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Pain Patients' Mistakes

 "Helping Patients Understand the World of Pain Medicine" 
By,  By Terri Lechnyr, Ph.D, Psychologist, on January 2nd, 2010
Article downloaded on 5/30/11  from :
http://www.drterrilechnyr.com/helping-patients-understand-pain-medicine/  

Patients need to better understand their health care providers’ concerns regarding alcohol, drugs and pain medications, as well as what is expected of them in their role as patients in order to maximize treatment outcomes.

Pain management is, by its nature, a multidisciplinary profession and so the over-emphasis on the medical model—while a central part of paint management—oftentimes misses the point. And so this article will frequently refer to “heath care provider” while at other times referring to physician or medical provider. This was done on purpose.

The questions patients bring up are often not directed at the physician or other prescriber but, instead, at the psychologist, clinical social worker and sometimes the physical therapists. The reason is that the latter professions spend much more time with the patient and are the ones who have to interpret what is happening and then work with the rest of the team, as well as the patient, to clarify issues. As one who has owned and operated two different pain centers with a large multidisciplinary team—along with working in a clinic with 44 physicians and with the U.S. Public Health Service—the lead author is keenly aware of the wider role played by all health care providers.

The purpose of this article is to be used as a handout to patients and is based on clinical experience interacting with pain patients and documenting patient behaviors over the years. In fact, after the authors had written this article, it was tested by having current patients read it. The result was a dramatic reduction in complaints and misunderstandings. The authors believe that it would be helpful to all pain patients to understand and clarify issues that typically arise in pain
management and, ultimately, improve patient-physician communication.

WHAT PAIN PATIENTS NEED TO KNOW

Do you every wonder what your pain medicine provider is thinking about you?

1. Have you ever felt your pain medication provider treats you as a ‘drug addict?’
2. Do you wonder why your health care provider is concerned about how you have used, or are using, chemicals such as
alcohol, drugs and/or pain medications?
3. Do you think that your provider is overly concerned about these issues and your past and present use of such chemicals?

So that you won’t feel that you are being treated as a criminal or a ‘drug addict,’ it might be helpful to know what your provider is thinking and concerned about. The following discussion is designed to help you work with him/her as a partner in your care. Please take time to read this so we can learn to speak the same language.

This information will:

1. help to reduce misunderstandings and problems later on that will cause both you, the patient, and your provider to be upset and on the defensive in some fashion;
2. help to make your life more comfortable as you are taking your pain medication;
3. help your provider feel more comfortable with you;
4. help your family members, and others, to understand the importance of your pain medication as part of an overall pain management approach to chronic pain problems;
5. help you understand that, sometimes, providers assume that patients understand all the issues that seem like ‘common sense’ to them since they deal with chronic pain issues on a regular basis; and
6. help answer some questions you may have which are not fully answered during your appointment with your provider since time seems to go quickly in appointments. all pain patients to understand and clarify issues that typically arise in pain management and, ultimately, improve patient-physician communication.

ADDICTION AND DEPENDENCE ISSUES

Many health care providers are overly worried about the use of pain medications. As a result, there is a tendency to ‘undermedicate’ patients who have chronic pain conditions. There are also times when patients are ‘overly-medicated’ for their pain problems. So the question for everyone involved in the process is how to find the proper dosage of medications that:

1. allows for the best pain relief;
2. is at a dose that will not cause as many side-effects; and
3. avoids the patient feeling overly-sedated and tired all the
time.

