In the United States, 2000-2010 was called the "Decade of Pain". In 2011, the Institute of Medicine Committee to Promote Pain Research, Care and Education found that the prevalence of chronic pain in our country exceeds the prevalence of diabetes, heart disease and cancer combined.
Unfortunately, this pain prevalence has continued, and it is for this reason that counselors need to be aware that substance abuse and pain management can be a problem for their clients – even if it is not a "problem" as the client does itself is represented. Clients may be particularly susceptible to opioid-specific substance abuse as they (or others in their life) may view these drugs as the best treatment for pain (i.e., a "quick fix").
There is a lot to know about drug abuse and pain therapy. Because of this, consultants can easily become overwhelmed and hesitate to work with these issues. I am writing this article to show counselors that they can easily incorporate some basic approaches to substance abuse and pain management into their current counseling practices and continue to practice in their area of responsibility.
Due to the prevalence of substance abuse and pain therapy in the USA, it would be advantageous for counselors to always wear the lenses of these two areas when assessing and treating their clients. However, for counselors working with clients specifically in either of these two areas (substance abuse or pain management), it is probably most important to intentionally examine the area that is not presented as a problem in order to examine the possible relationship between the two. For example, if you are advising someone struggling with chronic pain, a counselor would be well advised to ask about their substance use as well. The same investigation must take place when a customer is dealing with substance abuse. A counselor should ask about questions about pain and how to manage it.
While this research is important, it is also imperative for counselors to easily incorporate these “lenses” into their existing clinical approaches. Here are five suggestions for the general process of incorporating these two perspectives.
First, counselors need to accept the reality that there is a lot to know about substance abuse and pain management and ensure that they are working in their area of responsibility. One way to explore and address these areas with your clients (while they are still practicing in their area of expertise) is to use the "HOW" approach. This acronym encourages counselors to be honest, open, and willing to discuss substance abuse and pain management with their clients. For example, a counselor can be honest when they do not know much about the client's experience of pain, are open to being educated about the client's perspective, and are willing to discuss the experience of pain with the client.
Second, consultants can anchor their approach in the discussion with respect and authenticity towards the client. This client-centered approach inherently invites the client's story about their pain (including how they are trying to deal with the pain, such as opiates).
Third, counselors can assess and treat pain using their typical counseling approaches and continue reassessing throughout the treatment process. Counselors should act as collectors of information about the pain and, if necessary, consult with others (e.g. mentors, superiors, colleagues, medical professionals) about suitable options for treating the pain.
Fourth, counselors need to be aware of the countertransference that is related to their own and those of their loved ones with pain treatment and substance abuse. An awareness of their countertransference can improve the advisors' effectiveness in dealing with these overlapping areas.
Ultimately, consultants must operate within the realistic resource constraints that both they and their clients experience. For example, both counselors and their clients have limitations on the time, energy, and money that they can invest in learning about and addressing drug abuse and pain management issues. Maintaining such a realistic perspective can encourage more humane and practical counseling interventions that lead to less frustration for both the counselor and the client.
An overview of chronic pain
As noted, the Committee on the Promotion of Pain Research, Care and Education of the Institute of Medicine reported in 2011 that chronic pain outperformed the combination of diabetes, heart disease, and cancer in terms of prevalence in the United States. These historical statistics, in which the current issues of substance abuse and pain management are anchored, underscore the likelihood that many of our counseling clients suffer from chronic pain but did not mention it or its impact on their lives in the session. This prevalence should serve as an invitation for counselors to discuss pain and pain management with their clients.
In 2019, Beth Darnall, a pain scientist and director of the Stanford Pain Relief Innovations Lab, summarized the following information about chronic pain in her book, Treating Patients With Chronic Pain, Psychologically. By definition, chronic pain is pain that lasts more than three months or exceeds the expected time it takes to heal. Breakthrough pain is an acute version of chronic pain and is focused on days or times when the pain is worse.
Although Darnall referred to chronic pain as a "damage alert" that prompts the person to escape from pain in order to survive, she said the "enigma of chronic pain" is that it is impossible to escape. This knowledge must be merged into the perspective of how the perception of pain affects our consulting clients in a bio-psychosocial way. This biopsychosocial examination of the relationship between the overlapping areas of substance abuse and pain management can be facilitated by the key suggestions presented in the following section.
