OBJECTIVES Describe and Discuss what is Pain Recovery Identify the role Shame has with Chronic Pain Demonstrate the difference between Acute and Chronic Pain using case examples Explain the symbiotic relationship between Chronic Pain-Substance Abuse and Mental Health Disorders Identify and Recommend Multidisciplinary Treatment Options for the Behavioral HealthCare Field

1. Shame, Addiction & Chronic Pain
Louise Stanger Ed.d, LCSW, CDWF, CIP

2. Driftwood Recovery,Austin Texas
Thanks to my good friend and colleague
James Flowers PHD, CEO

3. Welcome

4. Objectives
Describe and Discuss what is Pain Recovery
Identify the role Shame has with Chronic Pain
Demonstrate the difference between Acute and Chronic Pain
using case examples
Explain the symbiotic relationship between Chronic Pain-
Substance Abuse and Mental Health Disorders
Identify and Recommend Multidisciplinary Treatment Options
for the Behavioral HealthCare Field

5. What is Addiction ?
ASAM , March 2011
Addiction is “primary, Chronic
Disease of Brain reward,
motivation, memory and
related circusy”, ..which leads
to an individual pathologically
pursuing reward and/or relief
by substance abuse or other
behaviors.
ASAM addiction involving
opioid abuse- Bio-psycho-
social-spiritual

6. Opioids
Class of drugs that include illicit heroin, illicit
prescription pain relievers, oxycodone, hydrocodone,
codeine, morphine, Fentanyal etc
Opioids are chemically related and interact with opioid
receptors on nerve cells in brain and nervous system to
produce pleasurable effects and relieve pain
ASAM 2016 Facts and Figures

8. Addiction Often Starts with
A Prescription
259 million prescriptions were
written in 2012 which is enough
to give every person in the
United States regardless of age
their own prescription bottle
4 out of 5 heroin users report
that their addiction started with
a prescription
In 2015 more then 1/3 of all
adults prescribed Opioids

9. Epidemic
A widespread occurrence of an infectious disease at a particular
time (A flu epidemic) Outbreak, Plague, Pandemic

10. Pandemic
Feb. 9, 2017
The Washington Post

11. Stat forecast 500,000
Max Blau June 27, 2017

12. Trick or TreatOct. 31,2000

13. Pain Policies
Controlled substances are necessary
for public health
Pain management is integral part of
medical practice. All physicians
must assess
Opioids are part of professional
practice
Physical dependence or analgesic
dependence cannot be confused
with dependence
Pain management encouraged

14. Did You Know ?
There are 133 million people in the US with
Chronic Pain
That is 1 in 5 adults globally
Physical pain increases when there is an
emotional factor -Anger-Anxiety-Depression
65% of all Americans see care for persistent
pain at some point in their lives
Opioids are frequently prescribed and over
prescribed
75% of all Heroin Users Started With
Prescriptions Drugs (JAMA Psychiatry 2014
Theodore Cicero University of Washington)

15. Fentanyl
ASAM 2016 Opioid Facts and Figures
Is 50 times more potent then
heroin
2013 Mass., New Hampshire
have seen large spikes in
overdoses attributed to heroin
with fentanyl
Fake Xanax pills with fentanyl
have cropped up in California
and Indiana

16. With a 10 day supply of opioids 1 in 5
become users
With a 6 day supply theres a 12%
chance of becoming a user
With a 10 day supply the odds on being
on opioids a year later hits 20 percent
91 people die daily from opioid
overdose
University ofArkansas 2016

17. Cost of Chronic Pain
635 Billion dollars per year The
Economic Costs of chronic pain
Pain effects work days , number of
annual hours worked and hourly
wages
Cost for year -$4,048.00 for joint
pain, $5,838.00 arthritis, $9680.00
functional disabilities
This is higher then what is spent
yearly on Heart Disease, Cancer and
Diabetes
Adolescent Chronic pain 189.5 billion
American Pain Society _Journal of American Pain 2012 - John Hopkins University (2008 Medical Expenditure Panel Survey )

18. Economic Costs
25.6 billion Workplace Cost
25 billion Medical costs (By insurers
and patients )
Criminal Justice 5.1 Billion (mostly jails
2.3 billion , police 1.5 billion )scientific
(2011 Howard Birnbaum Analysis
Group -)Boston
LEGAL Consequences
Scientific America,2016 Candid
Conversations

19. Acute vs Chronic Pain

20. Chronic Pain
Lasts for several weeks,
months and years and can
cause its own disease
Pain signals are sent to the
brain once the pain stops
brain signals with acute pain
stop
With Chronic pain brain
signals are sent to the brain
and the signals do not stop

