Pain and Addiction: A Challenging Co-Occurring Disorder. Mel Pohl
Pain and Addiction
A Challenging Co-Occuring Disorder
Mel Pohl, MD, FASAM
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Central Recovery Press, Las Vegas, NV 89129
© 2011 by Central Recovery Press
All rights reserved. Published 2011. Printed in the United States of America.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the written permission of the publisher.
Publisher: Central Recovery Press
3321 N. Buffalo Drive
Las Vegas, NV 89129
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ISBN-13: 978-1-936290-68-0 (e-book)
ISBN-10: 1-936290-68-5
Author Note: This e-book is derived from a presentation given to physicians and other helping professionals at a conference during the spring of 2011. What I share with the professionals is not to be a mystery as it is important for you, the reader, to understand as well.
While occasionally my remarks reference the audience, this adaptation of the presentation is designed for the general public. While it has been edited and modified for this format, it contains the information most important to the topic and preserves the essence of my presentation.
Mel Pohl. MD, FASAM August 2011
Central Recovery Press offers a diverse selection of titles focused on addiction, recovery, and behavioral health. Our books represent the experiences and opinions of their authors only. Every effort has been made to ensure that events, institutions, and statistics presented in our books as facts are accurate and up-to-date. The opinions expressed are those of the authors only.
Table of Contents
What Is Pain? What Influences the Pain Experience?
Types of Pain
Acute vs. Chronic Pain
Pain Management vs. Pain Recovery
What Is Addiction
Emotions and Suffering
The Placebo Effect and the Conditioned Response
Secondary Gain
Las Vegas Recovery Center Protocol for Medically Managed Withdrawal
Some Closing Thoughts
Pain and Addiction A Challenging Co-Occuring Disorder
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