By Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

Below are seven strategic steps that I believe are necessary to help chronic pain patients overcome obstacles that get in the way of obtaining appropriate and effective pain management. The rational and more in-depth explanation for each of the following steps can be found in my new book Managing Pain and Coexisting Disorders: Using the Addiction-Free Pain Management® System.

• 1. Developing an Initial Multidisciplinary Pain Management Plan: The first step of effective pain management is utilizing a multidisciplinary assessment protocol. The patient needs to objectively examine their current pain management program. They should list each of the medications and non-pharmacological pain management interventions they are currently using and answer pertinent questions about each one. They also need to list their professional and personal support system, identifying the strengths and weaknesses of each.
• 2. Looking At Pain Objectively: This component explores how to increase the patients' understanding of their pain and how to use that knowledge to improve their pain management. They need to learn the different aspects of pain-acute and chronic-and the bio-psycho-social components of pain as well as the difference between pain and suffering. They should learn about the stress-pain connection and how to rate their stress and pain levels accurately. Finally they need to explore how their thinking, emotions, behaviors, and social relationships change when they're having a "bad" pain day.
• 3. Understanding and Managing Depression: Since depression frequently affects people in chronic pain, in this component patients need objective and easy to understand information about depression and what constitutes effective depression management. They should learn how to accurately rate the type and level of depression symptoms they experience and then develop their own personal six-step depression management plan.
• 4. Exploring Effective Use of Medication: This component starts with educating patients about some common, and possibly misunderstood, terms like medication abuse, dependency, pseudo addiction, and addiction. Patients need to learn how to use a Red Flags checklist to see if they have a problematic relationship with their pain medication. They also need to learn the role of denial and finally explore the benefits and disadvantages of using appropriate pain medication.
• 5. Developing An Effective Pain Management Plan: In this component patients are exposed to the concept of a Pain Management Agreement and how to deal with urges/cravings that could tempt them to use pain medication in an inappropriate manner. They should develop a nonpharmacological (non-medication) pain management plan and learn to utilize a pain journaling process to increase their pain management skills.
• 6. Exploring Biological versus Psychological/Emotional Symptoms: This component focuses on explaining ascending versus descending pain signals and exploring and scoring the patients' biological and psychological/emotional pain symptoms. Patients also need to look at how their TFUARs (thinking, feeling, urges, actions, and social reactions) change on a bad pain day and how to manage their TFUARs more effectively.
• 7. Finalizing the Pain Management Plan: This component ties everything together by teaching patients to identify and rate their bio-psycho-social-spiritual pain management goals. Then they should learn how to improve their existing pain management foundation and test this new plan to make sure it is effective.

If you want to learn more about effective pain management for someone living with chronic pain and addiction check out my new book Managing Pain and Coexisting Disorders: Using the Addiction-Free Pain Management® System on the Publications page on our website at www.addiction-free.com. You can also visit our articles page for free downloads.

Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

Modern pain management systematically approaches the treatment of pain at all three levels (bio-psycho-social) simultaneously. This means using physical treatments to reduce the intensity of physical pain, psychological treatments to identify and change the thoughts, feelings, and behaviors that are making the pain more intense and replacing them with positive thinking, as well as feeling and behavior management skills that can reduce the intensity of the pain.

Finally, effective pain management must involve not only the pain patient, but also the significant people in their life who can help them to develop a social and cultural context in which to experience their pain in a way that will reduce suffering.

Biological pain is a signal that something is going wrong with the body. The biological, or physical, pain sensations are critical to human survival. Without pain we would have no way of knowing that something was wrong with our body. So without pain we would be unable to take action to correct the problem or deal with the situation that is causing our pain.

Psychological Pain results from the meaning that the brain assigns to the pain signal. The psychological symptoms include both cognitive (thinking changes) and emotional (uncomfortable feelings) that lead to suffering. Most people are not able to differentiate between the physical and psychological. All they know is "I hurt." For effective pain management you need to learn all you can about your pain.

Social and Cultural Pain, results from the social and cultural meaning assigned by other people to the pain experience, and whether or not the pain is recognized as being severe enough to warrant a socially approved sick role. These three components determine whether the signal from the body to the brain is interpreted as pain or suffering.

Imagine the following vignet: Bob is his college's star football player. In last week's homecoming game Bob scored the winning touchdown but broke his arm in the process. This week Bob is sitting on the bench with a cast on his arm that everyone has signed. This cast and how he earned it are seen as an honorable reason for him to be sitting on the bench. In that same game Karl, a big hulking lineman, "tweaked" his back and was also sitting on the bench this week. Unlike Bob, Karl doesn't have an observable injury and people were asking him why he wasn't out on the field helping his team. Karl is much more apt than Bob to experience shame/guilt, which could very likely amplify his pain symptoms.

