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[FOREWORD]

By themselves, addiction and chronic pain can be debilitating. When brought together, they comprise extremely complicated co-occurring disorders. In Some Assembly Required: A Balanced Approach to Recovery from Addiction and Chronic Pain, Dan Mager has written an extraordinary book that addresses both of these conditions. As a result of my work at Las Vegas Recovery Center (LVRC) I have seen the many sides that Dan artfully describes in his journey from addiction to recovery, from a life of chronic pain to pain recovery.

Addiction is among the most serious public health problems in the United States. In 2010, an estimated 22.1 million persons aged twelve or older were classified with substance dependence or abuse in the past year—8.7 percent of the population aged twelve or older.¹

In 2009, drug overdose exceeded motor vehicle accidents as a cause of death, killing at least 37,485 people nationwide, according to data from the US Centers for Disease Control and Prevention. Propelled by dramatic increases in prescription pain medication overdoses, this represents the first time that drugs have accounted for more fatalities than traffic accidents since the government started tracking drug-induced deaths in 1979. Overdoses of prescription opioids now cause more deaths than heroin and cocaine combined.²

Pain affects more Americans than diabetes, heart disease, and cancer combined.³ And 25 percent of the US population is affected by chronic pain, according to estimates from the National Center for Health Statistics.⁴ The annual cost of chronic pain in the United States, including healthcare expenses, lost income, and lost productivity, is estimated to be $100 billion.⁵ By far, the most prevalent treatment for both acute and chronic pain is narcotic medications, primarily opioids, such as oxycodone (Percocet, Oxycontin), hydrocodone (Vicodin, Lortab), morphine (MScontin), methadone, and fentanyl (Duragesic, Actiq). The quantity of prescription pain medications sold to pharmacies, hospitals, and doctors’ offices was four times larger in 2010 than in 1999. Enough opioids were prescribed in 2010 to medicate every American adult around-the-clock for one month.⁶

There is no data to confirm that using opioids beyond three months for chronic noncancer pain is an efficacious treatment. The rational way to prescribe opioids for chronic pain is as a trial with closely monitored results. As doctors, we need to give enough medication to decrease pain, when possible, but we must remain mindful that for some, stimulating the brain’s reward center will lead to problems including addiction. And we ought to use good clinical judgment by taking people off of opioids if their function is not improving. There are many potential problems with opioids. Their side effects include cognitive diminution, constipation, and opioid-induced hyperalgesia, to name just a few. Over time tolerance and physical dependence develop, and of course, the feelings of euphoria that opioid use can evoke in some make these medications potentially addictive.

Prescription drug abuse is by far the fastest-growing drug problem in the United States, and abuse of and addiction to the opioid medications prescribed for pain (the so-called painkillers) are at the forefront of this trend. More than 12 million people reported using prescription opioids nonmedically in 2010—in other words, using them without a prescription and/or specifically for the feelings of euphoria they cause.⁷ The misuse and abuse of these drugs was responsible for more than 475,000 emergency department visits in 2009, a number that nearly doubled in just five years.⁸

In 2011, in response to this epidemic of prescription drug abuse, the White House Office of National Drug Control Policy (ONDCP) released an action plan that combines public health and public safety components, including new federal requirements aimed at educating the medical community about proper prescribing practices. At the invitation of ONDCP, I had the privilege of serving as a consultant for this prescription drug abuse initiative.

Addiction is a disease of the brain’s reward system and is mediated by dopamine and other neurotransmitters. Addiction drives the need to take substances in pursuit of neurochemical reward. Chronic pain syndrome is a phenomenon described by the International Pain Society as pain that won’t go away—a persistent irritation that can’t be turned off and may become quite debilitating. The symptoms of addiction include compulsive substance use, depression and anxiety, sleep disturbance, physical problems, significant stress, and functional disability. Chronic pain often has the same set of symptoms, minus the compulsive substance use.

However, if you have both conditions, each one feeds on the other, so that functional disability with pain is made worse by addiction, and sleep disturbance is made worse because of withdrawal, and depression and anxiety are exacerbated by pain, and people use more drugs in the attempt to medicate their physical and emotional pain. When addiction and chronic pain co-occur, these conditions essentially activate each other continuously. There is continued use despite increasing harm, combined with craving. Craving for people with chronic pain and addiction is based around having pain. That’s what draws them to continue to use. Opioids relieve both physical and emotional pain for the moment, but eventually backfire, as Some Assembly Required depicts with painstaking clarity.

I commonly hear from my patients with chronic pain that “I can only be okay if I take something to relieve my pain,” even when the benefit has become minimal and transient, and with time the effects only diminish further. Like many with chronic pain, Dan truly believed that he couldn’t live without opioids.

With chronic pain comes the experience of suffering, and suffering is often more influential than the pain itself. Twenty-five hundred years ago, the Buddha said: “When touched with a feeling of pain, the ordinary uninstructed person sorrows, grieves, laments, beats his breast, and becomes distraught. So he feels two pains, physical and mental. Just as if they were to shoot a man with an arrow and, right afterward, were to shoot him with another one, so that he would feel the pains of two arrows.” The second arrow is suffering, and that is the overwhelming experience of chronic pain, which is well-characterized in this book.

Fueled by a sense of uniqueness and of being different, helping professionals are often the last to get treatment. With irony and dramatic accuracy, Dan details his parallel journey as a behavioral health/addiction treatment professional and addicted person with all the attendant denial, rationalization, dishonesty, and ambivalence. In describing his process of transcending a professional know-it-all attitude in surrendering to the truth and taking the difficult and necessary steps toward recovery and self-discovery, Dan evidences an honest, self-aware, and realistic view of himself.

Some Assembly Required blends a wonderful matrix of clinical and personal observations about the process of addiction and recovery. It discusses the commonalities between Western psychological theories, certain psychotherapeutic approaches, twelve-step recovery, and Taoism and Buddhism, and provides a comprehensive review of psychological and physical interventions for chronic pain. Dan articulates the complex interplay of thoughts (in the forms of negative self-talk, catastrophization, resistance, and self-judgment) and feelings (such as shame, guilt, anger, fear, depression, and anxiety) associated with his conditions, consistent with what I have observed in many patients who suffer from co-occurring pain and addiction.

As Some Assembly Required conveys, there are cognitive-behavioral and mindfulness-based ways to reduce both physical and emotional pain. Basically, if you think differently about your pain and/or you act differently in response to your pain, you have less pain. This is an important component of our pain recovery model at the Las Vegas Recovery Center and Central Recovery Treatment. Pain recovery is about balance. It involves the way we think, how we cope with feelings, how our body is functioning, and our spirituality. The net result is that people have relationships that are enhanced and much greater involvement in positive actions and behaviors. Nonmedication treatments are really all about movement: exercise, release of tissue adhesions through massage, yoga, chi kung, Reiki’s nontouch, energy work, and acupuncture.

What we see consistently in our program is that people give up opioids, and they go from a state of depression, despondency, and disability to a state of freedom they didn’t think was possible. It is possible to recover from the co-occurring conditions of chronic pain and addiction and live a better life. It can be very tough to get there, but it’s the closest thing to miracle work I’ve ever seen in my thirty-two years of clinical practice.

Some Assembly Required will be of benefit to anyone who struggles with addiction and chronic pain, as well as the professionals who treat them. It is a story of hope and success in the face of disabling illnesses: addiction and chronic pain.

Mel Pohl, MD, FASAM

Vice President of Medical Affairs

Medical Director

Las Vegas Recovery Center