22. When Folks Complain of
Chronic Pain
Physician visits increase
Rx increases
Rehabilitation increases
Diagnostic Procedures Increase’
Invasive Anesthesia Procedures
Increase
Surgical Ablative Techniques
Increases

25. Women and Chronic Pain
Woman more likely to have
chronic pain a be prescribed pain
killers & become dependent
Prescription pain reliever
overdose deaths increased more
the 400% 1999 to 2010
Heroin deaths have tripled in the
last few years from .04to1.2 per
100,000
CDC VITAL SIGNS 2013

26. Chronic Pain
Arthritis
Fibromyalgia
Crohn’s Disease
Concussions
Weekend Warrior accidents
Driver Distractions
Texting
Hips, Knees, Shoulders, Spines

27. Opioid Induced Hyperalgesia
University of Colorado-Peter Grace , May 2016

28. Screening & Assessment
Identify & Refer if urgent Psychiatric Problems
Physical Exam
Laboratory Testing
Pregnancy Testing
Clinical Mental Health , Pain and Psychiatric Assessment
Evaluation of Current and Past Substance Abuse

29. • .The Screener and Opioid Assessment
for Patients with Pain (SOAPP) 2003.
The Pain Medication Questionnaire
(PMQ 2004. The Opioid Risk Tool
(ORT) 2005.
The Diagnosis, Intractability, Risk,
Efficacy (DIRE) was
2006.
The Screener and Opioid Assessment
for Patients with Pain Revised (SOAPP-
R) 2007.

30. Additional Screening &
Assessment
Structured Clinical Interview
Tobacco Use query
Family History-Bio-Psycho-
Social Assessment is key
BAI
SF36
BDI
MPI
MMPI-II ( If Indicated)

31. Diagnosis
Provider confirm OUD
History and Physical Exam
Scale Measures OUD
Withdrawal
Frequency of Urine Testing
TBD

32. Co-ocurring Disorders
Mental Health Assessment
Suicide Assessment
Assess psychiatric disorder
Pharmacology & psychosocial
for OUD and Co-Occurring
psychiatric

33. Pain Perception
Is it all in my head ?
Why see a mental health
practitioner - I have pain?
Pain is medical - Not
Psychological
Culture does not allow for
problems in living with Mental
Health

35. Depression & Chronic Pain

36. Anxiety and Chronic Pain
Lifetime prevalence higher for
Chronic LBP then for general
medical population
Which Came First? Anxiety
may predate Pain
Anxiety exacerbates pain and
increases muscle tension

37. Accepting Persons Perception of Pain is Important
Anger can exists because others did not accept

39. Other Life Problems
Sleeplessness
LEGAL
Lack of Intimacy with Partner
Reduced Activity-Isolation
Somatic Issues
Children Act Out
Memory Issues
Poor Self Esteem
Helplessness
Kineisophia

40. Relationships & Chronic Pain
Help or Hinderance?

41. Trauma -Addiction-Chronic
Pain
With or Without Back surgery nearly
76% of patients with lower back pain
report having one trauma in their
past
90% of woman with fibromyalgia
report childhood or adult trauma
60% with arthritis
58% with migrates men and woman
report sexual abuse or neglect
Woman with chronic pelvic pain also
report high rates of sexual abuse
US National Library of Medicine & NIH 2016

42. Beliefs can be more painful
then pain itself
Research has found a strong
correlation between
Catastrophising and Pain
intensity, disability and distress

43. Chronic Pain Syndrome
The presence of CPS suggests
medical interventions (surgery)
will not be effective
Hence a multidisciplinary
approach becomes paramount
in treatment
Moving From Passive :Cure me to
Being an ACTIVE PARTICIPANT

44. Brain Plasticity
Pain is often a
perceptual issue
Evidence suggests that
“focused attention”can
increase neuronal
plasticity and can be
learned to reprogram
brain pathways

45. Paradigm Shift
Moving From
Passive :Cure me
Doctor to
Being an ACTIVE
PARTICIPANT

46. Treatment
Medically Supervised Detox
Residential, PHP, IOP, Extended Care
Medical and Psychological Evaluation
Individual and Group Therapy
Family Work

47. Modalities Used
Acceptance and Commitment
therapy (ACT)
Cognitive and Behavioral Therapy
(CBT)
Dialectical Behavior Therapy (DBT)
Motivational Interviewing (MI)
Solution Focused Therapy (SFT)
Adventure Based
12 Step Facilitation

48. Modalities Used
Chiropractic
Massage
Acupuncture
Somatic Experiencing
EDMR-Havening
Physical Therapy/Exercise
Adventure Based Interventions