Core proposals
I offer seven key suggestions that counselors can use as a guide to drug abuse and pain management from a biopsychosocial perspective.
1) Work from a systems perspective. From this perspective, the counselor considers the systemic interactions that arise separately for addiction and pain, as well as their systematic overlap. This means that the counselor knows the internal and external factors that contribute to both addiction and pain, and that the client may have developed an addiction in response to their pain, or vice versa. The addiction may be due to prescribed medication after surgery, or the pain may be due to an accident that occurred while the client was under the influence of alcohol or drugs.
2) Pay attention to prescribed and non-prescribed substance use. This suggestion means that the counselor will receive information from the client about prescribed drugs containing substances (such as drug-assisted treatment) in response to their pain or substance dependence, as well as about the client's non-prescribed use of opiates and marijuana for pain. Such a comprehensive collection of information provides the counselor with a broader view of the client's treatment responses to pain management.
3) Practice “compassionate accountability”. This phrase means that the counselor takes pity on the client while holding the client accountable for their behavior. For example, I can feel sorry for my client's addiction resulting from using opiates in response to chronic pain that prevents the client from engaging in activities of daily living. However, I also need to hold the client accountable for their behavior, such as stealing prescription opiates from a friend's medicine cabinet.
4) Use solid, direct, and honest communication. This is a complement to compassionate accountability as it avoids behaviors related to both pain management and addiction. Regardless, the clients are responsible for the decisions they make and the advisors need to make it clear to clients what they are seeing.
5) Consider a harm reduction perspective. This perspective means that the counselor treads the fine line of not allowing the client to use substance while at the same time not demanding that the client suddenly commit to abstinence. Instead, the counselor works within the reality of the client's willingness and ability to change without encouraging the client to remain at the same level of change.
6) Complete Addiction and Pain Assessment and Treatment Plans. This involves the counselor thoroughly investigating both areas, including the client's fear of the pain returning and his psychological withdrawal from pain medication.
7) Pay attention to behavioral indicators of pain during the session. A significant amount of information can be gathered when the client is actively in pain. The client's experience of pain can be processed in the moment, and the resulting information can support both the assessment and treatment process.
Evaluation
Counselors can use a simple anchoring assessment prompt to elicit the story of each client: "Tell me the story of your pain."
This open call has the power to draw narratives that clients may not have spoken about before. These clients may be used to asking closed-ended questions or scaling questions related to their pain, but they may never have asked anyone and then carefully listened to the actual history of their pain.
This motivational interview approach can easily provide information about the effects of community, cultural, family and multicultural factors on an individual's self-reporting. For example, the client can talk about how pain is simply not discussed in their family and culture. As a result, they have learned not to seek support to relieve their pain. The counselor could then help the client develop skills to reach others who would support them if they are living with their pain, or the counselor could refer the client to a group to discuss approaches to managing pain.
Another approach to assessment is for customers to keep diaries or logs of their pain, sleep and diet. These logs can help obtain information about pain patterns and contribute factors to pain. Such records must also focus on what the client is doing "right" and what he is doing "wrong", in addition to times when pain, sleep, and diet are going well for the client. The collection of this information is solution-oriented and strength-based. It can become the cornerstone on which healing treatment is built.
The assessment of pain must also be considered in connection with addiction. Although the client is in pain, it does not mean that they have to use substances to deal with the pain. The presence of pain also does not prevent the client from being confronted with his addiction as an "independent" diagnosis.
So there are two messages:
1) The client can learn to live with pain without the use of substances.
2) The client may only have to be confronted with the use of substances.
Treatment
The treatment of pain can include various therapy modalities such as individual, group or family counseling. The counselor and client can choose the modality that appears to best suit the client's needs, combined with the resources available in terms of client income, agency resources, and community resources.
