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Pain and Addiction A Challenging Co-Occuring Disorder

Chronic Pain and Addiction

I’d like to start with a story about a patient who I treated a number of years ago. His name is Mark. He was forty-two years old and his problem was chronic pain and addiction. That’s where I came into the picture. He had been an Army Ranger in his late twenties when he blew out his knee. This was a very serious injury. He had surgery to repair the meniscus and ligaments. The surgery did not help him and he ended up with a painful knee that would eventually need replacing, but no one would perform that procedure on him at age forty-two. In the meantime, he also ruptured a disc in his back.

He tried unsuccessfully to return to the military, and ended up with disc disease and terrible, terrible knee problems that eventually got him discharged from the Rangers and left him with chronic pain. On the pain scale of zero to ten, his pain was a nine to ten on most days, and he developed a serious drug addiction. Most of the drugs, including Fentanyl 100 micrograms patches, were prescribed by his physician. He was using one patch every couple of days instead of every three days as prescribed. He was known to chew them. One time he actually extracted the Fentanyl with a needle and injected it. For breakthrough pain, Oxycodone was prescribed and he took up to 360 of those per month. His doctors tried him on Suboxone with minimal success. It helped his pain a little, and he supplemented his medical prescription when he found he could get a supply of the drug across the border in Mexico. He would acquire the drug and then inject it. I couldn’t quite figure out how he could use that in addition to the other opioids since Suboxone contains an opioid (actually a partial opioid agonist) buprenorphine, and an opioid blocker, naloxone, but he did. Apparently, he overcame the opioid blockade provided by the naloxone with the high doses of Fentanyl and the Oxycodone.

He was also extremely anxious so he got prescriptions for diazepam, 60–80 milligrams a day and Ambien, 20–40 milligrams a day. After all these painkillers, tranquilizers, and sleep meds, not surprisingly, Mark was very tired and complained to his doctor that he was depressed. His doctor put him on Provigil, followed by Adderal, an amphetamine to use after the Provigil stopped working—about 30 milligrams three times a day, which he chewed. Moreover, he drank a half a quart of vodka per day. In his opinion, he didn’t have addiction, he had chronic pain and he was using all these medications and self-medicating to alleviate his pain.

At the first facility Mark went to for treatment he was horribly misunderstood. They wanted to take him off all of his drugs; he rebelled. The treatment program then referred him to me, but he took a side trip and ingested a whole bunch of drugs, including most of his Valium bottle and a quart of liquor. He ended up in ICU on a respirator. The next day he woke up and his mom said, “I can’t live like this anymore.” He and his wife were separated, and she told him, “Either you go to treatment at this last ditch place or I’m done. I’m not going to support you and I’m not going to be in your life.” It was sort of an intervention.

So Mark came to Las Vegas Recovery Center (LVRC), very grudgingly, arriving on a Sunday. He was one of the angriest guys I had ever met. He was angry at the Army Rangers for abandoning him; he was angry at the doctors who botched his surgeries and at the new surgeon who wouldn’t replace his knee; he was angry at the last treatment center because they wanted to take him off his drugs; he was really angry at his wife because she had abandoned him; and he was really, really angry at God. He felt completely abandoned. He felt like it wasn’t fair; why me, poor me, etc. You can imagine how he felt about me when I told him we were going to take him off all his medications, including Subutex.

So there we sat on a Sunday morning, reviewing his treatment plan, which was to take him off all mood-altering drugs—that meant no benzos, no benzo-like meds, no opioids. He received buprenorphine in decreasing doses to wean him off and we utilized anticonvulsants. At the end of the twelfth day, he was fully off all those habit-forming medications. When he came to the treatment center, his pain level was an 8.5, and when he was off all those drugs, it was still an 8.5. He then entered our chronic pain recovery program, which is multidisciplinary and involves multiple different treatments, such as acupuncture, massage, physical therapy, chiropractic, and cognitive behavioral interventions. He pretty much said, “I’m not going to participate. You can’t put needles in me. I can’t be touched because I have post-traumatic stress disorder.” He continued, “I’m not going to groups. If I go to groups, I’m not talking. If I am in a group, I’m not doing the assignments,” basically “screw you.” To which our response was, “In order to stay here, this is what you have to do.”

At that point we got his mom on the phone and conducted a mini-intervention so Mark would be clear as to what 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.