Learn how opioids can lead to depression, how depression worsens pain and what to do when you have both pain and depression.

Depression and pain go hand in hand – pain and disability can cause or worsen depression and depression worsens pain and disability… what a mess!

And to further complicate matters, though depression worsens pain perception and analgesic need, people with depression also get less pain relief from opioid medications.

Fortunately, it's not all doom and gloom - here’s the good news:

1. If depression ups your pain, treating the depression will almost certainly reduce pain and disability and improve your quality of life.
2. If you’re on high-dose opioids and suffer with pain and depression, you might find that reducing your daily dose improves both pain and mood.
3. If you have an addiction problem, dealing with your substance misuse generally eases pain and depression.

Read on to learn more about how pain and depression interact and about how to deal with this tough co-morbid situation.

Depression and Opioid Addiction

Longer Opioid Use = Increased Depression

An argument for time-limited opioid use.

In one major study of 50,000 military personal, researchers found that compared to people who used opioids for between 1 and 89 days:

1. People who used for 180 days or longer were 53% more likely to develop a first or new incidence of depression.
2. People who used for between 90 and 180 days were 25% more likely to develop a first or new incidence of depression. 
3. Also, people who used higher doses experienced more depression than people maintained on lower doses.

Depression Ups Opioid Misuse Risk

People with depression – even those with no history of substance abuse, are far more likely to take opioids for reasons beyond pain control than people from the general population.

• In one study, researchers from Western Illinois University found that people with severe depression were 2.4 times more likely to use opioids for reasons other than pain control and 2.89 times more likely to use more opioids than prescribed than people without depression.
  
• A huge Kaiser Permanente study which looked at the medical records of tens of thousands found that pain patients with a history of depression were three times more likely to receive a prescription for opioids than pain patients without a history of depression.
  

Why Are Opioids and Depression So Interlinked?

Opioids systems affect mood – and when things go wrong, this can cause depression.

• Opioids can produce intense pleasure (highs). Long term opioid use may disrupt reward pathways in the brain, making it harder to feel pleasure from normal everyday events like a good meal or the company of friends.
  
• Opioid receptors are located in areas of the brain that regulate emotion and cognition and opioids play a role in mood and anxiety regulation – for example, the brain releases endogenous opioids to self-soothe social rejection. So when opioid systems get dysregulated through over-stimulation, this affects emotional and stress systems as well.
  
• Chronic opioid use can lead to decreased testosterone, which can cause depression.
• People experiencing depressive symptoms are more likely to use opioids to self medicate psychological symptoms. This type of misuse ups addiction risks.
  
• Depression can worsen the perception of pain, causing a need for greater analgesia and higher opioid doses. Higher opioid doses increase addiction risks and can exacerbate depression.
  
• People with depression often have pain that doesn’t respond well to standard pain interventions. This leads to increased medication use - and increased addiction risks.
• People misusing opioids are less compliant on depression treatment directives.
  
• Opioid abuse may lead to life-consequences that worsen depression.

Worryingly, opioids increase the lethality of suicide attempts among people with psychiatric disorders.

Guidelines for Using Opioids when Depressed

According to the Canadian Guidelines for the Safe and Effective Use of Opioids for Chronic Non Cancer Pain, people with depression should:

• Titrate their opioid dose more slowly at the start of treatment.
• If you are working with a psychiatrist or psychologist, ask your prescribing physician to consult with this professional on the use, benefits and risks of opioid therapy for your situation.
• To prevent serious problems (like addiction) ask for frequent doing intervals and other conservative measures that prevent misuse.
• Monitor your mood and consider how opioids affect your functioning.
• Stop opioid therapy unless the medications work well – providing more than 30% pain reduction. 

Consider Lower Doses

If you take a high daily opioid dose, you may actually get better pain relief and experience less depression by slowly tapering down to a lower dose.

• In one study, doctors in California examined a group of patients who were on a very high daily opioid dose (300 mg per day or higher of morphine equivalent). At the start of the study, the average depression score among the patients was 13.5 on the Patient Health Questionairere-9; a score which indicates major depression.
• All patients agreed to a very gradual program of dose reduction, reducing at rates from 4% to 16% per 10 days, to a final dosage of 30% the starting dosage.
• After achieving this final reduced dosage, average patient depression scores dropped to 9.5. Study patients also reported less pain on the lower dose and less pain interference in quality of life.

The results indicate that for some people, chronic high opioid doses may actually worsen pain and depression, rather than alleviate suffering.  

Consider Addiction Treatment

Though lower doses may reduce depression and pain, once addicted, you probably can't control your daily usage. Once addicted, to manage depression and pain, you likely need addiction treatment.

Though the thought of facing withdrawal symptoms, un-medicated pain and depression all at once seems scary and overwhelming, It’s probably not as bad as you think, in fact, most people find that pain and depression get better once they address addiction issues:

• On average, addiction treatment causes reduced depression, particularly maintenance treatment with methadone or Suboxone.
• Results are further improved by supplementing addiction treatment with depression-focused cognitive behavioral therapy. In fact, though reducing opioid use alone can reduce depression, untreated depression ups relapse risks, so it’s important to address both the addiction and the mood disorder at the same time.
  

Take Home Messages

• Since longer opioid use and higher doses are associated with greater depression, be cautious with using opioids for persistent pain. If you must use opioids, make sure to supplement medication with active forms of pain management, such as exercise, relaxation exercises, mindfulness and acceptance techniques.
  
• People with chronic pain and depression commonly use opioids to self-medicate depressive symptoms. However, since depression worsens pain and reduces pain intervention effectiveness, it’s very important to treat the depression and pain at the same time. Simply relying on pain medication to relieve the depression isn’t a good strategy; in fact it’s likely to worsen depression and pain.
• If you find that pain gets worse, even with increasing opioid doses, you should consider whether depression affects your pain management.
• People on high opioid doses may experience less pain and depression by reducing daily dosages.
• Opiate addicted people will generally experience less depression and less pain by getting addiction treatment, especially MAT.

Should you take opioids? Pain and addiction go hand-in-hand. Learn why pain ups addiction risks and who’s most at risk to develop a problem.

Does America have a drug problem or is it more of a pain problem that we suffer through?

OK, well obviously pain suppression needs alone can’t explain the scale of use, but on the other hand, you can’t look at our opioid problem and ignore the fact that many people who abuse these drugs have legitimate pain-relief needs. So what do you do when the medicine you need might do you more harm than good?

Well, for starters, you get informed and you learn how to reduce your risks, so read on to:

1. Learn how and why pain increases addiction risks.
2. Determine your addiction susceptibility - by comparing your current situation against 19 addiction indicators.
3. Learn how to take opioids safely to reduce your risks of addiction.
   

To gain an understanding of how pain and drug problems intersect, consider the following statistics that illustrate the situation.

Pain and Opioid Use Statistics

Statistics from SAMHSA’s Tip 54: Managing Chronic Pain.¹

• As many as 32% of people with chronic pain also have addictive disorders.
• 36% of Americans report experiencing disabling pain within the last 12 months and 56% of adults over the age of 20 report having experienced chronic pain at some point in life (pain that endured for 3 months or more).
• For those over the age of 65, 57% report having experienced pain that lasted for more than a year.
• Between 29% and 60% of people with opioid addiction report chronic pain.

So we can see that pain is all too common and we find a strong association between pain and addiction – but why is this? Beyond the obvious (opioids), what is it about pain that causes such an increased addiction risk?

How Pain Increases Addiction Risk

At one fundamental level, it’s easy to see how pain increases addiction risk:

1. Pain creates a need for strong analgesia.
   
2. You take opioids to control pain.
   
3. Opioids feel very good so you start taking more than you should.
4. Eventually the regular over-stimulation of the brain’s reward and motivation circuits leads to dysfunction and persistent addiction.

Humans are hard-wired to seek pleasure…it’s in our DNA, and it’s why experimenting with addictive drugs can lead to lasting brain changes and a loss of control over use (addiction). Many people who'd never try a drug like heroin will take OxyContin that’s prescribed for pain – and this exposure, easy availability and social acceptance puts a much wider audience at risk of opioid addiction.

But this doesn’t tell the whole story

Chasing pleasure while controlling pain is certainly one pathway to addiction, but if you dig a little deeper you find many other factors that also increase addiction risks, such as:

1. Pain can lead to insomnia, lack of physical activity, lack of engagement with life, reduced social engagement and excessive stress.
2. Life changes like sleeplessness, increased stress, inactivity and social seclusion increase the risks of other mental health conditions, like depression, anxiety or suicidal thinking.
3. Opioids are then used to self-medicate mental health symptoms.
   

If pain and worry keep you tossing in bed at night – night after night – who wouldn’t consider taking a little medication boost to get a good night’s sleep? And once you did it once, you could easily see how that could become a habitual thing…

Should You Take Opioids?

• Should you take opioids? Are you at elevated risk of addiction?
  
• And if you decide to take opioids, should you consider extra precautionary measures (such as limiting your access)?

Well, you shouldn’t make medical decisions without consulting with a doctor – after all, pain management is a complex and not always intuitive business, but for research purposes, you can gain a better sense of your risk profile by considering how many of the following risk factors match your situation.

Opioid Risk Factors

Compare yourself to the addiction risk indicators listed below. The more indicators that match your situation, the greater your risk of addiction.

