Pain and Addiction: A Challenging Co-Occurring Disorder. Mel Pohl

his options were. His mother told him, “Either you do this or I’m done.” And staff is giving him the message, “Either you participate in our program or you can’t stay here.” So, under that coercion he began the process, and said with a smirk, “You know what, Doc, you’ll see, I’ll be a model patient.” And he really was. He was still angry. He was still kind of nasty at times, but even in spite of that his suffering began to diminish. He went to groups. There were a couple of other first responders in the group—a former police officer and a former firefighter—with whom he was able to identify. He started to share, and he started to work on writing assignments, completing a First Step and working on his pain issues. He let the acupuncturist do acupressure for the first two treatments; starting with the third treatment, she was able to use needles. The massage therapist started with his feet and worked her way up. Mark began the process of recovery in earnest, began to get better, and his pain actually went down. With these interventions, even off all his meds, his self-reported pain level was about five to six out of ten.

      By the third week he was involved in the treatment community, going to twelve-step meetings and smiling. As he continued to improve, we received a call from his mom informing us that his wife had filed for divorce. When we told him that the next day, he said, “I’m done. I’m packing and I’m getting out of here. I’m going to go home and take care of things.” I asked him, “What does that mean? Take care of things? Are you suicidal?” He rolled his eyes and said, “Doc, I’m not going to tell you that.” I then asked, “Are you going to kill your wife?” He replied, “Please, just leave me alone. I’m fine. Just let me go. I’m done. Thanks, you really did way more than I thought you could do, and I’m going to go home and take care of things.” Then I said, “Remember how I told you that you couldn’t stay unless you did certain things. Well, now you can’t leave.”

      (If there are any psychiatrists in the room, you understand.) He really was at risk—serious risk. He had a history of a recent serious suicide attempt; he had just lost the one thing in his life that he was really connected to, and he said, “Well, I’m leaving here and you can’t make me stay.” And I said, “Well, you know actually I can.” And we held him legally. He was taken by ambulance with a police escort to the ER, not the psych hospital. I got the records from the ER three weeks later. When the ER doc assessed Mark, he told the doctor, “I’m not suicidal. That doc is crazy. He should be locked up, not me. He took me off all my drugs and then I had all this pain. My wife is divorcing me and I just sort of had a moment, but I’m fine.” The social worker came in and cleared him, and he was discharged. They didn’t call to inform me or ask for my input. Instead they sent him home with written discharge instructions that said, “Call if feeling suicidal.” And what happened? He got in a cab, went to the airport, flew home, and shot himself in the head.

      Pain and addiction are very complicated co-occurring disorders that can result in death. The topics I will address include how pain occurs in the brain and what characterizes suffering—Mark was a true example of chronic pain and intense suffering. We’ll look at treatments and at medications used for pain—both opioids and nonopioids, and medications vs. nonmedication. We’ll look at what happens if people have the co-occurring disorder of chronic pain and addiction, then review the effects of the emotions on pain, and explain pain recovery.

      I’m the Medical Director at Las Vegas Recovery Center, and some of the situations I’ve experienced there, I will be discussing today. I will share with you my clinical experience, and reference research whenever possible. The PowerPoint slides and bibliography for many of the studies that I cite in this presentation are available on our website, www.lasvegasrecovery.com.

What Is Pain? What Influences the Pain Experience?

      Just take a moment and think about pain. It’s in the news; we treat it in our practices, but to frame this discussion, here is a brief definition from the International Association for the Study of Pain. Pain is an “unpleasant sensory and emotional experience.” And those are the keywords. Pain exists to protect us from damaging tissue and/or from further damaging tissue that’s already damaged. Pain is a God-given neurocircuited response to keep us alive and to help us be less damaged. So if you have pain in your ankle, you don’t walk on it because it’s injured. That definition really applies to acute pain, but it is also the only definition we have for chronic pain, and the real key is that pain is an experience. If I interviewed every person in the room and asked you to tell me about your pain, each of you would likely have a totally different report. Maybe similar words, but no one can have the same experience with pain as the person sitting next to him or her.

      There are a lot of things that influence pain. One is culture. For example, I was raised in a Jewish home. I will be whining a good part of the afternoon. He has a cold, poor guy, and I have back pain, and I will gladly tell you about it if you want to know because that’s the way I was raised. Whining was sort of what we ate for dinner. My mother was such an expert at it that she didn’t have to say anything. It was just “Ma, how are you?” “Ahhh . . .” And that’s the way it is in my culture. There are a lot of cultures I’m told—personally, I don’t get it—where they don’t express pain; they are stoic, such as the Norwegian, Native American, and African cultures where it’s not acceptable to show any response to pain. These people tend to have less pain. These are cultures where women deliver babies without anesthesia and without uttering a sound. I don’t know how that happens, but it does.