In 2009, the Food and Drug Administration (FDA) and the Center for Disease Control and Prevention (CDC) expressed concern about a surge in accidental overdose of opioid medications. They are now working together to study this problem while, at the same time, wanting to promote an environment in which health care professionals make appropriate use of pain medications while minimizing inappropriate use and diversion of medications that may cause serious problems. Research suggests that 90 percent of the patients who are receiving pain management treatment were prescribed opiate medication. The concern is that 9 to 41 percent of these patients end up with abuse and addiction issues. Further, 16 percent also used illicit drugs while on pain medications. There are some indications that those who are recovered alcoholics or drug addicts may also have more abuse problems with their use of pain medications. For this reason, it is important that all concerned be open and honest in working together so that you obtain the best results from your pain medication treatment. Our goal is to have the best results in being able to manage your pain problems and this means that we all know as much as possible about these issues. We know the majority of patients will use their medications appropriately. For this to happen, however, we all have to be working together on the same team to be sure everything is being accurately monitored for your well-being. The use of pain medication requires an understanding that the medication can slow down the transmission of pain messages to the brain centers that control the awareness of pain in the body. This center in the brain that controls pain is also the same one that controls our moods: anxiety, tension, depression, and so on. The medication ‘binds’ to certain opioid sites throughout the body. This results in the body becoming ‘dependent’ on the medications. Stopping the medications abruptly will result in withdrawal symptoms. This is normal with many medications. However, if you ever stop your medication, it is important to first talk with your medical provider. It is always better to work out a plan that will allow you to slowly decrease the dosage and the usage of the medication over several days, or longer, depending on what your medical provider knows about the particular medication you are taking.

DIFFERENCE BETWEEN ADDICTION AND DEPENDENCE ISSUES AS IT RELATES TO PAIN MEDICATIONS

What was just described above explains how the body can become dependent on the medications.

• Addiction involves a higher level of cravings for the medications, a desire for the euphoric, or high, effects of a medication, and a use of the medication to help one to moderate their moods.
• It also involves a desire for the ‘feeling’ that is created by the medication.
• Patients who have chronic pain usually only note that the medications are helpful in reducing their pain, improving their ability to think more clearly as their pain is reduced, and the ability to feel more functional in life.
• The goal is not the complete elimination of pain.
• It is usually helpful in reducing the pain by 50-60 percent.

Addiction, though, can happen to anyone, no matter how smart you are, how educated or regardless of what type of job you hold. So it is important to know:

• Abuse is the step prior to becoming an addict.
• When one is addicted, there is a loss of control with a focus only on the addictive substance.
• The person becomes a slave psychologically, behaviorally, and physically to the substance—though they will strongly deny that they have a problem.
• Any plans you have for your life are no longer important.
• Anyone can become an addict so it is important to work together with all of your health care providers to insure that this does not happen.

Further, it is easy for denial to be an important part of any addiction. The addicted person is usually the last one to admit that they have a problem. In fact, ‘denial’ is a passive process since it forces the person to not pay attention to the reality of one’s present life responses and issues. The type of reactions patients in denial demonstrate include:

• reacting as if the addiction is just not a possibility;
• believing that they can handle it and/or would never have that problem ‘so why ask’;
• becoming defensive or angry, either of which suggests that there is a problem noted in this area of the person’s life;
• taking more medication than is prescribed because ‘they have more pain’;
• running out of medication before their next refill resulting in them experiencing withdrawal symptoms;
• using the behavior called ‘chasing the pain’ which does not work well for pain management but, instead, is a step toward addiction; or
• ‘losing their medication’ as it ‘fell into the sink and down the drain.’

So working in an open manner from the outset with your providers is important to insuring that you do not become addicted. This allows your physician to also prescribe medications for those times when you do have ‘break-through’ pain. This all requires honesty and openness on the part of both the patient and provider as they work together in the relationship.

UNDERSTANDING THE VARIOUS ISSUES IN THE TREATMENT OF CHRONIC PAIN DISORDERS

Pain Medication and Family Members

Sometimes family members, spouse, your kids or other relatives may take your medication if it is easily accessible. This can make your pill count come out short which then raises alarms in the minds of your providers about what might be happening. Since it is easy to misuse pain medications, it is important that you keep your medications locked up and only available to yourself. This helps you to avoid feeding others’ addictions or dependencies.

CNS Depressant Medications

Many medications, including alcohol and drugs, are designed to depress, or slow down, the transmission of nerve signals, such as pain, to the brain. In fact, the use of pain medications is focused on slowing down the pain signals to the center in the brain that processes pain messages. The central nervous system (CNS) includes the spinal cord, the base of the brain that controls breathing sleep/awake functions, as well as the brain centers that are activated, or turned on, when one experiences pain. Pain medications, alcohol, and drugs are very effective chemicals that can work quickly in your system. It does not take very long for our bodies to become dependent on them. Being dependent on these chemicals does not necessarily mean one is addicted to them. However, when these chemicals are not present, our bodies will ‘crave them’ and this will result in withdrawal symptoms.