While many of the following risk factors may seem unrelated to your likelihood of drug misuse, they are research-proven indicators and since they aren’t intuitive, they may give you an alternate look at your risk situation.

• You smoke a cigarette within an hour of waking up.
• You have close friends that have or had drug or alcohol problems.
• One or more family members has or had a drug or alcohol problem.
• You have been treated more than once in the past for a substance abuse problem.
• You have frequent mood swings.
• You often take medication for reasons other than what it was prescribed for.
• Other people sometimes say you have an alcohol or drug problem.
• In the last 5 years, you have used illegal drugs a number of times.
• You are often worried about being left all alone.
• You worry that people close to you will judge you if you take opioids.
• You have a mental illness.
• You often feel like things are overwhelming and that you can’t handle everything.
• You have been arrested or had legal problems more than once in your life.
• You have attended more than a few AA or NA meetings in your lifetime.
• You have been sexually abused more than once.
• You have been in an argument that got out of control and led to one or more people getting hurt on more than one occasion.
• Other people often block you from the success you deserve in life.
• Other people sometimes tell you that you have a bad temper.
• You often feel impatient with your doctor(s).

If the risks of opioids exceed the likely benefits – and this includes most people deemed at high risk to abuse opioids prescribed for chronic pain² - you may want to at least start with trying alternative pain management techniques, such as:³

• Lower risk medications.
• Physical therapy or acupuncture.
• Heat or cold treatment (ice packs or hot packs) - Cold therapy reduces the inflammation and pain of acute injury and hot therapy eases stiff or sore muscles and joint pain.
• Massage or vibration treatment – Muscle manipulation with hands, rollers or vibration devices can ease muscle pain.
• The use of braces or elastic supports (for example a back or knee brace)  – Relieves pressure and pain on afflicted areas.
• Trans Cutaneous Electrical Nerve Stimulation (TENS) – Small electrical pulses to affected nerve regions can block pain signals.
• Chiropractic Therapy.
• Meditation – Can increase calm and coping skills.

Reducing the Risks

If non opioid forms of analgesia don’t provide sufficient pain relief, or, if after examining the situation you and your doctor feel that the benefits still outweigh the dangers, you can reduce your risks by implementing precautionary measures, right from the start.

Examples of safety measures to prevent misuse include:⁴

• Getting small prescriptions to refill frequently, rather than larger more occasional prescriptions (in extreme cases, you can even travel to a pharmacy each day to take a single daily dose under supervision).
• Signing a treatment agreement and knowing that by breaking your end of the agreement you forfeit your right to continuing opioid therapy.
• Agreeing to random urine screening.
• Agreeing to frequent monitoring and frequent visits (with pill counts).
• Agreeing to submit to pill counts – bringing all your opioids in to each office visit. By submitting to frequent pill counts you are less likely to over-use or binge use.

Three opioid addiction treatment options for people with chronic pain – including options for people who still need opioids for analgesia.

What do you do when you’re addicted to opioids, you have/develop a chronic pain condition and you decide you want to get your life back under control with addiction treatment – how can you manage your pain without the use of potent opioid medications?

Though this seems like an impossible situation, with treatment and monitoring you can retake control and still get the opioid analgesia you need.

Three Primary Treatment Options

According to the Canadian Guidelines for the Safe and Effective Use of Opioids for Non Cancer Pain, the three primary treatment options for opioid addicted chronic pain patients are:¹

1. Addiction treatment combined with structured opioid therapy (best for patients who are misusing but not severely dependent).
2. Medication assisted treatment supplemented with short-acting opioids for analgesia as needed.
3. Abstinence-based treatment and non-opioid medications along with non-pharmacological pain treatments.

Read on for a brief explanation of these three primary treatment options.

Structured Opioid Therapy

Opioid abusers can sometimes move back to controlled use by initiating a very structured opioid therapy program.

With this method you get the full benefit of opioids for pain management, and when it works, misuse-controls stop overuse. Examples of patient controls include:

• Patient education.
• Avoiding the riskiest medications (hydromorphone and oxycodone.)
• A written treatment agreement.
• A urine testing program.
• Frequent dosing intervals and regular pill counts – intervals can be as frequent as once daily or twice a week.
• Frequent office visits and other forms of monitoring.
• The involvement of other family members.
• Regular evaluations to ensure that opioids offer significant pain relief (at least a 30% reduction).

Moving to structured opioid therapy is a reasonable first step, especially for not-yet-addicted opioid misusers. If it does not work (you continue to misuse/get addicted) then you have to move on to either medication assisted treatment (MAT) or abstinence-based treatment.

Medication Assisted Treatment

If structured opioid therapy doesn’t work (or if you or your doctor want to take a more aggressive treatment approach) MAT with methadone or buprenorphine can help you gain control of your opioid addiction.

• People on methadone can supplement with short acting opioids for pain relief, and since blockade-level methadone doses eliminate the euphoria from additional opioid use, there is little risk of further abuse.
• People on Suboxone may find that a slightly higher than normal daily dose of Suboxone, split into twice or three times a day dosing, may provide adequate pain relief.

Methadone and Suboxone (buprenorphine) are opioid addiction medications that replace your opioid of abuse. When you take an appropriate daily dose of methadone or Suboxone:

• You feel no withdrawal symptoms.
• You feel no or few drug cravings.
• You are far less able to get high when you use supplementary opioids.

Methadone and buprenorphine are also pain medications. But, though a once daily dose stops withdrawal symptoms and drug cravings for 24 hours, it will only offer a few hours of analgesia (methadone and buprenorphine provide 6 to 8 hours of analgesia.)² To gain sufficient pain relief your doctor might recommend:

• Splitting your daily dose of buprenorphine to expand the analgesic window. In some cases, splitting your daily dose into two or three intervals expands pain relief over the full 24 hours while also providing adequate withdrawal and cravings relief.
• Supplementing your daily dose of methadone or buprenorphine with additional short acting opioids.
  

Note*

Many people in MAT worry that using additional opioids for pain control could rekindle active addiction. However, under-treated pain is a more serious relapse trigger, especially since people on sufficient daily methadone doses won’t feel euphoria from supplementary opioids used to treat legitimate pain.³

Other Issues to Consider

• People on methadone may develop a tolerance to opioid effects and require a higher than normal dosing of short acting opioids for pain relief.
• Although supplementary opioids can be used for buprenorphine patients, because buprenorphine is a partial agonist with a strong affinity for the mu opioid receptor, high doses are typically needed to provide any significant analgesia. For this reason, people on Suboxone who have an ongoing need for supplementary opioid pain management may want to switch from Suboxone to methadone.
• Taking opioids on a fixed schedule, rather than as-needed, takes the decision-making away (do I need this for pain or do I just want to feel good).
  

People on sufficient daily doses of methadone for addiction treatment can take supplementary opioids for pain control without having to worry that these pain-control opioids will cause drug cravings or euphoria.

In an Ideal World

Ideally, you would address your addiction and pain issues at the same time and your ‘pain team’ and ‘addiction team’ would work together. You may find this type of treatment at a multidisciplinary pain clinic or similar.

Abstinence-Based Treatment

Medically assisted detoxification followed by abstinence-based treatment on an inpatient or outpatient basis is an option for people who don’t have easy access to methadone or Suboxone or those who prefer to avoid MAT for personal reasons.

• People in abstinence-based treatment will not use opioids for pain management. Since pain is a major relapse trigger, it’s best to combine intensive addiction treatment with non-opioid and non-pharmacological pain treatments.
  
• Opioid addicted people in abstinence-based treatment – especially people dealing with chronic pain problems – are at elevated risk of relapse. Since even brief periods of opioid abstinence can reset your tolerance to zero, using your 'normal' dose after a week or two of abstinence can lead to fatal overdose.

Addressing Addiction Reduces Overdose Risks

People with chronic pain and addiction are more likely than people with chronic pain alone to overdose. Reasons for this elevated risk of overdose include:

• Increased opioid tolerance from high dose use.
• Increased opioid cravings and binge use.
• Increased use of opioids to self-medicate psychological issues.
• Pain exacerbation from the opioid withdrawal symptoms associated with the ebb and flow blood plasma levels of binging and abuse.⁵
  

Take Home Messages

• If you are abusing your pain medications, you may find that a structured opioid plan allows you to continue using opioids..
• If this does not work, you may want to consider MAT with methadone or Suboxone. These medications will remove drug cravings and withdrawal symptoms and will also provide some degree of analgesia. If more analgesia is needed, you could use supplementary opioids with methadone without experiencing euphoria.
• Abstinence based treatments are an option for people who prefer to avoid MAT. People using abstinence based treatments have to be careful, since relapse is common and even short periods of abstinence can reset tolerance to novice level.
• It’s important to treat chronic pain and addiction at the same time.

Do you use opioids (or does someone you love)? It’s so easy to slide from responsible use to dangerous misuse. Test yourself to make sure you’re not falling into addiction.

Do you have a legitimate need for opioids but wonder if you might use them for more than just pain management? Or, does someone you love use opioids for legitimate reasons but you wonder if they might take more than they should?

