May 30, 2017

Interviewer: Treating pain without feeding an addiction to harmful drugs. We'll talk about that next on The Scope.

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Interviewer: Overcoming an addiction to pain killers can be a downward spiral for some people who suffer from chronic pain. Mark Ilgen is an Associate Professor in the Department of Psychiatry at the University of Michigan, and he's developed a new approach that can help address both the problem of addiction and chronic pain. Dr. Ilgen, tell us about your approach.

Dr. Ilgen: So what we want to do is to understand how we could help people with both pain and addiction. For a long time, it was true that both clinicians and researchers wanted to sort patients into categories of either chronic pain patients or patients with addiction. And there was this, I think, false belief that we could improve pain treatment if we could get the patients with addiction problems out of pain treatment and into addiction treatment and we could improve addiction treatment if we clearly convey to people to stop complaining about their pain and just focus on their recovery, meaning their recovery from addiction.

And so there was a kind of an either or sort of thinking in both treatment worlds. So we wanted to first kind of document that level of pain in that setting and then say, "Okay, those patients are present, now, what should we do to help them and how can we do something that's more therapeutic than just saying, you know, let's ignore the pain for now and focus on the addiction side?"

So what we did is developed a psychotherapy intervention that is a mixture of what are called cognitive behavioral approaches, kind of focusing on activities people can do to manage their pain, and perceptions of their pain. And we pulled in an element of acceptance and commitment therapy, which is really a psychotherapy that is designed to help people identify the values that they want to move towards and keep pursuing fulfilling activities in spite of things that are outside their control, in this case, pain.

Interviewer: When you say psychotherapy interventions, cognitive and behaviors, is that mindfulness to use a layman's term?

Dr. Ilgen: Sure. So mindfulness, there are . . . So psychotherapy comes in many different forms and the type that we're talking about does not have an explicit focus on mindfulness. Mindfulness is a technique that exists actually outside of psychotherapy and sometimes brought in to psychotherapy and it wasn't a focus of what we were doing. Instead, what we were doing was really talking to people about the ways that they structure their day and they structure their time and the ways that they think about their pain as potential factors that influence how they cope with the pain.

So I can give you an example with the thinking part. A lot of times, patients who've had really severe pain for a long period of time developed what's called pain catastrophizing or a fear of the pain. They know how uncomfortable it is when they experience pain. They obviously don't want to experience that and so they're often on the lookout for potential things that might make them hurt more. And so they tend to be very anxious looking for cues that remind them of triggers for their pain.

For substance use, it often means that they'll take pain medications in anticipation of feeling the pain before the pain even starts. Sometimes, that's a good thing, sometimes, not so much. And what we try to do is help them have a less, what we would call, catastrophic view of the pain that understands that it is something that they can ride out and that they can employ different coping mechanisms as it starts to build instead of just shutting down or avoiding the pain and doing things that might make the pain worse.

Interviewer: And then the acceptance and commitment therapy that, once again with my question, I'm going to show my ignorance. Is that kind of akin to motivational interviewing, just really getting to the root of some of the people's values or could you explain that a little bit more?

Dr. Ilgen: Again, within the psychotherapy world, it is a different camp but it doesn't mean that there are shared elements. The idea behind acceptance and commitment therapy is really, and this is a type of therapy that has grown out of the anxiety disorder and depression treatment world that's actually used also to treat substance use disorders as a stand alone treatment. And the idea there is really to help people identify what their values are and how they see themselves doing and then how that differs from what they're doing day to day, and to find some of those discrepancies and to use that as a way to make different choices in the moment.

The main messages that we're focusing on are just accepting the reality of pain and the fact that pain is really something people are going to have to cope with and instead of avoiding and trying to shut down, and trying to help people figure out fulfilling activities they can be engaged in even though they're experiencing pain. So a lot of times by the time people make it into treatment, and especially addiction treatment, they've been through a number of failed treatments, they're extremely frustrated, and they've often stop doing the things in their life that are fulfilling and enjoyable. And so what we're trying to help them do is identify some of those things they could do that could still help them feel better and cope better with their pain.

I mean, an example might be someone who has significant pain and has stopped going on hikes because they know that pain will really hurt and then they've decided, you know, it's not just hikes, even when they go for a walk it hurts, and so someone who has very active is now pretty sedentary and the pain has kind of constricted their ability to do recreational activities they used to enjoy. So what we would do is help them identify more, I want to say, kind of manageable or small scale recreational activities they could do like even just going for a walk around the block to try and turn the tide and start getting enjoyable things back in their lives and then building up greater strength and tolerance so they can start moving towards some of the things they enjoy more.

Interviewer: When people go through this process, do you find them genuinely surprised that it does work?

Dr. Ilgen: Yes, I think people are, especially in our culture and especially people with addiction, are prone to thinking that the solution to their issues are going to be in a medication that's going to be something they can ingest. And I think that the challenge with some of the techniques that we teach is that they pay off slowly over time in subtle ways and part of what we're trying to do is encourage people to actually notice those more subtle benefits and then appreciate those and continue to make those small changes so that they can see the larger changes over time.

And yes, I mean the fulfilling thing to me about doing this work is that patients with both pain and addiction feel very stigmatized in our health system. When they go to pain providers, they feel like they're treated like second-class citizens because people assume they're going to be what's referred to as med seeking or only there to get medications and that makes pain treatment providers feel used and so the patients feel uncomfortable in that setting. And then they go to addiction treatment settings and they get the message that their pain complaints aren't legitimate or aren't really valid or they're told, you know, "We can't help you here."

So to be able to be in a setting where you can talk openly or the patients can talk openly about what they're going through and the frustrations with that and the difficulty of experiencing both physical pain and craving and withdrawal and other issues that are specific to addiction, I think it creates a nice environment and I think they often really appreciate it.

Interviewer: Not everybody is close to you and your intervention. Are there for people that are not, what would they look for? How would they begin this process of finding something similar or is your program available nationwide?

Dr. Ilgen: Our program is definitely not available nationwide and I think like many types of psychotherapy that come out research literature, we struggle with how to expand beyond the first couple of studies. So I think we're good at designing studies that work on a small scale but we're not so good at scaling up. However, I think all of the elements that we put into our treatment program are actually available in the community.

So behavioral treatments for pain are available from pain clinics and other forms of cognitive behavioral and acceptance-based therapy are available from addictions providers in the community. And so I think unfortunately, it's piecemeal but the good news is the elements are out there in most places and if someone who is struggling with both pain and addiction realizes that these are both treatable and can be managed at once, they could seek out this type of care in their own community.

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