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Shame, addiction & chronic pain


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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

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Shame, addiction & chronic pain

  1. 1. Shame, Addiction & Chronic Pain Louise Stanger Ed.d, LCSW, CDWF, CIP
  2. 2. Driftwood Recovery,Austin Texas Thanks to my good friend and colleague James Flowers PHD, CEO
  3. 3. Welcome
  4. 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. 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. 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
  7. 7. 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
  8. 8. Epidemic A widespread occurrence of an infectious disease at a particular time (A flu epidemic) Outbreak, Plague, Pandemic
  9. 9. Pandemic Feb. 9, 2017 The Washington Post
  10. 10. Stat forecast 500,000 Max Blau June 27, 2017
  11. 11. Trick or TreatOct. 31,2000
  12. 12. 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
  13. 13. 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)
  14. 14. 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
  15. 15. 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
  16. 16. 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 )
  17. 17. 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
  18. 18. Acute vs Chronic Pain
  19. 19. 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
  20. 20. When Folks Complain of Chronic Pain Physician visits increase Rx increases Rehabilitation increases Diagnostic Procedures Increase’ Invasive Anesthesia Procedures Increase Surgical Ablative Techniques Increases
  21. 21. 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
  22. 22. Chronic Pain Arthritis Fibromyalgia Crohn’s Disease Concussions Weekend Warrior accidents Driver Distractions Texting Hips, Knees, Shoulders, Spines
  23. 23. Opioid Induced Hyperalgesia University of Colorado-Peter Grace , May 2016
  24. 24. 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
  25. 25. • .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.
  26. 26. 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)
  27. 27. Diagnosis Provider confirm OUD History and Physical Exam Scale Measures OUD Withdrawal Frequency of Urine Testing TBD
  28. 28. Co-ocurring Disorders Mental Health Assessment Suicide Assessment Assess psychiatric disorder Pharmacology & psychosocial for OUD and Co-Occurring psychiatric
  29. 29. 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
  30. 30. Depression & Chronic Pain
  31. 31. 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
  32. 32. Accepting Persons Perception of Pain is Important Anger can exists because others did not accept
  33. 33. 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
  34. 34. Relationships & Chronic Pain Help or Hinderance?
  35. 35. 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
  36. 36. Beliefs can be more painful then pain itself Research has found a strong correlation between Catastrophising and Pain intensity, disability and distress
  37. 37. 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
  38. 38. 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
  39. 39. Paradigm Shift Moving From Passive :Cure me Doctor to Being an ACTIVE PARTICIPANT
  40. 40. Treatment Medically Supervised Detox Residential, PHP, IOP, Extended Care Medical and Psychological Evaluation Individual and Group Therapy Family Work
  41. 41. 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
  42. 42. Modalities Used Chiropractic Massage Acupuncture Somatic Experiencing EDMR-Havening Physical Therapy/Exercise Adventure Based Interventions
  43. 43. 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
  44. 44. 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
  45. 45. Meet Doug
  46. 46. 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
  47. 47. What’s working!
  48. 48. Showing Up
  49. 49. Meet The Family Susan
  50. 50. Stole Prescription books Put Spouses medical license at risk Nodded off at Outings Emotionally unavailable to Family Embarrassed, Ashamed, In Pain-Hand and Arm
  51. 51. 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
  52. 52. Gardening - Nature Exercise - Water , gym etc Massage-Acupuncture Mindful Meditation 12 Step Service Work-Gratefulness Family Therapy
  53. 53. Chad -32 y.o Motocross Accident
  54. 54. Mindfulness was key to his Recovery Battered Opiates On his own Family Not Interested
  55. 55. Meet Harriet - 62 y.o Female
  56. 56. 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
  57. 57. I Have Lost Relationships Family Business Insurance Money Self Esteem Ability to Walk Smile
  58. 58. Strategies 15 day detox- Pain still 20% due to Hyperalgesia Education Cognitive Behavioral Therapy Mindfulness Mediation Yoga etc Peer Support
  60. 60. Pain Recovery Treatment Physical Plant-Environment Staff Training and Credentials Philosophical Beliefs Ethical Standards Spiritual Underpinnings Medical Interventions
  61. 61. 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.
  62. 62. Transforming Opioid Prescribing In Primary Care More then 1/3 of US adults prescribed Opioids in about_topcare/ Boston Medical Center
  63. 63. 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
  64. 64. Resources Driftwood Recovery 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:// epidemic-could-turn-into-a-pandemic-if-were-not-careful/? utm_term=.d7f5c8218e3c
  65. 65. Resources Stanger articles pain-management-and-opioid-addiction/http:// Stanger, Porter, Flowers Huffington Post-Trauma and Addiction trauma-addiction-whats-the- difference_us_58d14912e4b0e0d348b347f3