Well, unfortunately, it’s nearly impossible to see the line that separates abuse from addiction as you pass it, and once addicted, responsible opioid use becomes almost impossible.*

Fortunately, you don’t jump straight from use to addiction. The normal progression goes from:

1. Legitimate Use, Novel Experimentation

to -->

2.  Misuse, Increasing Opioid Abuse

to -->

3.  Opioid Addiction
   

So, though it's hard to see the line that separates abuse from addiction as you pass it, since abuse is defined by behaviors rather than by brain changes, abuse is much easier to recognize - so long as you know what to look-out for!

*Addiction is characterized by progressive changes to brain function and structure that lead to compulsive use and hijacked memory and motivation systems. Though you can often look back and remember when behaviors became compulsive, it’s very difficult to self-observe this in real time. This inability to self-recognize addiction helps to explain addiction denial.

Opioid Abuse Self-Test

Are you starting to behave in ways that indicate opioid abuse/misuse – are you starting down that dangerous path to addiction? To check yourself, read the list below of 15 indicators that warn of potential opioid misuse.¹

1. In the past month, have you visited the emergency room one or more times?
2. In the past 30 days, have you ever felt worried about your opioid use and the way you take these medications?
3. Over the past month, have you had to use more medication that you are prescribed?
4. Over the past month, have you used your pain medication for reasons other than for what it is prescribed – for example, to boost mood, handle difficult situations or get a good night’s rest?
5. In the past month, have you ever asked to borrow pain medication from another person?
6. In the past month, have you ever taken another person’s pain medications?
7. Over the past month, have you been in more arguments than normal?
8. Over the past 30 days, have you had a more difficult time than normal controlling your temper?
9. Over the past 30 days, has anyone you know expressed concern about your use of opioids or about the way they affect you?
10. Over the past month, have you spent a lot of time thinking about opioids (getting enough, when to take them, etc.)
11. Over the past 30 days, have you had more trouble with memory problems or with clear thinking?
12. Have you ever thought seriously about hurting yourself over the past 30 days?
13. Within the last 30 days, has anyone complained about your failure to meet responsibilities at work, school or home.
14. Over the past month, did you ever get opioids from any person other than your prescribing doctor (E.R. doctor, friend, family member, street, dentist, etc.)
15. Over the past month, have you used your medications differently from how they are prescribed to you (different schedule or dosing)?

Scoring

The more yes answers you tally the greater the likelihood that you misuse your medication and the greater the risk of opioid addiction.

• A strong yes answer to 3 more of the preceding 15 questions is strongly indicative of an opioid misuse problem.

Beyond this list above, additional signs of opioid misuse include:

• Ever altering the route of administration (crushing a pill to snort or inject, for example)
• Arguing with your doctor about a need for stronger prescriptions
• Deteriorating social functioning

Be especially careful to avoid opioid misuse if:

• You have any family history of drug or alcohol addiction
• You have any personal history of drug or alcohol abuse or addiction
• You have any current mental illness
• You have a history of preadolescent sexual abuse

How to Respond to Misuse

Realizing that you abuse your opioid medications before you develop an addiction is fortunate – think of it as like waking up in a canoe drifting steadily down river toward a waterfall:

• If you take action soon enough you have an excellent chance to make it safely to shore.
• If you decide to do nothing, you’ll continue to drift – picking up speed as you go – until you fall over the lip of the falls…and from there, you can’t ever go back.

So if you realize that you abuse your meds, you may still have an opportunity to save the situation before you fall into addiction – and remember, moving from abuse to responsible use is easy, pulling back from addiction is incredibly hard (some people can never manage this feat).

What to do…

Talk to your doctor about your concerns. If it helps frame the discussion, you can print off the list of 15 indicators to show him or her which warning signs you’re most worried about.

• Although you might feel awkward to admit abuse worries, your willingness to discuss the situation proves your responsible intentions.

Based on your situation, your doctor may:

• Suggest trying a different combination of medications (for example, a lower dose of opioids combined with additional non-reinforcing medications).
• Suggest that you taper off opioids and move to alternate forms of pain management.
• Suggest you meet with a specialist or get involved with a pain clinic, for more comprehensive treatment options.
• Suggest continuing with opioids while employing control strategies that limit your access, such as having a person you trust handle your medication, bringing your medication for pill counts at all visits or making an agreement to use urine samples as a way to ensure instruction compliance.

Image Copyright: Send Me Adrift

Pain ups stress and stress worsens pain – and BOTH increase relapse risks. Learn how to control stress to manage pain.

You’ve got enough to deal with just managing chronic pain, the last thing you need is uncontrolled stress in your life, especially since chronic pain + chronic stress = worsened pain, an increased risk of addiction or addiction relapse and an increased risk of serious mental illnesses.

Read on to learn:

• How stress worsens pain.
• How pain worsens stress.
• How both contribute to relapse.
• How to manage excessive stress.

Stress Worsens Pain

When you're stressed-out, pain feels worse, but why is this?

Well, it turns out that excessive stress has direct pain-raising effects over the short and long term, such as:

• Stress increases muscle tension and this can lead to headache and neck, shoulder or back pain.
• Stress decreases blood flow to the digestive system. Excessive chronic stress can cause abdominal pain and diarrhea.¹ Chronic changes to blood flow can also lead to chest pain and painful skin rashes.
• Excessive stress causes a reduction in brain serotonin levels. Low serotonin decreases your pain threshold and worsens pain perception.
• Excessive stress increases cortisol release. In small doses, cortisol inhibits pain, but chronic over-release causes dysregulation – so you have too much at some points of the day and insufficient release at others.²
• Excessive stress reduces immune system functioning. Impaired immune system functioning can worsen symptoms of many diseases (such as arthritis). It may also accelerate disease progression, in conditions like endometriosis.³
  
• Stress leads to inflammation, in part because stress increases the release of inflammatory cytokines. Inflammation leads to pain.⁴

So, stress increases pain through immediate and long-term processes:

1. Unmanaged acute stress leads to short term pain through processes like increased muscle tension and shallow breathing.
2. Unmanaged chronic stress bumps-up discomfort through lasting immune, hormonal and neurochemical imbalances.

Pain Worsens Stress

So we know that stress worsens pain; but unfortunately, pain also creates stress.

• Pain is an uncomfortable sensation. Prolonged pain causes stress.
• Pain causes secondary stresses, for example: medical treatment costs and inability to work can cause financial stresses, or, insufficient social participation can lead to depression and social stress.
  

The Pain/Stress Cycle

So pain and stress combine in a very negative way - pain causes stress -> stress worsens pain -> worsened pain causes worsened stress…

Pain and stress are so closely linked, in fact, that they cause very similar physiological responses in the body. Both lead to:

• Increased muscle tension.
• Quickened respiration rate (breathing gets faster and shallower).
• Increased heart rate.
• Elevated blood pressure.⁵
  

Stress and Relapse

For people in recovery, both pain and stress increase relapse risks.

• Acute pain is a known relapse trigger. For this reason, a doctor might still recommend opiates for acute analgesia - even for people with serious addiction histories.
• Addiction causes lasting changes to the limbic system and prefrontal cortex. One consequence of these changes is disrupted stress management. For people in recovery, stress activates areas of the brain associated with addiction and causes drug or alcohol cravings, even after long periods of abstinence.⁶

It’s very important for anyone in recovery to take a proactive stance on both pain and stress management.

Stress and Other Mental Health Problems

Chronic pain increases the risks of depression and other mental health problems, especially if pain limits mobility and social participation.⁷

Are You Overly Stressed?

With pain it’s easy to let stress build. Be watchful for any of the following signs that may indicate a stress-problem:^{8 9}

• Anxiety, irritability, sadness, lack of focus and lack of motivation.
• Headache, neck pain, muscle tension or chest pain.
• Clenching your jaw or grinding your teeth.
• Fatigue and sleeping problems.
• Changes to sex drive.
• Unexplained rashes, hives or other ‘allergy’ symptoms.
• G.I. problems, such as nausea or stomach upset, heartburn, gas, diarrhea or constipation.
• Overeating or undereating, or excessive, drug, alcohol or tobacco use. 
  

Controlling Stress Reduces Pain

There are 2 primary ways to beat stress and stress-related pain:

1. Prevent it/reduce it.
2. Learn to cope with it.

Preventing Stress

It’s generally easier to prevent stress than mange it after the fact, and this is doubly so for people with chronic pain who must also cope with the increased pain that stress may create.

To prevent or reduce stress:

• Learn to identify what causes you stress, and then avoid these provocations when possible, or, if you can’t avoid exposure, take frequent stress-breaks to limit overload.
• Learn to say no to more than you can comfortably handle. It’s easy to get stressed when commitments leave you exhausted, and likewise, don’t try to please everyone all of the time – it’s impossible.
• Learn to pace yourself so you don’t overdo it. For example, when scheduling your day – it’s as important to schedule in rest periods as it is activity periods. 
• Learn to temper your emotions and avoid overreacting to difficult situations – try to keep things in perspective.¹⁰
• Get organized and avoid last-minute frenzy-stress.
• Avoid drugs and the excessive use of alcohol – These invariably take more than they give.
• Stay social/have fun – Try to work around your pain to maintain a social life. Having fun is important and since with pain you don’t have as much energy for everything as you used to, unless you make an effort to schedule fun activities, they probably won’t just happen.
• Set reasonable goals to work toward – We all need something to work toward; a reason to get out of bed in the morning and a reason to push past minor inconveniences.
• Stay healthy – Get enough exercise and sleep and maintain a healthy diet.
• Get professional help, if needed – For example, If staying independent at home seems impossible, working with an occupational therapist could make things easier.

