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Pain Management for Recovering Addicts: What Are the Challenges?

Many chronic illnesses come with the burden of pain, or exacerbate existing pain conditions. We know pain can be physical as well as emotional, and that there is a real correlation between the two. Adding addiction to the mix complicates matters, but not just for medical reasons.

In speaking with medical and behavioral health professionals, there are common threads that impede proper treatment for people with addictive disease. One of the most common is stigma. Almost anyone with a history of drug use is seen as drug-seeking, manipulative, non-compliant and just downright difficult. They are often undertreated if not denied care outright. Overcoming stigma can change the way we practice, and change people’s lives.

I would like to present one such case to illustrate these complexities.

Anita*: A case of stigma
Patient: 50 y/o divorced African American female. Diagnosed with HIV/AIDS in 1994. Diagnosed with sacroiliac joint dysfunction and associated chronic lower back pain in 2007. Treated by pain, orthopedic, and chiropractic specialists throughout 2008. Treatments included opioid therapies, lidocaine patches, TENS unit and physical therapy. Passenger in motor vehicle accident in 2009, no acute injury. Diagnosed with inguinal hernia in 2011. Surgery canceled the day after pre-op visit due to lapse in Medicaid; repaired in 2012 when Medicaid was reinstated. In January 2013, diagnosed with severe cervical dysplasia, anal and vulvar condyloma requiring multiple biopsies and two invasive surgeries including laser ablation.

Needless to say, Anita’s case is complicated. It would seem obvious that pain management specialists would be central to her multidisciplinary care.

So why does her HIV doctor provide her pain medication?

Because she’s an addict.

In 2009 she missed three appointments at the pain clinic, and was summarily discharged. Her HIV provider tried his best to work with her but she continued to use. He eventually stopped prescribing narcotics, and she dropped out of care. In late 2012 that provider left, and she restarted treatment. Because of her history, her new HIV provider (Dr. Johnson*) would not prescribe her narcotics. She was irate, but immediately set up an appointment with me as he requested. He advocated for her reinstatement to the pain clinic. Their protocol dictated that she undergo a psychological evaluation. Dr. Johnson learned quickly what her previous provider had been through. He got her the first available appointment, which was four weeks out. Until it was rescheduled. At that assessment (two months later) she was deemed “Level 4 for Chronic Opioid Pain Management,” ineligible for opioid therapy due to recorded history of intermittent positive cocaine screens dating back to 1996.

Did I mention by then she’d been verifiably drug-free for over a year?

The hospital referred Anita to the one local pain clinic that accepts Medicaid. After two weeks with no follow-up, I called the clinic. They informed me that they were not taking any new referrals, and had informed the referring provider the day they received the referral. She was asked not to call us, that we would follow-up, so she waited. No one called her.
She called me, in tears. She couldn’t understand. She was sober for a year, taking her psych meds, making every appointment, peeing on command. Still no one would treat her pain.

She couldn’t understand. She was sober for a year, taking her psych meds, making every appointment… Still no one would treat her pain.

We were told by all departments, from ortho to oncology, that they are not responsible for managing her pain. Dr. Johnson realized if he didn’t treat her pain she would decompensate, relapse, fall out of care, and become ill and infectious. He could not let that happen. So Dr. Johnson worked closely with Anita and myself to create a viable, appropriate treatment plan. We amended the standard narcotics contract, and staffed any transgressions as a team.

For a while, she was still difficult. Her distress tolerance was low, and her behavior did smack of drug seeking “addict behavior.” She may have been “non-compliant” for coming to an appointment three hours late, but for Dr. Johnson it mattered that she had been in the E.R. with her pregnant daughter and grandson with leukemia. It mattered that she came, (a screaming toddler in tow) and that said more to him about her compliance than the clock on the wall.

We talked about her life. Seven children, ages 17 through 32, two in prison, one in jail; 9 grandchildren, the youngest 6 months and one on the way. She was never seen without some number of grandchildren, nieces, nephews, even neighborhood children at her feet. Because she had been a high functioning addict, her children relied on her heavily, particularly for child care. Previously she had been “non-compliant” with consistent behavioral health treatment. Dr. Johnson learned that it was because agencies shut down without notice or referral. She was seen by four different agencies between 2007 and 2011.

We talked about how her history is related to her neurochemistry, how PTSD and depression contributed to her pain.

We talked about her (not) sleeping under the bed with her grandchildren because of the gunshots in the projects. We talked about how her history is related to her neurochemistry, how PTSD and depression contributed to her pain. And quite often we just talked about how she felt as a result of repeatedly hearing “you don’t deserve treatment.”

She was grateful for Dr. Johnson’s compassion and his willingness to listen and treat her as an individual with unique circumstances. He encouraged her while she took classes and pursued employment. He celebrated her victories. He stopped thinking she was drug seeking because he understood her pain in the context of her life. And she had stopped behaving as such.

This year, after another change in medical providers, a cancer scare, multiple painful surgeries and procedures and continued stress at home, Anita made the decision to taper off narcotics. She made the decision, after someone explained opioid-induced hyperalgesia again, and this time it made sense. Even after the first step-down, she acknowledged overall reduction in pain. She has completed CNA 1 training and will proceed to the next level, despite physical limitations. She is celebrating three and a half years verifiably drug and alcohol free.

One size does not fit all. The pain of an addict is as real as the pain of a teetotaler, but no one judges the abstinent. It’s time we started educating the field on the effects of stigma rather than just the science of addiction.

*Doctor, patient names and identifying details changed for confidentiality.
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