49. Mindfulness
Reduces Anxiety and Stress
Live Fully with Pain
Foster Discipline
Breath-work provides a ready
focus for the mind
The breath is the doorway to the
here and now
Creates a Space for us to be in
here and now

50. Families
Must learn about Chronic Pain
and how it co-exists with
Substance Abuse and Mental
health issues
Learn how to detach and not
enable their loved one because
of perceived pain
Join in the Solution

52. Meet Doug

53. About Doug
Back Pain Severe-Not able to lift young children- possible candidate spine surgery
Mother Dying -house full of edibles and pills
Previous treatment for substance abuse
Unemployed
Stealing from wife and mother
Isolating
Lying
Family History
Co-Ocurring

55. What’s working!

56. Showing Up

57. Meet The Family
Susan

58. Stole Prescription books
Put Spouses medical license at
risk
Nodded off at Outings
Emotionally unavailable to
Family
Embarrassed, Ashamed,
In Pain-Hand and Arm

59. Whats Working?
Pain Recovery Doctor
Neuropsych Testing
ACT, CBT , MI, SFT etc
Somatic Therapies-Havening , EDMR
Trauma Based Therapies
Family Therapy -Couples Counseling
Children -ACA

60. Gardening - Nature
Exercise - Water , gym etc
Massage-Acupuncture
Mindful Meditation
12 Step
Service Work-Gratefulness
Family Therapy

61. Chad -32 y.o
Motocross Accident

62. Mindfulness was key to his
Recovery
Battered
Opiates
On his own
Family Not Interested

63. Meet Harriet - 62 y.o Female

64. How Harriet’s Lights Went Out
Small Tumor on Cervical
Spine- Operation-Radiation
& Chemo
Oops clipped a nerve-
INTENSE PAIN =
OxyContin, Xanax , Ambien
on and on and on
Finally ended with a Actig
Fentanyal Lollipop

65. I Have Lost
Relationships
Family Business
Insurance
Money
Self Esteem
Ability to Walk
Smile

66. Strategies
15 day detox- Pain still 20% due to
Hyperalgesia
Education
Cognitive Behavioral Therapy
Mindfulness
Mediation
Yoga etc
Peer Support

67. OutComes
REDUCED PAIN
45 days later lightly jogging
3 miles
SMILE REMADE
BUSINESS BACK ON TRACK
MARRIAGE BACK ON TRACK
GRANDMOTHER DUTY

69. Pain Recovery Treatment
Physical Plant-Environment
Staff Training and Credentials
Philosophical Beliefs
Ethical Standards
Spiritual Underpinnings
Medical Interventions

70. Concluding Remarks
Many Behaviors with pain and opioid dependent
patients are persistent , and represent manifestations of
serious comorbidities,psychiatric disorders , such as
mood, personality disorder, PTSD, or Cognitive
dysfunction.
Consultation, Referral, or Co-management with
specialists who understand PAIN RECOVERY,
MENTAL HEALTH and SUBSTANCE ABUSE
Disorders is paramount.

71. Transforming Opioid
Prescribing In Primary Care
More then 1/3 of US adults
prescribed Opioids in
http://mytopcare.org/
about_topcare/ Boston
Medical Center

72. Resources
Center for Disease Control, March 2016
Scientific America -Crucial Conservations , May, 2016
ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction
and Opioid Use,2016
Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy
for chronic pain: a systematic review for a National Institutes of Health Pathways to
Prevention Workshop. Ann Int Med. 2015;162(4):276-286.
Centers for Disease Control and Prevention. NCHS Data Brief. Prescription opioid analgesic
use among adults:United States 1999-2012 , Number 189, February,2015
2013 National Drug Student Data Bank
Driftwood Recovery https://www.driftwoodrecovery.com

73. Resources
Driftwood Recovery https://www.driftwoodrecovery.com
http://www.nbcnews.com/nightly-news/video/louisville-kentucky-sees-
spike-in-heroin-overdoses-876423747884
Achenbach, Joel.The Washington Post, Dec.23, 2016. An opioid
epidemic is what happens when only treated with pills.
Gebelhoff, R. The opioid epidemic can turn into a pandemic if we are
not careful. The Washington Post .Feb. 9, 2017 https://
www.washingtonpost.com/news/in-theory/wp/2017/02/09/the-opioid-
epidemic-could-turn-into-a-pandemic-if-were-not-careful/?
utm_term=.d7f5c8218e3c

74. Resources
Stanger articles https://www.allaboutinterventions.com/
pain-management-and-opioid-addiction/http://
www.huffingtonpost.com/entry/
Stanger, Porter, Flowers Huffington Post-Trauma and
Addiction http://www.huffingtonpost.com/entry/
trauma-addiction-whats-the-
difference_us_58d14912e4b0e0d348b347f3