Coping with Stress 

• Incorporate relaxation exercises into your daily routine and use whenever you feel stress or pain levels creeping up. Relaxation exercises work best when used before pain or stress gets too intense.
• Relax with a music exercise. Background music can soothe your nerves, but you can get more out of the experience through close attention – by turning music listening into a focused relaxation exercise. To do this: choose any music you enjoy, sit comfortably and take three deep breaths and then put on your headphones or stereo and listen very closely to the music. Close your eyes as you do this and try to focus so intently on the music that you block out all other thoughts. Even twenty minutes of this easy meditative exercise can ease stress and pain in a very enjoyable way.
• Mindfulness meditation – A daily meditation habit can reduce current stress, protect you from future stress, increase your ability to cope with pain and improve happiness and well-being – so a pretty impressive list of benefits that come with as little as 20 minutes a day of quiet practice. Read Meditation Benefits for more on how meditation can change your life.
• Deep breathing exercises – These exercises offer stress and pain relief after as little as 2 or 3 minutes of effort. Two of the many possible variations are yoga breathing and 4-square. Yoga breathing is as easily done as sitting straight up with your back supported, relaxing and then breathing in slowly and deeply for a count of 4 and then exhaling slowly for a count of 6 – and repeating this for about 2 minutes. To do a 4-square exercise: breathe in for a slow count of 4, hold for a slow count of 4 and then exhale for a slow count of 4 – and repeat this cycle 10 times.^{11 12}
  
• Guided imagery audio exercises – People who find mindfulness meditation difficult to sustain may have more luck with guided imagery exercises. For these, you find a comfortable spot and close your eyes and relax your body as you follow the instructions from an audio program.
  
• Prayer – You can also listen to audio recordings of spiritual messages you find comforting.
• Aromatherapy – In one study, the scent of vanilla helped people in a stressful situation control heart rate and blood pressure.¹³
• Massage or self massage – By learning self massage techniques you can give yourself a pain-relieving and stress-easing rub-down whenever you feel the need. 
• Biofeeback – By learning relaxation exercises while hooked up to a heart rate monitor, a skin temperature monitor or a muscle tension monitor, you can see in real-time how relaxing changes physiological functioning and you can see which exercises work best for you.
• Venting – communicating your stress lets you process and release it. Healthy ways to vent stress include talking with a good friend, raising your issues at a support group, or journaling.¹⁴
• Positive self-talk – Learn to correct the negative voice in your head with a more balanced perspective. For example, change, “I can’t do this” to, “I’ll try my best.”¹⁵
  
• Hypnosis or self hypnosis

Tips for Success

To get the most stress-busting benefit, remember:

• It’s hard to relax in a hectic environment; if you can, steal a few minutes for yourself in a quiet environment where you won’t be disturbed.
• Get comfortable before you start.
• Controlling your breathing is a key aspect of most relaxation techniques. Slow your breathing rate and your stress will almost always ease-up.
• Don’t get hung-up on worrying about getting into a deep state of relaxation. Focus on doing your exercises and the relaxation will follow.
• Don’t worry if random thoughts keep intruding during meditation or imagery exercises. Let them flow through without chasing them and then return your focus inward.
• Make relaxation exercises a regular habit. You’ll start to see greater benefits as you incorporate these into your daily routine, and the more you practice these exercises, the easier they get.
  

Read on to learn how to reduce pain and disability, avoid mental illness and achieve greater quality of life.

“One good thing about music – when it hits, you feel no pain.” Bob Marley, Trenchtown Rock.¹

OK, for people in chronic pain, that’s maybe a slight exaggeration, but it’s also based on something true – you can manipulate your pain experience and you can reduce its negative impact on your daily life.

Taking active steps to reduce pain’s impact is called pain self management, and people who work on their own to control pain have better outcomes than people who rely mostly on external sources of pain relief.

Pain self management leads to:

1. Less pain and disability.
2. Reduced healthcare costs and medication side effects.
3. Less mental illness.
4. Greater quality of life.

So, 4 pretty solid reasons to give this a try!

Read on to learn more about:

• Pain self management and its benefits.
  
• 14 essential pain management strategies to incorporate into your routine and lifestyle.
• Warning signs of long term disability.

What Is Pain Self Management?

We all manage pain – it’s a skill that we learn in early childhood. However, the idea of pain self management for severe or chronic pain is that with focused learning and effort, you can increase your pain management abilities.

For a number of reasons, relying solely on your medical team and/or medications for pain relief isn’t as effective as getting involved on your own:

• Pain treatment isn’t a one-size-fits-all type of therapy. You are a unique person with a unique history, health profile and psychological make-up. What works for another person, or even for most other people, may not work for you. By taking an active role and by trying a wide range of interventions, you are more likely to find a few therapies that work well for you.
  

You know what works for you better than anyone else. By getting informed about your options and by experimenting with different pain-control strategies, you can develop a better pain management system for yourself than any outside expert ever could.

But no one else can do it for you! You have to live with your pain and your behaviors and habits will influence your experience of pain. Since what you do matters, pain management is your responsibility.²

Limiting Pain's Impact without Limiting Pain

You can reduce pain or you can reduce pain's impact.

Pain negatively impacts many areas of your life, for example: work ability, finances, recreation, sex life, mental outlook, sleep, self esteem and many more.

Obviously you can reduce this impact by reducing pain, but sometimes that’s not possible – or not possible beyond a certain point. Fortunately, with conscious effort, you can find ways to limit pain’s impact on your life even when you can’t eliminate pain completely.

First Find Acceptance

Accepting that pain is a part of your life now frees you from trying to be what you once were and lets you be what you are now.

Once you accept that you have persistent pain and that it’s not going anywhere anytime soon, you can move past fighting for a pain-cure and move toward working for pain management.

• Once you can accept that with pain you can’t do everything you once could you’ll be more able to move on to filling your life with rewarding activities that you can do now.³

Examples of Pain Self Management Tools

Pain isn’t just a physiological occurrence, it affects all domains of human experience – physical, social, mental, psychological and spiritual – so it’s not surprising that you have a wide range of effective pain management tools to choose from.

Some (not all examples) of effective pain self management tools include:

1. Exercising

Chronic pain can lead to decreased activity, and this can lead to decreased strength and flexibility and to greater disability and pain. Therefore, exercise is an essential component of any self management strategy.

• Learn and engage in regular exercises to build or maintain strength, endurance, balance and flexibility.

2. Making Use of Pacing Strategies

Avoiding the ‘good days/bad days’ cycle of overdoing it on 'good' days and then recovering on subsequent ‘bad’ days.

• Pace yourself - Learn to take breaks before you need them to prevent pain exacerbation.
• Work slower – learn to work at a sustainable pace.
• Break up tasks – to prevent the overuse of any one part of the body.
• Prioritize and plan out your days – do the must-do's first and leave the could-do's for last.

3. Appropriate Medication Use

Learn to use medications effectively (and avoid their overuse).

• Learn as much as you can about your medications: about safe use, their side effects and possible interaction effects to watch-for.
• Develop a system to keep track of all medication instructions (a file).
• Use of an app or alarm to stay on a medication schedule.
• Use a daily-schedule pill box.

4. Stress and Tension Relievers

Stress increases your perception of pain and since stress causes muscle tension, it can also directly worsen pain. By learning effective stress-control and relaxation exercises you can decrease pain and increase overall quality of life.

• Learn to recognize the early signs of stress and then use techniques like deep breathing or progressive muscle relaxation exercises to self-soothe.
• Take time each day for relaxing activities that help you unwind – such as reading, walking, gardening, etc.

5. Constructive Thinking

Learn better ways to handle negative emotions. Cognitive behavioral therapy (CBT) training can help with this.

• Keep a pain diary to chart your successes and failures. This written record provides tangible evidence of your ability to self manage pain.
• Increase positive thinking.
• Learn assertive communication techniques.

6. Ergonomics

Ergonomics = Setting up your home and work environments to reduce pain and improve efficiency and learning new techniques that allow you to perform essential tasks with less pain.

• Improving posture when sitting or standing.
• Learning healthy lifting techniques.
• Setting up your work or home environment to reduce pain.
• Making use of assistive devices, when available.

7. Improving Mood (Avoiding Depression)

Chronic pain often leads to activity disruption and reduced social participation. For these reasons and others, people with chronic pain are at elevated risk of depression. Taking active steps to ward off low mood makes sense.

• Laughter – try watching comedy shows or movies.
• Helping others – volunteering or other altruistic acts can improve mood.
• Learn CBT techniques to overcome negative maladaptive thinking patterns.

8. Better Healthcare Usage

Taking an active and involved role in the healthcare process helps you get more benefit from professional expertise and interventions.⁴

• Understand your condition. Be capable of monitoring your condition and managing and understanding your symptoms.
• Know the full names of all your medications, the dosages you must take and what each medication does for you.
• Communicate honestly with your health care providers and get answers for any questions that you have about your condition.
• Share in the decision making process with your doctor and others on your healthcare team.
• Take full advantage of support services.
• Learn how to evaluate the merits of new treatments⁵

9. Social Life

With pain it’s harder to stay social, but social isolation and loneliness increase your pain focus and lower your mood. Staying social helps you ward off depression and as long as you don’t overdo it, socializing can even reduce pain.