These are chemicals that the body can get used to. We call this stage ‘developing a tolerance’ to medications. In other words, the body has adjusted to them and now the same amount of chemicals that once ‘worked’ does not seem to be as effective. This can result in an attempt to ‘chase the pain’ by increasing the dosage more than might be helpful. We know that having too low of a dosage of pain medications does not adequately treat the pain problems. However, too high of a dose does not help either. The goal for medication is not the total elimination of pain. Instead, it is being able to reduce the pain by 50-60 percent. Being able to achieve and stay at this level is one of the goals you should have when working with your medical and other health care providers.

Chemicals and the Brain

Chemicals we put into our body directly affects the brain and can cause problems—being either too sedated to a sense of not having any energy or feeling exhausted. For example, while alcohol appears ‘very helpful’ as it is quickly absorbed into the body and brain. However, the CNS depressant effects of alcohol can cause more problems with depression and anxiety the next day. It is hard to understand this issue as it makes you feel so much better and relaxed at the time you’re drinking. Recent research on the use of alcohol has recently discovered how it changes the brain. What has been noted is that regular long-term use of alcohol can make the person much more sensitive to stress/tension and more likely to reach for additional alcohol to reduce the feelings of anxiety and tensions. When researchers used functional MRIs to detect brain activity, they noticed that the region of the brain that controls cravings, the insula, was much more active. These regions of the brain are seen as stress pathways specific to the use of chemicals. This actually can explain why it is so difficult to stop drinking—or even to stop smoking. What we do know is that when we use CNS-depressant chemicals we are changing the brain. This is the reason your health professionals need to constantly monitor your use of your medications. It makes a great deal of difference in how they need to work with you to achieve the best results medically.

However, we also know that long-term use of any chemicals affecting the CNS can cause problems. Some people may experience more pain even with small reductions in pain medications. Taking pain medications regularly sometimes causes rebound pain. Research has shown that, especially for headache patients, stopping pain medications for three months can cause a reduction in pain. The same is true for smoking and alcohol. We do know that smokers have more aches and pains and do not heal as well from surgery. Though it may take a while achieve, you may actually be less anxious and stressed if not drinking or smoking on a  regular basis.

Alcohol and Pain Medications

You will notice that your pharmacist always puts a label on your medication bottle warning against drinking alcohol. This is because alcohol can magnify the effects of the medications up to ten times and tends to magnify the side-effects of the medications. The use of other chemicals also alters the brain and this can make it difficult for your medical provider to find the right dose for you.

Present and Past Alcohol Use

You may think that your past history of alcohol use has little bearing on your pain problems. However, what is well-known is that those patients who have over-used alcohol in the past are now more likely to overuse pain medications. Further, the past use of alcohol and drugs may enable them to actually tolerate much higher doses of the medication before finding it helpful. This can complicate the situation for your medical provider as it presents confusing results. Further, past chemical users have a tendency to want to ‘block all stress and pain,’ escalating a desire for more and more pain medications. So when your provider asks about your past use of chemicals, it is important to report everything even if you do not think that you ‘used that much.’ In this manner, you will become more of a ‘partner’ with your physician. Don’t feel that your health care providers are talking down to you when they ask about your past use of chemicals. It is all part of trying to help you in the best possible way.

Chemicals and Heredity

One important thing that is known about genetics is that there are people who are more prone to becoming addicted. It seems that some people genetically inherit a trait that makes them more prone to overusing chemicals. What you can do is to look at your family history and notice how other family members used chemicals in their lives. The authors have noted that the person who has inherited the tendency towards becoming easily dependent on alcohol, drugs or smoking, has family members who also seem to have had emotional problems, overused chemicals or have had problems with alcohol. Though many families try to deny and avoid talking about such family problems and traits, it is not always hard to figure out family secrets. One thing that providers know is that ‘strong people’ have problems like everyone else. The difference is that strong people and families will admit these problems and then work to do something about them. The saying that “those who don’t learn from history are bound to repeat it’’ seems to apply in this case.

