication. Then, we factor in any history of substance use because we don’t want to under-treat or worsen either condition.

So how do we weave this together with addictions?

Nobody can avoid feeling pain and nobody should be barred from getting pain relief. The complexity lies less in the diagnosis than in the treatment. The key is to understand how the presentation and treatment are tightly intertwined.

I’ve raised the subject of medication and recovery and I believe strongly that appropriate medication prescribing can safely be part of the formula of recovery

When it comes to medications for pain, there are two broad categories: opioid/opioid-like and non-opioids.

Opioids (morphine, codeine, methadone, percocet, and oxycodone) have been a historic medication for the treatment of pain because they work through the “µ” receptor (pronounced “mu” which stands for morphine). Different opioids have different strengths and time courses so these are targeted to specific needs. The problem is the opioid system influences pain as well as reward and addictive behaviors. The opioid system also develops tolerance = growing accustomed to same dose and “needing” more.  Finally, the opioid system is critical in breathing regulation.

Luckily the pain pathways work through more than just the mu opioid receptor system, so we are able to use any number of other medications to target these paths including anti-inflammatory, antidepressants and anticonvulsants. Needless to say, this means using drugs that have other applications for pain relief. For that reason we suggest an addictions’ specialist evaluate whether it is safe to take the chance with such a medication if you have been diagnosed with significant or persistent pain.

Leave the diagnostics and medications to the experts. When it comes to pain seek advice and support from qualified professionals who understand the challenges of managing pain while recovering from a substance addiction. As always, do not try to play doctor/pharmacists and DO NOT TAKE OTHER PEOPLES MEDICATIONS! Let’s fight the good fight for freedom from addictions!

– Dr. Acampora