• Don’t let pain curtail your social life – plan manageable ways to get out and see friends and family; try shorter visits and schedule in plenty of times for breaks.

10. Distraction

Excessive pain-focus worsens pain sensations; sometimes getting your mind off your pain helps a lot – in fact, MRI studies show that brain activity in pain processing areas goes down when people get engaged in a secondary task.⁶

• Try getting more involved in activities you used to enjoy before pain interfered. If these activities aren’t realistic now, experiment with new manageable activities.
• Listen intently to music – try using headphones to immerse yourself in the sensory experience.⁷
• Visit with friends or family members.
• Read, play video games or watch TV or movies.

11. Mindful Consumption

• Avoid alcohol and illicit drugs – these can disrupt sleep, cause medication interaction effects and worsen side effects.
• Avoid tobacco –  it worsens general health and may interfere with endogenous pain management.
• Eat well – to increase energy levels, stabilize mood and increase medication effectiveness.
• Drink enough water – staying hydrated is especially important for anyone using opioids or other medications that can constipate.

12. Sleep

Pain makes it hard to fall and stay asleep and sleeplessness leads to fatigue, irritability and stress, which can all exacerbate pain.  Anything you can do to improve sleep will pay dividends in reduced pain.

• Maintain good sleep hygiene – Make your sleeping area inviting, avoid stimulating exercise immediately prior to sleep, avoid heavy meals prior to sleep - and many more.
• Consider medications that can help with sleeplessness.

13. Imagery Techniques

Use sensory imagery to alter your sensation of pain. Imagery techniques take a little practice to master and you may find working with a professional to learn these skills useful.

• There are many effective imagery techniques – here’s one example: imagine healing energy moving through your body toward your pain. As you breathe in the energy travels to your pain and soothes it. As you breathe out, the energy leaves your body, taking some of your pain away on each exhalation.

14. Problem Solving

Though you might have been an adequate problem solver prior to your pain condition, chronic pain brings novel complex problems and makes finding solutions more difficult. For this reason, and because research shows that people who learn problem solving skills have better health outcomes, learning effective problem solving skills makes a lot of sense.⁸

• One common problem solving model is based on a 6 step method: 1. identify the problem -> 2. set goals -> 3. brainstorm solutions -> 4. choose a solution -> 5. make a detailed plan and execute it -> 6. review and revise after the fact.

The Benefits of Pain Self Management

Pain self management techniques probably won’t cure you completely, but that’s OK – because self management techniques will likely reduce your pain and improve your overall quality of life. 

Some commonly experienced benefits include:⁹

• Reducing the frequency of severe pain flare-ups.
• An improved sense of self control over pain.
• Reduced pain-related stress.
• Reduced pain-related relationship discord.
• Decreased disability.
• Increased physical activity.
• Decreased anxiety and pain catastrophizing.
• Reduced healthcare costs.¹⁰
  
• Better sleep.

Taking a Pain Self Management Course

Disease self management works well and saves money – so it’s not surprising that a wide array of hospitals and other institutions offer brief outpatient or online courses to provide an introduction to pain self management and some initial instruction on some effective management techniques. Ask your doctor for a referral to a course near you, or simply search online for a course with the search term ‘pain self management + your city/county name'.

Your State of Mind and Long Term Disability Risk

Not yet convinced that by taking control of your pain management you improve your quality of life? Well consider the following risk factors of long term disability that medical professionals watch for during pain-assessments. If some or all of the following match your experience you’ll need to work a little bit harder to avoid long term disability - and you’ve got extra incentive to get started with pain self management right away.

Warning Signs of Long-Term Disability:¹¹

• Believing that pain does you harm.
• Feeling very distressed about your pain.
• Believing that passive pain control strategies work best.
• Significant pain catastrophizing.
• Excessive fear of pain (and fear avoidance).
• Psychosomatic tendencies.
• Low problem solving abilities.
• Believing that you probably can’t return to work.
• Believing that you probably won’t be able to do your job well again. 

Image Copyright: Malloreigh

Scared to use opioids? Worried about overdose, addiction or diversion? Well for most people, cutting your risks substantially is as easy as following the 8 recommendations from the American Academy of Pain Medicine.

Opioids offer you amazing pain relief …with serious risks attached.

• Risks of addiction
• Risks of overdose
• Risks of diversion (your children or others that you care about)

Fortunately, with responsible use and safe practices you eliminate most of your risks.

Worried about taking opioids? Well, you don’t have to be, just adhere to the following 8 guidelines from the American Academy of Pain Medicine and you cut your risks of ever experiencing a problem substantially.

The 8 Commandments of Safe Opioid Use¹

1. If it wasn’t prescribed to you – don’t take it! Never share or borrow prescription medications, especially opioids.
2. Alcohol and opioids don’t mix. To be safe, never combine them.
3. Know that anti-anxiety medications and sleeping medications can be dangerous when combined with opioids. Don’t use the two together without talking to your doctor first (some benzodiazepines can stay in your system for more than a day, so the anti-anxiety pill you took yesterday could interact with an opioid you take today.)
4. Don’t change your dose. Sometimes you might feel like you need more pain relief than usual and you might feel tempted to up your dosage a little bit. Don’t do this! Upping your doses on your own is a stepping stone on the path to addiction.
5. Tell your doctor about all medications you use, including OTC medications and herbal supplements.
6. Keep track of when you take your medication. Inadvertently doubling your dose increases your risks of overdose – have a system in place to reduce the odds of double dosing, such as always taking medications at the same time each day, or by separating your daily meds into pill boxes that are separate from your supply.
7. Lock up your medication. Medicine cabinet opioids are tempting to teens and others. By limiting access you could save a life.
8. Likewise, never save unused medication.

That’s it. Follow these 8 easy guidelines and your odds of ever having a problem plummet.

Image Copyright: Zeston

Don't consider (continue) chronic opioid therapy unless you can answer the following 10 questions.

Managing chronic non-cancer pain with opioids? Are you as educated about your condition as you need to be?

Here are 10 questions you need answers to. If you don’t have comprehensive answers for any of the following questions:

1. You’ll know what to ask your doctor the next time you see her. You’ll get far more from doctor's visits by going in knowing the specific questions you want to ask.
   
2. You should get informed. A few hours spent in preliminary internet research (on authoritative health sites) can help you get prepared for your next appointment.

What’s the Point of Education?

What’s the point of spending so much time wading through complicated health information anyway? Can’t you just rely on your doctor’s expertise and follow her instructions? Isn’t that good enough?

Well, following treatment directives makes more sense than trying to self-diagnose and self-treat a serious condition, but at the same time, you can’t get optimum care unless you play an active role in the healthcare relationship.

According to the experts at SAMHSA, people who get more informed about their condition and treatment:¹

• Are more compliant on treatment plans - You’re more likely to follow-through with treatment directives when you understand the point and necessity of each step.
• Worry less – You know which medication side-effects are normal and expected and which indicate a potential problem or a need for immediate medical care.
• Are more satisfied with their treatments – By understanding what you can realistically expect from treatment you eliminate false expectations and possible disappointments.
• Have better health, well being and outcomes.

10 Questions to Answer

1. What are the most common medical treatments available for your condition – both medication-based and non-pharmacological?
2. How much pain relief can you expect from your current treatment?
3. What are the risks and benefits of your current treatment? What are the risks and benefits of other possible treatment options?
4. What does each of your medications do? What other medications will negatively interact with any of the drugs you currently use?
5. What common side effects do your medications cause? Which of these side effects do you sometimes experience? What are the most effective ways to manage the side effects you experience (are you currently taking steps to minimize the severity or to cope with side effects? If not…why not?)
6. What serious adverse effects are possible with the medications you use?
7. What complementary and alternative treatments are available to treat your condition? What are the pros and cons and risks and benefits of each?
8. What's the best way to deal with symptoms flare-ups? Do you change your medication intake to respond to flare-ups?
9. What are some trustworthy and authoritative internet sites with information on your condition that you can turn to for answers? How do you know these provide good information? Have you ever asked your doctor about the sites that you rely on? Have you ever asked him or her for internet site recommendations?
10. Under what circumstances do you need to get emergency medical care? Do other people in your household know what symptoms indicate that you need emergency medical care? What symptoms indicate that you need to call your doctor?

Image Copyright: Alessandro Baffa

Worried about taking opioids or wondering how you’ll manage pain without them? Here are 42 largely side-effect free pain interventions to try.

For acute severe pain opioids make a lot of sense. They work quickly and well, and short-term side effects aren’t a significant issue.

However, for longer-term pain relief, opioids aren’t necessarily such a good idea. They have significant side effects and risks, and in many cases, researchers find that people who manage chronic pain with less opioid medication have better outcomes than those who rely more heavily on these potent drugs.¹

• In one study, researchers found that people using high doses of opioids for pain relief stayed off work 3 times longer than people who used lower doses.
• In another study, researcher found that when people who had been long time opioid users received multidisciplinary pain treatment, tapering off opioids resulted in decreased pain and increased physical functioning.
• Several studies have found a linear association between daily dose and overdose risk – the more you take each day, the more likely you are to overdose.

So then, if you need pain relief and you want to avoid or limit your opioid use, what are you supposed to do?

Well, by combining non-medication interventions with opioids you may find you can achieve acceptable pain management with a smaller daily dose – you may find that you can stop taking opioids completely or at least reduce your need.

