Allan N. Schwartz, Ph.D., LCSW

woman holding back in pain

It is important to understand what we are talking about when we refer to addiction. The American Psychiatric Association states that “addiction is a complex condition, a brain disease that is manifested by compulsive substance use despite harmful consequence. People with addiction (severe substance use disorder) have an intense focus on using a certain substance(s), such as alcohol or drugs, to the point that it takes over their life.”

Those with chronic pain tend to be vulnerable to opioid addiction. Opioid drugs are used to ameliorate the effects of pain on patients. Typically, the type of pain that seems to lend itself to addiction are those of the lower back. Patients complain that it’s difficult to sit, stand or lie down because of lower back injuries.

Patients with chronic back pain could try such alternative therapies as tai chi, yoga, acupuncture, and mindful meditation before being prescribed opioid painkilling drugs, according to new guidelines from the nation’s largest specialty physicians group.

A recent commentary from the American College of Physicians is the latest in a continuing flow of recommendations that seek to change how patients and doctors think regarding prescription painkilling drugs, blamed for the national addiction crisis.

Still, the information hasn’t gotten to many people.

“I think most patients want medications as a fast fix,” said Anita Gupta, vice chair of Drexel University College of Medicine’s division of pain medicine. “What patients understand is often far from what the evidence tells us to do. Dr. Gupta stated that her practice at Hahnemann University Hospital gets patients’ “family and friends involved in care, and often includes psychotherapy because pain can cause isolation and depression.”

People living with chronic lower back pain are more likely to
use illicit drugs, including marijuana, cocaine, heroin, and methamphetamine, compared to those without back pain, reports a study in Spine, published by Wolters Kluwer.

According to the report, all four specific drugs were more commonly used by patients with lower back pain. “Rates of lifetime use were about 46.5 versus 42 percent for marijuana, 22 versus 14 percent for cocaine, nine versus five percent for methamphetamine, and five versus two percent for heroin. After adjustment for other factors, participants with lower back pain were more than twice as likely to report methamphetamine and heroin use.

Many other studies show that prescription opioids are widely used by patients with lower back pain, raising worries about addiction, misuse, and accidental overdose. Older studies found that people with a history of illicit drug use are more likely to misuse prescription opioids.

In a recent scholarly article published in the New England Journal of Medicine, it said “addressed the problem of opioid misuse in the context of chronic pain, a big part of the problem of prescription opioid addiction. They pointed out that chronic pain and its accompanying disability are huge problems and opioid analgesics are now the most commonly prescribed class of medications in the United States. They further noted that opioid analgesics are widely diverted and improperly used, resulting in a national epidemic of addiction, opioid overdose and death, and that the major source of misused and diverted opioids is prescription by physicians.”

During my years of psychotherapy practice, I have seen a sharp increase in the number of clients addicted to opioids because of lower back pain. These are people of all ages from young to old. Even though they suffer from the pain, they unfortunately become drug seekers, going from one pain clinic or MD to another to fill more prescriptions. By the time they get to me, they are not functioning. Their marriages are in trouble and they are no longer able to work. Many of them are trying to make cases for disability and are often denied. Finally, they feel depressed and hopeless. Many of these clients had no history of drug abuse despite the finding that was cited in this article. However, once they became addicted, denial set in and they justified the use of the drugs. Always having pain was their justification for the continued use of the drugs.

There is one major observation of mine that is notable. Even though there was no history of drug abuse, these clients all had personality disorders.

What are Personality Disorders?

The American Psychiatric Association states:

“Personality is the way of thinking, feeling and behaving that makes a person different from other people. An individual’s personality is influenced by experiences, environment (surroundings, life situations) and inherited characteristics. A personality disorder
is a way of thinking, feeling and behaving that deviates from the expectations of the culture, causes distress or problems functioning, and lasts over time.”

These problems functioning are chronic and repetitive. They are behaviors learned during childhood and clients are often unaware that they have a personality disorder except for the fact that they know they are having problems. Chronic pain also leads to feelings of depression and hopelessness. Opioid medications exacerbate those feelings. That is why psychotherapy, as well as alternative self-help techniques, are recommended and listed below.

What is the solution?

As the beginning of the article stated, there are some alternative methods for patients to use to find relief. Among these are tai chi, yoga, acupuncture, and mindful meditation. Research has found that all or any of these are effective in reducing pain, stress and anxiety. In addition, there is psychotherapy that can be useful. There is Cognitive Behavioral Therapy, better known as CBT that helps people restructure their thinking- yes, there is the sensation of pain but then there is how we think about it. Many times, our thinking worsens the situation. Then, there are the other psychotherapies such as psychoanalysis, psychodynamic therapy, group therapy and marriage counseling. After all, the spouse and family are also affected by what the patient is experiencing.

Success is being reported with the use of CBT to help refocus thoughts on things other than pain: “CBT consists of teaching patient’s cognitive (reframing maladaptive thoughts) and behavioral coping skills (e.g., relaxation strategies). The technique was shown to improve pain and function in patients with several pain modalities, including back pain and pain associated with arthritis and fibromyalgia.

Finally, attitude is very important. For example, several of my friends have gone through rotator cuff surgery. The pain is intense after the surgery. Physical therapy is also extremely painful. Added to this is the necessity of having to sleep in an upright position because the shoulder must remain in a sling, rendering one feeling very awkward. The friends’ I am referring to refused opioid pain medications despite the recommendations of the physicians. They toughed it out mostly using aspirin until the worst of the pain was over. These friends of mine are just ordinary people. So how is it that they tolerated pain while others can’t seem to do so? In an article about Dr. John Sarno, MD, one of the foremost experts on back pain- much of it is all in your head.

Dr. Schwartz has been a psychotherapist for forty years. He has a Ph.D. in Educational Psychology, an MSW in Clinical Social Work and certification in Psychoanalysis from NPAP, a New York Psychoanalytic Institute. Dr. Schwartz has appeared in a variety of radio and television shows around the country and has written for, one of the finest mental health websites on the internet.