The Challenge of Treating Chronic Pain and Addiction

This week I want to share two articles about chronic pain, opioids and how to treat the effects. The first article is about opioid addiction and the (hidden to some) negatives of prescribing gabapentin. The second article is how a doctor specializing in addiction believes adverse childhood experiences are the cause of addiction. Below are these articles and my thoughts on their implications.

Disclaimer: The views and opinions expressed below are those of Mark Pew, Senior Vice President of Product Development and Marketing, and do not necessarily reflect the views of Preferred Medical.

Chronic Pain Is an Impossible Problem 

Chronic pain affects thousands of Americans every day and for years it was treated with prescription painkillers such as opioids. However, these drugs were overused and in some cases abused which caused dependence, addiction and overdoses. For years doctors have been prescribing gabapentin and baclofen as a safer alternative to opioids. By not reading the label for side effects and drug interactions many potential issues were overlooked. However, recent findings are suggesting they may be just as dangerous as opioids as people are using them to either get high or attempt suicide and which is why gabapentin is receiving more scrutiny from stakeholders.

Mark’s Thoughts:
“Though gabapentin (common namebrand = Neurontin) and baclofen (common namebrand = Lioresal) are much safer alternatives to opioids, recent research suggests that they’re not as safe as some doctors might have hoped, especially in combination with other sedating medications. The findings are a frustrating turn that suggests there’s still no silver bullet for chronic pain.” It’s high-dosage and use in combination with opioids and/or benzodiazepines that increases the risk. Both drugs can produce withdrawal symptoms with immediate discontinuation.

  • “We have very limited drug options for pain.” True.
  • “The medical community should take a closer look at non-pill remedies such as physical therapy and psychotherapy.” Absolutely.

However, I disagree with the title’s premise that “chronic pain is an impossible problem.” For those wishing for a “silver bullet” it probably is. For those actually with chronic pain it could feel that way. However, for those that have a broader perspective and toolkit and are willing to look beyond a pill, it is challenging but not impossible. #BioPsychoSocialSpiritual #ThinkOutsideYOURBox

Addiction doc says: It’s not the drugs. It’s the ACEs…adverse childhood experiences.

Dr. Daniel Sumrok, an addiction specialist, believes that the solution to opioid addiction is to treat the underlying cause—adverse childhood experiences. He believes that addiction is simply the normal response to some sort of adversity in childhood such as being homeless, abused or witnessing violence in their homes. Dr. Sumrok says the solution is individual and group therapy to confront the challenging background and treating people with respect, helping them cultivate alternative behaviors that are constructive.

Mark’s Thoughts:
ACEs has been part of my vernacular this entire decade related to the opioid epidemic. Adverse Childhood Experiences is not as well understood as it should be. While this article is specifically about addiction, it’s lessons can be applied to almost every situation. I think everyone with some level of common sense can agree that the past influences the present and can dictate the future. However, it gets real when a Workers Comp claim has sub-optimal outcomes where there shouldn’t be. The industry is starting to understand that we’re paying for ACEs, in dollars and/or outcomes, if we don’t address them—even if they’re not directly within the scope of the work-related injury. Ignore them at your peril (payer and patient). If you’ve never heard about ACEs, or have but think it should not impact how you manage claims, invest 10 minutes and read this entire article. This post elicited an interesting question and my response (that’s hopefully also interesting):

Chris Garland: “In my jurisdiction, we are not responsible for the underlying addictive personality but instead, just the abuse of opioids themselves. I don’t understand why payers are not just detoxing them, period. Instead, they spend a ton of money and sometimes over a year trying to cure the underlying disorder after a relapse.  While this is a fascinating article, I don’t understand the connection to workers’ compensation Mark. Can you speak to this a little more?”

Me: “Thanks for your thoughtful inquiry. I’m not aware of any jurisdiction that requires payment for treatment of underlying psychosocial issues unrelated to the Work Comp injury. And I totally understand how identifying then trying to resolve those red flags can end up being a quixotic quest that goes far beyond the intention of the law / regulations and the scope of the insurance coverage. I’m certainly not advocating that it is Work Comp’s responsibility to “fix” someone that was broken before being injured at work. What I am saying, however, is that when the Work Comp claim clearly devolves into something more catastrophic (health and wellbeing or financial) than the original injury would imply, then there are other forces at work beyond what was physically injured. Which goes to the psychosocial component. I’ve known, I’m sure you’ve known, probably everyone has known two identical Work Comp claims (or, just generally in life) that had similar injuries, competent clinicians and no complications and one injured worker returned to life/function timely while the other did not (and became a “legacy” claim). The difference was not the quality / scope of care but the psychological baggage the person brought with them to the injury. You could try every medical procedure and drug known to humans and nothing would work because of those psychosocial issues (that often include ACEs). So the only legitimate way to actual achieve the clinical / financial / life outcomes we want is to go beyond the BioMedical and to the #BioPsychoSocialSpiritual. Hopefully that helps explain my thoughts on how ACEs (and psychosocial considerations in general) are connected to Work Comp. Obviously, this is just my opinion. But it has been formed by my experience (typically during that “legacy” phase, after the claim has already gone “south”), by reading clinical materials where healthcare is starting to understand the BioMedical model is incomplete, from conversations with claims people around the country flummoxed by claims-gone-bad, and from the psychologists I tagged in my original post and other clinicians that have shared their experiences and expertise.

Chris: Thank you for your reply. I’ve heard of a doctor in Colorado who designed a short test to determine, just after the accident, which of the two identically injured employees will end up with the legacy claim and the factors seem purely psychological. Therefore early detection is critical. However, our business here is made up of mostly legacy claims which are decades old which we’ve been tasked with “fixing” so I’m always open to ideas.

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Until Next Week,