So if you can achieve the same level of analgesia without opioids or on smaller doses, you eliminate or reduce troublesome side effects, risk of overdose, disability risks and addiction risks – and since many people find better long-term pain relief through self management strategies than with a medication centered approach, you really have little to lose and potentially much to gain with trying a comprehensive approach.

Here are some non-opioid pain management ideas to consider…

42 Non Opioid Pain Therapies

1. Non opioid medications, such as NSAIDs, anticonvulsants, skeletal muscle relaxants, antidepressants and others.
2. Topical creams or patches such as capsaicin therapy.²
3. Topical lidocaine patches.
4. Acupuncture or acupressure.
5. Transcutaneous Electrical Nerve Stimulation (TENS).
6. Spinal cord stimulation (an electrode implanted near your spinal cord can relax nerves that cause you pain).³
7. Nerve blocks.
8. Heat therapy.
9. Cold therapy.
10. Ultrasound.
11. Splints.
12. Strapping.
13. Braces.
14. Massage therapy and self massage.
15. Steroids.
16. Weight loss (if needed and will only relieve certain types of pain).
17. Cognitive behavioral therapy.
18. Education (not knowing what to expect or what symptoms truly mean increases stress and stress increases pain.)
19. Psychotherapy (to alleviate co-occurring anxiety or depression).
20. Acceptance and commitment therapy.
21. Mindfulness meditation.
22. Loving kindness meditation.
23. Physical therapy.
24. Strengthening exercises.
25. Stretching.
26. Learning and making use of pacing strategies.
27. Improving nutrition or sleeping habits.
28. Relaxation exercises (deep breathing exercises, progressive muscle relaxation, hypnotherapy and more.)
29. Imagery exercises.
30. Hydrotherapy.
31. Distraction techniques.
32. Biofeedback.
33. Yoga.
34. Hypnosis and self hypnosis.
35. Aromatherapy.
36. Laughter.
37. Joint manipulation.
38. Radiofrequency radioablation (deadening pain-causing nerves).⁴
39. Pastoral therapy or spiritual exploration.
40. Music, drama or art therapy.
41. Social companionship (hanging out with people you enjoy or care about.)
42. Desensitization (for neuropathic pain).⁵

This is far from a complete list of opioid alternatives for pain management. If you’ve had success with a pain management technique not on this list, please leave a comment below to share your knowledge and to extend this list of options.

Image Copyright: Glen Scott

Changing your thinking can make a huge difference to your outlook, mood and disability level. CBT is research proven and gets you results in a hurry.

CBT teaches you the answers to your problems!

Cognitive behavioral therapy (CBT) is a kind of talk therapy – but it's not introspective or historically-focused.

1. In CBT you look for solutions to a current problem and then you learn effective techniques to put these solutions into practice.
2. So if you struggle with pain that’s not going away (the problem) learning techniques that help you cope with pain (the solution) makes a lot of sense.

CBT isn't always focused on reducing pain; sometimes pain-reduction happens as a side effect. CBT gives you effective tools to manage and cope with pain so you can get out and enjoy life - whether your pain goes away or not. Fortunately, as you increase your activity level, reduce stress, sleep better and stay more positive and hopeful, you'll likely also see a substantial pain reduction.

Why Does Maladaptive Thinking Increase Pain?

Your medical condition causes you pain – but social, environmental and psychological  factors influence your perception of pain. If you can’t eliminate pain, you can still sometimes alter your pain experience through changes to thinking and behaviors.¹

The way you think about pain affects your perceptions, and if you fall into maladaptive pain thinking habits, you can actually think your way into greater discomfort.²

For example:

• If episodes of back pain normally last for days and leave you bed-ridden, the first unusual twinge in your back might prompt worst-case scenario predictions of the pain that you’ll be in, the plans you’ll have to cancel and all the work you won’t get done.
• These thoughts increase stress and anxiety and cause the release of stress hormones, a blood pressure spike and increased muscle tension. These physiological changes can cause or exacerbate pain.
• Physiological responses to stress and anxiety make it more likely that an innocuous twinge turns into a severe pain episode and/or something that increases disability.

The way you think matters! Here's a short list of some non-medical variables that worsen pain and disability:

• A strong fear of pain or of re-injury.
• A strong avoidance of activities that might be painful or reinjure - resting too much and for too long after injury or pain.
• Catastrophizing (worse case scenario thinking).
• Excessive use of passive pain relief (an over-reliance on medication, resting, etc.).
• Depression.
• Stress – chronic pain often causes financial worries, anxiety about meeting responsibilities and guilt feelings related to failing to meet responsibilities.
• Poor concentration and muddled thinking – pain can leave you distraction-prone and memory-short, this can compound the problems you already have in meeting your daily responsibilities and can lead to feelings of helplessness, anxiety and depression (all of which can worsen pain perception).
• Poor problem solving.
• Poor use of coping strategies, for example, insufficient pacing – pushing yourself to exhaustion one day and needing to spend the following 2 days recovering and in pain.
• Receiving overly responsive home caretaking.

This short list of examples demonstrates how non-medical variables can have a profound impact on your pain experience and quality of life.

Fortunately, if you look at this list from a CBT perspective, you see a list of solvable problems - and a huge opportunity for pain reduction!

What CBT Can Teach You

Some common pain CBT goals include:³

1. Learning to become an active pain management problem solver.
2. Learning to stop living in the past, pining for what you used to be able to do. By living in the present you can focus on problem solving and adapting to your limitations to create the best life you can today.
3. Learning how negative thinking can worsen pain and then learning how to monitor and change thoughts as needed to avoid worsening pain.
4. Learning effective pain management skills and incorporating these into daily life (relaxation exercises, journaling, etc.)

Here are some examples of CBT techniques you might learn to solve pain-problems. Most of these are fairly easily understood – the real trick is in putting these easy techniques into regular daily practice.

Changing Unhealthy Thinking Habits

Most people make use of one or more unhealthy and unhelpful thinking habits, and when it comes to chronic pain, maladaptive cognition leads to extra aches and pains.

Some examples of maladaptive thinking habits include:

• Catastrophizing – predicting the worst case scenario.
• Black and white thinking – forgetting that reality is composed of many shades of gray.
• Unrealistic expectations for the world - (should statements).
• Mind reading – believing we know what others are thinking about us.
• Emotional reasoning - believing our feelings indicate truth. Believing that if we feel worried about our pain that means our pain is causing harm.

CBT Tools That Reduce Pain

Scheduling

With pain, it’s easy to lose life-balance - for example, you have less energy so you spend it all at work and have nothing left for fun or social relationships.

To get back in balance, take stock of what’s important in your life (for example: achievement at work, school or volunteering, social outings and relationships, hobbies and fun) and then schedule your days so that you find time for all of what's most important, making sure to include ample time for rest along the way.

• Active planning ensures that you fill your time with what’s most important and helps you eliminate the tiring less important stuff. 

Relaxation Training

Stress and tension increase pain and anxiety; learning relaxation techniques helps you keep pain under control by reversing much of the stress and tension that cause it.

Some examples of relaxation techniques/exercise you might learn include:⁴

• Deep breathing exercises.
• Progressive muscle relaxation.
• Yoga.
• Meditation or mindfulness.
• Imagery techniques.
• Many others.

Pacing Techniques

To live well with chronic pain you need to get out of the cycle of overdoing it when you feel well and then paying the consequences for days thereafter.

You can break this negative cycle with pacing techniques. Some components of chronic pain pacing include:

• Keeping an activity log to identify pain and fatigue patterns (for example at certain times each day or after certain regular activities.)
• Planning activities (with scheduled rest periods) to end before you get over-tired.
• Monitoring your activity log over time to identify which activities help and which worsen pain and fatigue, and then adjusting your routines accordingly. 

Problem Solving Techniques

Poor problem solving leads to stress and stress worsens pain, so learning a few structured problem solving techniques can help a lot. Here's one common 7 step method:⁵

1. Decide if this is a solvable problem or an unsolvable problem.
2. If it's solvable – brainstorm a list of possible solutions or options.
3. Pick the best solutions or options from your brainstormed list.
4. Take the top 3 or 4 options and write down the advantages and disadvantages of each option.
5. Decide on an option/solution.
6. Take action.
7. Revisit after the fact to evaluate the success of your chosen solution. 

Professional Help or On Your Own?

There are advantages to working with a CBT counselor or joining a pain group to learn CBT techniques, but if these aren’t accessible in your area or if you just prefer the idea of doing it on your own, you can also learn CBT techniques through self help books or through online learning programs. CBT is one type of intervention that you really can learn ‘on your own’.

Two examples of free online CBT programs are Mood Gym and Living Life to the Full,  though there are many other good options for this.

Treatment Duration

CBT is a solution-focused time-limited therapy. A typical course of CBT for chronic pain might occur over 10 to 15 once or twice a week hour long sessions, though people with more significant pain and disability may require more intensive therapy.⁶

Research Proving Effectiveness

Many studies illustrate CBT’s effectiveness as a pain treatment, such as:

The Cochrane Review of CBT for Chronic Pain

A Cochrane Summaries study collected data from 35 quality research trials conducted on CBT and behavioral therapy for chronic pain. Based on these studies, the researchers concluded that CBT decreases catastrophic thinking, disability and distress and improves mood. Changes were small to moderate in magnitude.⁷

CBT Increases Grey Matter

Chronic pain conditions are often associated with grey matter loss in the brain, fortunately, these losses are reversible – researchers have shown that when surgical procedures ease pain, grey mater size and density returns to normal.⁸

CBT, it seems, has the same effect. Researchers at Duke and The University of Vermont found that people with chronic musculoskeletal pain had significantly increased grey matter density after just 11 weeks of group CBT.