Medicating Moods

Another inherited trait may be one of having a depressive or anxious gene in the family. When this happens you will see a history how others have self-medicated their moods by the use of alcohol, tobacco, drugs or pain medications. For example, since alcohol works so well in calming our tensions and anxiety it is easy to use it to medicate our moods. Rather than dealing with the real problems (the tension and anxiety), it seems easier to ‘chase it away’ with a chemical. However, as noted previously, the use of alcohol may, over time, make us even more sensitive to stress, tension and anxious feelings. At the same time, alcohol blocks our real awareness that it is overused and is changing us. So it is hard to get people to see that they have a problem.

Even if we don’t use chemicals, we can have ‘addictive behaviors.’ These behaviors include care-taking behaviors, that is, doing too much for others, pushing and working too hard, etc. This can especially happen for those who have the ‘genetic predisposition’ and say they will not use chemicals. People who come from addictive families don’t fully know what is normal because of how the family has denied, kept things secret, and tried not to see any problems with the use of chemicals. Though you may be different from others with this history, it helps to know your family history in order to avoid any potential pitfalls. We can become addicted to many things that don’t involve chemicals but which, nevertheless, tend to drain our energies and leave us feeling overwhelmed and exhausted.

Chemicals are also used by some for sleep problems. Even though many chemicals disrupt the normal sleep brain wave patterns and blocks the work that the brain needs to do during the time we are asleep, the immediate effects of alcohol seem ‘worth it.’ For example, the middle frontal cortex in our brains (in the front) helps us to notice our mistakes and slip-ups. It also is responsible for helping us to learn from our mistakes. We can also learn to predict our mistakes by how two different networks, or areas, of our brains become active and interact together. Proper sleep/brain waves helps to improve our memories better than what happens when we are awake. When the brain is sleeping, it is also active in rehearsing the more difficult parts of new tasks. This is why we many times find solutions to problems while we are sleeping. Our brains are busy processing what we have learned when we were awake. Further, alcohol stops natural rapid eye movement (REM) dream sleep that is so essential to our overall health.

Pain Medications as ‘The Solution’

It is important to know that helping your pain problems involves more than just taking pain medications. If you want to have long-term help, it is important to know that the magic phrase ‘pain management’ does not include the word ‘cure.’ It is learning to manage the pain over time by working with many different professionals to learn techniques for active self-care skills. These are skills for chronic pain patients that will need to be employed the rest of their lives. Chronic pain is ‘managed over time.’ It requires remembering that everything has changed. Patients need to learn to pace their activities and not overdo things just because they are feeling good on any particular day. This results in the patient having more pain the next day. So it is important to not just rely on pain medication to help your pain issues. Work with other professionals such as pain psychologists and chronic pain physical therapists who have special skills to teach you as part of the ongoing management of your chronic pain.

Break-Through Pain

There will be times that you will have what is known as ‘breakthrough pain.’ Hopefully these can be learning experiences for you in finding out what may have caused the problem. However, sometimes pain ‘just happens’ to be more intense than at other times. Working with your medical provider about these issues will allow you to have other medications to take during these break-through pain periods. If you and your medical provider have a good working relationship and open, honest conversations
about these various issues, then it is possible to develop a plan for helping during these more difficult times.

Timing of Medications
What we have come to learn is that taking pain medications on a regular, prescribed basis is much more helpful in the long run than taking the medications only when the pain is felt. The latter approach is known as ‘chasing the pain’ and it does not work as well to help stabilize the functioning of patients. So remember to take your medication as prescribed by your medical provider.

Terri Lechnyr, PhD, LCSW is a Psychologist Resident and Clinical Social Worker.

Ron Lechnyr, PhD, DSW is a Clinical Medical Psychologist

P.O. Box 40668, 2401 River Road, Suite 103, Eugene, OR 97404; 344-
CALM 2256). Their clinical practice coordinates with a multidisciplinary
team of independent pain management professionals. These
include physicians James R. Morris, MD, and Anita Dekker, MD, MPH;
Psychologist Resident Supervisor, Teri Strong, PhD; nurse practitioners;
psychologists; clinical social workers; and a team of chronic pain
physical therapists of AXIS-PT. While each professional group is
independent, they share clinic space with a focus on the multi-disciplinary
coordination of care for patients having chronic pain and complex
health care problems.

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