To learn more about effective treatment for chronic pain-especially when other coexisting disorders are present-please check out our website at http://www.addiction-free.com and go to the Articles page for free informational downloads about this topic. (Randy please link Articles to http://www.addiction-free.com/articles/

Pain can be classified as either acute or chronic. Because the conditions are dissimilar, the treatment for acute pain is very different than the treatment for chronic pain. Distinguishing between the two and understanding the difference is very important for effective pain management.

Acute pain tells your body that something has gone wrong or that damage to the system has occurred. The source of acute pain can usually be easily identified, and typically does not last very long; it is a symptom of an immediate underlying problem.

An example of acute pain is when you touch a hot burner on the stove. Your first reaction is to pull away your hand. Contact with the heat will leave you with symptoms from minor redness to serious tissue damage, but in each case there is a predictable period of time for the burn to heal. There are also effective medical treatments that promote quick healing. Some other causes of acute pain include cuts and broken bones.

No matter what the source of acute pain, the result is to drive you to search for relief. Once the problem is identified, it is standard and usually safe to use analgesic and/or opiate medication for acute pain relief, unless you have a history of substance abuse or dependency. If you are in recovery for chemical dependency, an addiction medicine practitioner/specialist should be consulted before any opiate or other psychoactive medications are taken.

Acute Pain

· Gives an immediate signal to the brain

· Signals damage/dysfunction

· Is readily treatable

· Is of limited duration

Another example of an acute pain episode is when your pain worsens (also known as a pain flare up or recurrent acute pain). These flare ups require different treatment than your typical day-to-day pain management plan. An upcoming article explains how to develop an effective pain flare up plan.

Chronic pain, on the other hand, is a condition that frequently fails to respond to standard medical interventions. In some cases there is no easily recognizable reason for the pain, or the original acute condition seems to be resolved but the pain signals keep firing and lasts three to six months. The usual medical criterion for a chronic condition is at least three to six-months in duration. In many cases chronic pain no longer serves a useful purpose; the pain system gets turned on and stays on well after the initial cause-or pain trigger-is resolved.

Chronic Pain

· Fails to respond to typical treatments

· Sometimes has no recognizable source

· Lasts at least three to six months

· May no longer serve a useful purpose

Some other common chronic pain conditions include phantom limb pain, headaches, peripheral neuropathy, neck pain, and fibromyalgia. A more in-depth explanation of pain can be found in my new book Managing Pain and Coexisting Disorders, which you can review on my website www.addiction-free.com on the Publications page.

It is not uncommon for a person with a chronic pain condition to wonder if the pain will ever go away or if they'll ever get better. These types of thoughts lead to anxiety. Although most people believe that their anxiety will subside when the pain goes away, the anxiety frequently leads to a significant increase in pain perception. This results in a vicious cycle of pain, anxiety, more pain, and more anxiety. When the pain continues for longer than six months and people haven't yet learned to manage their anxiety, the symptoms only get worse.

In most cases anxiety about living with pain is more likely to occur at the acute pain stage while at the chronic pain stage feelings of depression prevail. At the acute stage the person in pain generally feels a reasonable sense of hope that the pain will resolve within the near future. Between the acute stage and the beginning of the chronic stage, people's thoughts and emotions about the pain begin to change.

Anxiety can occur at different intensities, all the way from mild nervousness to full blown panic attacks. Anxiety can be characterized by the following:

• Muscle tension, including shakiness, jitteriness, trembling, muscle aches, fatigue, restlessness, and inability to relax.
• Nervous system hyperactivity, including sweaty palms, heart racing, dry mouth, upset stomach, diarrhea, lump in throat, shortness of breath, etc.
• Apprehensive expectations, including anxiety, worry, fear, anticipation of misfortune.
• Trouble concentrating, including distractibility, insomnia, feelings of edginess or irritability, and impatience.

Excess anxiety and tension can cause people to experience heightened emotional upset (anxiety, depression and anger), increased pain, slower healing times, and increased side-effects to medications, among other things. An ongoing stress response causes numerous negative problems such as increasing muscle tension and pain while also decreasing the activity of their immune system and blood flow to their extremities. This in turn worsens a person's perception of their pain and the pain condition continues to worsen and needs specialized treatment.

Psychological treatment for chronic pain focuses on the emotional toll people experience living with pain on a daily basis. The treatment for chronic pain does not include magical interventions; rather, it is a combination of proven psychological treatment approaches in addition to medication management and other non-chemical interventions that addresses all the issues people in chronic pain experience.

To learn more about effective chronic pain management for people with coexisting disorders please visit our website www.addiction-free.com and read my article Pain versus Suffering or go to our Publications page to review my new book Managing Pain and Coexisting Disorders.