So not only does CBT cause perceived pain reductions, we can also see these changes with an MRI scan. 

CBT Risks and Side Effects?

All medications come with risks and side effects – especially potent opioids.

Cognitive behavioral therapy has no adverse risks, side effects or interaction effects, and by learning better mental and behavioral management of pain you may need less medicines.

Is CBT Right for You?

Most people with persistent pain can benefit from learning better coping skills and thinking strategies, especially people who:⁹

• Have lived with chronic pain lasting 6 months or longer.
• Feel that pain rules their life.
• Feel frustrated at persistent pain for an injury that should have healed.
• Find that pain gets worse with stress or anger.
• Feel hopeless about their ability to live with pain or to manage pain.
• Don’t get full pain relief from pain medication (even at maximum doses).
• Find that pain has a negative impact on social life and important relationships.
• Miss work due to pain.
• Have pain related sleeping problems.
• Find that life isn’t as enjoyable due to pain.

Image Copyright: GregPC

Does your pain limit your quality of life severely enough to warrant opioid treatment? If on opioids, do they improve your quality of life enough to justify their risks? Test yourself to find out.

Opioids work very well to reduce certain kinds of pain. However, these medications have serious side effects and risks and it’s important to make sure that the benefits of use outweigh the risks.

And this is doubly so for people in recovery or other people at elevated risk to develop an addiction problem.

There are many factors to consider when evaluating the suitability of opioid therapy; one important variable to think about is how pain affects your ability to function - and by extension, your general quality of life.

In this article you will learn how to:

• Rate your current ability to function on a scale of 0 to 10 (a standardized function rating scale).
• Learn how to evaluate changes to your ability to function over time (such as over the course of chronic opioid therapy).
  

By rating your ability to function and by updating your rating score (from 1 to 10) over time, you’ll gain a better sense of:

1. Whether starting opioid therapy makes sense for you – if you’re at high risk of addiction and your current pain doesn’t greatly compromise your ability to function, then you might decide that the risks of use outweigh the benefits of initiation.
2. Whether continuing with opioid therapy makes sense – if opioids don't cause any significant improvement in your ability to function, you may want to consider another form of pain management.
   

Ability to Function Self Test

The following rating scale was developed by the American Chronic Pain Association. Discuss your score with your prescribing doctor as one factor to consider in any decision on using or continuing to use opioid medications.¹

Select whichever of the following descriptions best matches your activity/energy level.

• 10 – Though you experience pain you are still able to go to work or school or volunteer each day as normal. You can also participate fully in other normal family, daily-life and social activities. 
• 9 – You can still work/volunteer/go to school for a full day as normal and participate fully in family life but your pain causes you to limit social activities a bit.
• 8 – You can work/volunteer/go to school each day but only for a three-quarter day. You still have enough energy for one weekday social outing per week and you’re normally active on weekends.
• 7 – You can work/go to school or volunteer for a few hours a day and can be active for about 5 hours each day. Only easy social activities on weekends.
• 6 – You can still participate in work/school/volunteering – but only on a limited basis. You only take part in occasional limited social activities on weekends.
• 5 – You can’t participate in outside activities (no school/work/volunteering) but you can still manage, with difficulty, your daily household responsibilities.
• 4 – You can manage to help a bit at home but not as much as you used to. No outside work/school or volunteering and only occasional limited outings beyond the home, once or twice a week.
• 3 – You still get dressed in the morning but you don’t leave the home. You can only engage in minimal activities at home and you basically keep in touch socially via phone or online.
• 2 – You get out of bed but don’t get dressed. You stay at home all day.
• 1 – You’re in bed at least half the day and don’t maintain any social contact.
• 0 – You stay in bed all day. You feel hopeless.

The lower your score, the more serious the situation. If you earn a low score then you may want to keep all pain management options on the table.

Should You Stop Taking Opioids?

If you’re on opioids and they help a bit – but not a lot – why not just continue to take them while you also pursue other forms of analgesia? After all, isn’t some pain reduction better than none at all?

Well, whether the opioids help you enough is a personal decision, but beyond the risk of addiction (which is pretty substantial) additional reasons to consider discontinuing opioid therapy include:²

• Opioids may have diminished efficacy over time.
• As tolerance and dosage increases, adverse side effects can worsen.
• There is a risk that opioids can induce hyperalgesia – worsened pain.
• Opioids interact with alcohol and with many different OTC and prescription medications. With interactions there is a substantial risk of fatal overdose, especially as tolerance drives your daily dose up. 

Rating Daily Activity Improvements

Sometimes it’s hard to recognize how much improvement you’re making – and by extension, whether opioids work well enough to justify their risks.

An exercise that can help with this is to take stock, on a regular basis, of how much trouble you’re having with common everyday activities. If you rate activity-difficulty before starting opioid therapy, and then update your activity ratings over time as you continue with it, you’ll have a visual record of your gains and an objective way to decide on future therapies.

Give yourself a numerical score for any of the following activities that you engage in on a regular basis.

• 1 = Pain prevents me from doing this.
• 2 = Pain makes it difficult to do this.
• 3 = It takes extra effort to do this because of pain.
• 4 = It takes a little extra effort to do this because of pain.
• 5 = I have no problem with this.

Here are some example activities that you can use to take stock of pain’s influence on your daily activities. To get the most out of this exercise, think about any everyday activities that give you trouble, and if they're not on the list now, add them on at the bottom. Using this measure, over time, you'll see how significantly opioids improve your functioning.³

Image Copyright: Helga Weber

Pain leads to relapse, but opioids are dangerous for people with substance use disorders or addiction histories. Get pain relief while reducing your relapse risks by following SAMHSA’s opioid guidelines.

Pain management for people with substance use disorders or addiction histories is tricky business.

1. People with substance use disorders or addiction histories often experience chronic pain (for example, up to 60% of people with opioid addictions report chronic pain.)¹
2. Though opioid drugs provide strong analgesia, people with active addiction or addictive histories are at higher risk of drug-misuse and addiction. For this reason, many people in recovery feel reluctant to use opioids for pain management and many doctors feel reluctant to prescribe opioids to people with addiction or addiction history issues.
3. However, uncontrolled pain is a significant risk factor for relapse or worsened substance use.

So if you’ve got pain and addiction/addiction history, you may feel like you’re between a rock and a hard place - what should you do?

Well, to help you with this, read over the opioid use guidelines from SAMHSA for people with active addiction, people in recovery and people on methadone or Suboxone.  These guidelines take you step-by-step from low-risk pain management strategies all the way to opioid use (if needed). By following these guidelines and by observing safe opioid use practices, you can reduce your risk of opioid misuse and addiction while still keeping all pain-management strategies on the table.

Opioids Guidelines for Active Addiction/Recovery

Here are the chronic pain treatment progression guidelines (from SAMHSA) for people:²

1. With active substance use disorders.
2. In recovery.
3. In recovery using methadone or Suboxone.

Opioid Progression Guidelines – People In Recovery

1. Try opioid alternatives first and proceed to opioids only if the benefits clearly outweigh the risks.
2. Start with non-opioid analgesic medications, such as NSAIDs and others. Combine medications with non-pharmacological treatments (massage, heat and cold therapy, TENS and others), physical and occupational therapies for functional restoration and mental health treatments to reduce aggravating issues, such as poor sleep, uncontrolled stress, untreated mental illness and others.
3. If this combination of non-opioids and non-pharmacological treatment results in sufficient pain relief, stop here and do not continue on to opioid use. If analgesia isn’t sufficient, consider whether the benefits of opioid use outweigh the risks, and they do, start an opioid trial.
4. If opioids don’t cause a substantial improvement in pain, quality of life or functioning, then wean off and continue with other therapies. If opioids result in significant improvements, continue with them while monitoring to make certain that positive results continue (pain relief may diminish over time) and while monitoring for adverse effects, like addiction.
5. Should addiction relapse occur, initiate substance abuse treatment and begin the pain management guidelines for people in active addiction (see below)

Opioid Guidelines for Methadone and Suboxone Users

1. Consider increasing the methadone or Suboxone dose for improved pain-relief. At the same time, begin non-pharmacological pain treatments, physical and occupational therapy and mental health and wellness treatments.
   
2. If pain relief remains inadequate and if the benefits of opioids outweigh the risks, begin an opioid trial (opioids in conjunction with methadone therapy).
3. If opioids don’t provide significant pain relief, quality of life or functional improvements, discontinue by weaning off.
4. If opioids provide significant benefits, continue with the therapy while monitoring for misuse and any reductions in benefits.
5. Should opioid addiction relapse occur (uncontrolled use) intensify substance abuse treatment and begin the pain management guidelines for people in active addiction (see below).

Because at sufficient doses, methadone blocks the euphoria of supplementary opioids, a person can use opioids for pain while on methadone without getting high and without losing control over their use.