Specific therapeutic approaches can include motivational interviews, cognitive behavioral therapy, acceptance and attachment therapy and grief counseling (since clients often have problems with loss when dealing with chronic pain). Within these forms of therapy, clinicians can legitimately practice counseling in their areas of competence by simply anchoring themselves in their treatment approach (e.g. therapy modalities, specific therapeutic approaches) and adding the lenses “pain” and “drug abuse” to questions about information in the assessment process that these Address areas largely. Such a comprehensive assessment can help the counselor know whether treatment for pain and substance use can be easily incorporated into treatment, or whether more specific assessment and targeted treatment of these areas is required.
Treatments that change the client's relationship to pain by focusing on the present (e.g. mindfulness, yoga, biofeedback, acupuncture) are also potential resources. In such cases, clients may remain aware of the pain, but work with the knowledge that the intensity of their pain is draining and draining and learn to deal with this process. You can also find techniques to relieve their pain.
Another treatment approach, described in 2017 by Kirsten Weir in Monitor on Psychology, encourages the client to practice self-care of the body through diet, exercise and sleep. It uses the metaphor of a stool with three legs. I developed the above diagram for the fifth edition of my book Learning the Language of Addiction Counseling (currently in press) to illustrate this metaphor.
The three-pronged chair is precariously balanced, which shows that self-care is not a static unit, but one that has to fluctuate depending on the client and context. Each leg of the chair (diet, exercise, sleep) is needed to keep the entire chair (self-care) in balance. In other words, each leg affects the other. For example, experiencing pain can negatively affect a client's sleep, which then prevents them from exercising and leads them to eat unhealthy comfort foods. In contrast, if a client gets enough sleep, they may experience less pain, which encourages them to exercise and exercise healthily. However, counselors need to remind clients that “pretty good” self-care is good enough. you don't have to practice “perfect” self-care to reap the benefits.
A definitive approach to treatment is for counselors to consider themselves part of a health management team. Such a team can consist of a variety of health professionals, each of whom has an important perspective on the unique aspects of pain and pain management for each client. The unique components of the client's pain determine the composition of such a team and the treatment system in which the team exists (e.g., hospital setting, private practice). Regardless of whether the team is formally or informally established by the counselor or by the system in which the counselor works, the counselor provides a critical perspective on mental health that is required for a holistic approach to treatment.
As part of such a team, counselors familiarize themselves with all the prescribed medications the client is taking for chronic, active disorders. Advisors then play a role in the planned and gradual reduction of the medication taken. Consultants do not have to be experts in pain management or medication to be part of such a team or to be assigned to a formal team. The team approach can be extremely effective in promoting the well-being of customers.
The counseling perspective offers important contributions for such teams, including an increased sensitivity to the clients' pain stories and an obligation to stand up for clients. Such a perspective can lead to an effective and humane approach to pain management and the use of prescription drugs. Furthermore, this perspective can prevent clients from feeling like they are being dehumanized on a “medical assembly line” during the treatment process.
Conclusions
Clinicians can work effectively with clients by integrating pain management and substance abuse approaches into their existing counseling approaches. Awareness of the prevalence of chronic pain and its possible interaction with substance use can help counselors with assessment and treatment.
Chronic pain and substance use often overlap, but they are areas that can easily be overlooked in terms of their impact on clients' problems. By simply integrating pain management and substance use lenses into their counseling – asking questions and intervening when needed – clinicians can offer their clients a more holistic approach.
The development of these lenses can be improved through further training, further training and information about current research results. There are some excellent resources (see below) that consultants can add to their clinical toolboxes. Counselors who commit to further research into pain management and substance use can improve their overall treatment effectiveness and act in the best interests of their clients.
Recommended Resources
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Geri Miller is a licensed professional counselor, licensed clinical addiction specialist, certified clinical supervisor, master's addiction counselor, licensed psychologist, diplomat in counseling psychology and professor in the department of human development and psychological counseling from Appalachian State University. She has been in the counseling profession since 1976 and in the field of addiction since 1979. She has published and presented research results for advice. The fifth edition of her book “Learning the Language of Addiction Counseling” is currently in print. Contact them at [email protected].
Knowledge-sharing articles developed from sessions presented at American Counseling Association conferences.
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Opinions and statements in articles appearing on CT Online should not be assumed to reflect the opinions of the editors or guidelines of the American Counseling Association.
