Finding the best treatment approaches
Effective treatment of chronic pain may draw from 4 broad categories: psychobehavioral, physical therapeutic, and interventionalist approaches, as well as medications.
Psychobehavioral and physical therapeutic approaches can provide a foundation for recovery from chronic pain and a context in which strategic use of interventionalist procedures and medications may be more effective. Fortunately, many self-management strategies that have been shown to be effective in pain management are also effective in the treatment of addiction. Among these are: cognitive-behavioral therapy, meditation, emerging 12-step programs for pain, and physical reconditioning.
As you plan out each patient’s therapeutic regimen, consider these options:
Cognitive-behavioral therapy (CBT) aims to change behaviors and thought patterns to help patients gain control over their condition. It has been shown to be effective in improving outcomes in chronic pain and substance abuse treatment.15,16 In the treatment of chronic pain, patients often identify negative self-talk that is impeding their recovery—”My pain is killing me. I’ll never be able to work.” They are encouraged to substitute more positive thoughts that favor recovery, eg, “My pain is hurtful but not harmful. My pain will lead me to new and more meaningful work.”
Patients also examine physical activities, stress, sleep challenges, and mood fluctuations that can increase pain and engage in approaches such as activity pacing, stretching, and relaxation that may mitigate their pain. When CBT is used in addiction treatment, patients similarly explore triggers for drug use (often people, places, and things), and they substitute alternatives that support abstinence and recovery.
For example, patients may elect social opportunities with friends who do not get high, participate in valued activities that don’t involve alcohol or drugs, and frequent places not associated with old drug use patterns. They reframe negative thinking to gain a more positive perspective that favors recovery and prevents relapse. “I can’t live without alcohol forever” becomes “I can enjoy today without alcohol.” They also apply relaxation or meditation skills to reduce stress, and they develop coping skills to address high-risk situations.17
Meditation-relaxation. Despite some scientific debate about the relative merits of different relaxation approaches, such as hypnosis, guided imagery, progressive muscle relaxation, and meditation, there is clear evidence that deep relaxation practices can play an important role in pain management. Recent studies have shown benefit for mindfulness meditation in the treatment of pain.18 Other studies suggest various forms of meditation may help patients recover from addiction.19 The physiologic basis of pain relief associated with meditation or deep relaxation has been variously attributed to muscular relaxation, reduction in sympathetic arousal, and changes in activity of different brain centers that process pain and pain inhibition. Effects on sleep enhancement and reduction in anxiety may also contribute to recovery from pain and substance abuse.
One simple approach to meditation is for the patient to sit comfortably for 10 to 20 minutes while focusing awareness on the natural flow of his or her breath going in and out. The patient is instructed to note thoughts, sounds, and sensations as they pass by and gently bring attention back to the flow of breath. A word or phrase can be silently thought on the outbreath to enhance focus.
12-step programs. Twelve-step programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) have been a key element of self-management of recovery from addiction for at least 7 decades. AA and similar meetings engage attendees in a process of self-reflection, reframing of perspectives, interpersonal sharing, and acceptance that for many are powerful supports for substance abuse recovery.20
12-step programs for pain. Recently 12-step programs for chronic pain that use the same basic strategies and paradigm to engage individuals in a process of recovery have begun to proliferate; these meetings are open to people both with pain alone and those with pain and addiction.21 And when pain-specific 12-step groups are not available, many patients find they can adapt the steps in an AA or NA meeting to address their pain.
The strengths of 12-step groups are that they are free and widely available. Patients may need to try different groups, however, to find one at which they feel comfortable.
| Key Point There are now 12-step programs for chronic pain that use the same basic strategies as Alcoholics Anonymous and Narcotics Anonymous to engage in the process of recovery. |
Physical reconditioning. The benefits of exercise and movement therapies in chronic pain management are well documented. Exercise activates central endorphin release and descending pain inhibition. Aerobic exercise, such as cycling, using an elliptical machine, or walking, may improve circulation and tissue oxygenation, which in turn can improve healing. Stretching can relieve muscular tension and normalize joint motion; however, stretches must be tailored to the condition of the particular patient. Improved posture and proper biomechanics during movement reduce physical stress. Similarly, toning or strengthening can provide support for spinal and other joints and reduce propensity for spasm. It is usually important for a patient to initiate exercise under the guidance of a physical therapist.