Opioid Guidelines – People with Active Addiction

Opioids are rarely an appropriate chronic pain treatment for people with an active drug or alcohol use disorder.  If someone with active addiction requires chronic pain treatment, the steps are:

1. Start addiction treatment. Do not use opioids yet. If you are abusing opioids, either start tapering off or continue to use under the close direction of an addiction professional while receiving addiction treatment.
   
2. Try non-opioid analgesics and non-pharmacological pain treatments, such as physical therapy, CBT and complementary therapies.
3. Once stabilized and in recovery, continue with the pain management steps outlined above, within the ‘in recovery’ guidelines.

Reducing Opioid Risks

If you and your doctor feel opioids are necessary despite an elevated risk for addiction, you can safeguard against problems by taking precautionary measures to reduce your risks. Examples of precautionary measures include:

• Agreeing to a program of urine testing (which checks for drug misuse)
• Agreeing to frequent visit intervals and small prescriptions.
• Agreeing to have family members or others from your support network involved – these people can be entrusted with keeping the supply and handing medications on schedule and monitoring for signs of abuse.
• Using opioids with less rewarding properties (such as codeine or tramadol) rather than more potent opioids like oxycodone.
• Using slow release opioids when possible – possibly transdermal patches. 

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In pain? Your attitude predicts more about your long-term chances of future pain and disability than your disease or your current pain level.

Two people have the same serious injury. Both get surgery and start rehab. One person reports manageable pain and gets back to work within a series of weeks. The other person reports unmanageable pain and stays on long-term disability. How can similar injuries and diseases cause such dramatically different outcomes?

Well, variables like pre-injury health, genetics and rehab compliance play an influential role, but surprisingly, research shows that the way you think about pain is one of the most significant predictors of negative pain and disability outcomes. In fact, pain catastrophizing is a better predictor of future pain and disability than current pain, disease, anxiety, depression and neuroticism.¹

It’s not what you’d expect, but a lengthy body of research demonstrates that when you get preoccupied with pain and feel helpless in your ability to control it – it feels much worse.

Fortunately, this means that by learning a few relatively simple techniques, you can change the way you look at pain and dramatically reduce discomfort and disability.

Read on to learn more about:

• Pain catastrophizing; what is it?
• How do you think about pain? – Take a self test to find out
• How and why does our thinking affect pain perception?
• Most importantly, if you have a pain catastrophizing problem, what can you do to correct it?

What Is Pain Catastrophizing?

Although you might think that you have little control over your pain experience, the way you think about pain can substantially change your pain perception – both for the good and for the bad.

Some people develop extremely negative beliefs and thinking patterns about pain. This is called pain catastrophization and research shows that catastrophizing worsens pain. People who catastrophize:²

1. Focus excessively on their pain and on anticipation of future pain (rumination).
2. Magnify the threat that pain poses to everyday functioning (this limits activity and increases disability).
3. Feel helpless to manage their pain.

Test Yourself

This self test is based on the pain catastrophizing scale.

Would changing your thinking and beliefs on pain help to reduce your pain and improve your quality of life?

As a starting point to answering this difficult life-question, give yourself a score for each of the following statements about how you think and feel while experiencing pain. For each statement, choose the score that best represents your experience:

• 0 = Not at all
• 1 = Occasionally
• 2 = Sometimes
• 3 = Usually
• 4 = Always

 Pain Catastrophizing Self Test

1. When I am in pain I feel worried about it and I want the pain to disappear.
2. When I’m in pain I can’t get the pain out of my mind.
3. When I’m in pain I feel worried that the pain will never get better.
4. When I am in pain I feel like I can’t take it any longer.
5. When I am in pain I am scared that the pain is going to intensify.
6. When I am in pain I can’t do anything to ease my discomfort.
7. When I am in pain I worry that something bad might happen.
8. When I am in pain I focus a lot on how much it hurts.
9. When I am in pain I think a lot about other experiences that hurt.
10. When I am in pain it is so horrible that I feel overwhelmed.
11. When I am in pain I often think about how much I wish the pain would go away or get better.
12. When I am in pain I feel bad and I think the pain is never going to get better.
13. When I am in pain I feel anxious and really want it to disappear.

Scoring

The maximum possible score is 52. Scores higher than 30 indicate significant catastrophizing.

Why Should You Care?

If you earned a high score on the self test above, do you really need to take any action? Can changing your thinking really have any significant impact on your pain and quality of life?

Well, people who score highly on measures of pain catastrophizing tend to experience greater pain-related problems, such as:³

• Increased healthcare needs/use (more frequent doctor’s visits, etc.).
• Greater acute and chronic pain perception.
• Reduced natural pain suppression and inhibition ability (CNS alterations).
• Increased disability.
• Worsened post surgical outcomes.
• Greater pain related disruption to daily life activities.
• Increased likelihood of intentional medication overdoses and other suicide attempts.⁴
  

Basically, people who have overly negative pain related thinking styles feel more pain and experience more disability – and reducing pain and disability are two pretty solid reasons to care about how you think about pain.

How and Why Does Pain Catastrophizing Worsen Pain?

Researchers know that pain catastrophizing increases your pain perception but they’re not totally sure why this happens. It likely increases your perception of pain in a couple of ways:⁵

1. It leads to a hyper-focus on pain and on the anticipation of pain. This increases the sensation of pain.
2. It causes an exaggerated emotional response to pain (worry, anxiety, hopelessness, etc.) which also increases the perception of pain.

Using MRI scans, we can see that during a painful experience (blunt pressure pain) people with higher pain catastrophizing scores have increased activation in a number of areas of the brain, such as:

• The medial frontal cortex and the cerebellum – Elevated activity in these areas corresponds to increased anticipation/worry in before pain.
• The dorsolateral prefrontal cortex – Related to increased attention to pain.
• The claustrum and amygdala – Related to the emotional consequences of pain.

There is some research evidence to suggests that pain catastrophizing also disrupts endogenous (natural) pain control systems – something that could diminish the effectiveness of analgesic medications like opioids.⁶

Overcoming Catastrophizing with CBT

1. So catastrophizing can cause you pain and disability; if you tallied a high score on the test above, this is probably not something you’d feel very happy about.
2. But if you look at it another way, you might decide that being a current pain catastrophizer isn’t so unlucky after all – since research shows that with a brief period of treatment, you can change your negative thinking habits and substantially decrease pain and disability!

To reduce pain catastrophizing you need to change your thinking from fear-based vigilance to acceptance and broadened thinking – and to reduce hopelessness and helplessness you need to learn effective techniques for pain management and coping.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is the most commonly recommended intervention for pain catastrophizing.¹ Pain can distort your core beliefs, assumptions and automatic thoughts, and these distortions can cause increased disability and pain. By learning to challenge and correct distorted thinking, you can improve function and reduce pain. As you gain coping and pain management skills that actually work you retake a sense of control over your life and reduce helplessness and hopelessness with action and self directed competence.⁷

Here are some examples of the kinds of knowledge, tools and skills you might gain from a CBT for pain catastrophizing therapy program.

• Learning how stress and mood affect pain and learning that you can control your pain to some degree by learning strategies to control stress and mood.
• Learning to identify, challenge and replace unhealthy automatic thoughts – for example, to replace, “This pain will never get better.” With, “The pain is bad right now but I can ease it a bit with heat therapy.”
• Learning to challenge unhealthy core beliefs – for example, to replace “I can’t exercise because of my back pain.” With, “I can’t do certain activities but actually some low impact exercises ease my discomfort.” Or, “Since I can’t sit for more than an hour I’ll never be able to go back to work again.” Could become, “I’ll probably have to modify my work routine, but with adjustments I’ll be able to contribute at work again soon.”

Why Get CBT?

CBT is a structured and time-limited form of therapy – so you can expect to see benefits quickly and finish with therapy within a period of weeks or months. Much of the work is done outside of therapy sessions as homework and you’ll gain transferable skills that last a lifetime. Research proves that CBT is a very effective psychological pain treatment, whether you have catastrophizing issues or not.

There are no worrisome side effects associated with CBT (unlike that seen with opioid medications, for example.)

Other Common Treatments

 Some other common interventions for pain catastrophizing include:

• Group therapy – Therapy groups can provide support and information on how to cope and thrive while living with pain. Group therapy can help people solve specific problems, learn new approaches, learn healthier ways to respond to and manage pain and much more.
• Mindfulness and acceptance therapy.
• Physical therapy – By increasing stamina and strength and by decreasing your fear of certain movements and activities you can reduce inactivity and disability.
• Occupational therapy – For many people, pain controls activities – pain is in charge. By learning new techniques for everyday activities you can retake control and increase independence and functioning.
• Biofeedback – Biofeedback gets you in tune with your body and increases your ability to self-soothe and manage pain.
• Stress management and relaxation training  – Pain causes stress, pain reduces your stress tolerance and stress worsens pain. By learning effective stress management techniques you can reduce pain.
• Learning activity moderation – Both insufficient and excessive activity worsen pain. The key is to learn pacing and moderation techniques that maximize your activity potential.

Quick Improvements

One very exciting aspect of cognitive behavioral and multimodal pain treatments to reduce catastrophizing is that you can see big gains in a short time period. For example, the Mayo Clinic runs a 3 week outpatient multimodal pain program. After 3 weeks of treatment, 75% of participants score a reduction in pain catastrophizing and improved overall health – and 85% reported improved physical functioning.⁸

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