For those who suffer from chronic pain, it can be difficult to separate who they are from what they feel. For many, the pain can cause a host of other ailments from depression and anxiety to weight loss or gain, lack of sleep, sexual dysfunction and more. The treatment of choice for many physicians, opiates to curb the pain, can often lead to dependence and substance abuse, further curtailing their ability to live productive lives.
While there are many programs that work with chronic pain and/or addiction, the eight-bed, residential Chronic Pain and Recovery Center (CPRC) at Silver Hill Hospital in New Canaan, Conn., has created a program to work with both – with the unique perspective that not all patients will be required to abstain from the use of pain medications but could still have an improved quality of life.
New England Psychologist’s Catherine Robertson Souter spoke with Bruce Singer, Psy.D. program director of the CPRC about the center’s unique approach to treatment.
Q: Tell us about the program.
A: It is a 28-day residential program with a year of outpatient aftercare designed to be a bio-psycho-social approach to treatment of chronic pain syndrome. We see chronic pain syndrome as a collection of psychosocial symptoms that are both magnified by pain and also seem to magnify the chronic pain itself. Symptoms such as chemical dependence, depression or mood dis-regulation, social isolation, weight gain or loss, sexual dysfunction, unemployment, muscle atrophy and sleep disturbance become a constellation of symptoms around the chronic pain. If we do our job well, we treat those symptoms and in resolving those, help people to see that they can manage chronic pain from the inside out.
Q: The program has a strong interdisciplinary structure?
A: Yes, I was doing this kind of work in Napa Valley at a residential psychosocial pain treatment program so I had the knowledge of how to work with individuals in an interdisciplinary fashion that I was able to integrate with the resources we have here. We have a medical doctor, psychiatrist, social worker, doctoral level therapist, art therapy, pet therapy and family support education, a huge piece of this program. We are talking with each other and coordinating care over the span of treatment for each individual in the program. It is primarily a group-based modality but because we are a small program, we can give that individual attention.
Q: What is your approach to detox and abstinence?
A: We made a very conscious decision not to be an abstinence-based program. While the vast majority of our patients do leave without utilizing opiates, a small number of patients may leave with a lesser amount of that opiate for pain management as well as relapse prevention or a different opiate than they came in on, minimally effective dosing. We take each person case by case and, after detox, if their pain goes down and their function goes up, then there may be no need to remain on opiates. But if functioning plummets and their pain goes through the roof, then we would definitely consider using opiates as part of an overall plan that includes exercise therapy, meditation, aquatic therapy and cognitive behavior therapy. The opiates become part of a much bigger plan but not the plan itself. It is not opiate mono-therapy which is what some of our patients come in on.
Q: In your opinion, are opiates over-prescribed for pain management?
A: I think pain physicians are in a difficult position with chronic pain. It is much easier to write a prescription than to take an extra half hour to discern that maybe the patient doesn’t only just have chronic pain but has chronic pain syndrome. The mission that I am on is to help doctors to prescribe less of what I call the junk food of pain medicine, opiates for chronic pain, and to take that prescription pad and maybe write one for exercise-based physical therapy along with an eight-week mindfulness class and psychotherapy.
There are some recent statistics that there may be as many as 100 million Americans with chronic pain at any one time. And 25 percent of these people with chronic pain have chronic pain syndrome. If we can only treat eight at a time, you can see how many people are under-treated and probably misunderstood. It’s a serious problem we can only make the tiniest dent in. My mission is to spread word to primary care physicians that if they can begin to treat patients in a different way sooner, we may have less catastrophic pain down the road.
Q: The program is relatively new. Have you seen much success?
A: We have been open a year and a half and we are in the process of collecting data. We do testing on mood functioning, personality and pain and we are compiling numbers. Preliminary indications are that we are doing very well with increasing enjoyment of life in spite of pain and, for those patients who require abstinence from opiates, sustaining that abstinence with a minimum of relapse over the course of 13 months.
The goal of our program is not to make pain go away, we would never promise that. The goal of the program is to improve quality of life and functioning in spite of pain. Some patients do leave here with no pain. An equally good outcome for us is someone coming in reporting 8-over-10 pain and leave reporting 8-over-10 pain but when I ask them about their wellness level they put that at 8-over-10. They learn to unhook physical pain from wellness, from quality of life. That is more realistic outcome for our patients.
Q: How did you personally choose to work with chronic pain management?
A: You meet people who are very shattered when they first come in. Their pain is front and center and they are reduced to a kind of passive dependence on medications or interventions that don’t successfully treat the pain and leave them with very little productive functioning in the course of their day. What we can do in 28 days is not miracles but what we see are dramatic changes in people as they undo old habits and learn new habits. As they take charge of their lives again and engage in more meaningful activities, the volume of the pain diminishes and the quality of their life improves.
I have seen people put down canes and get out of wheelchairs and let go of years of opiate use. For a clinician, it is extremely rewarding to help facilitate these kinds of change in a short period of time. It is very intense work and it is not always successful but, when it works and someone really wants to walk through the door to their health again, it is extremely satisfying to be part of that.
Q: What message would you give to a psychologist reading this?
A: I would say I think if you are working with people who have chronic pain co-occurring with depression or anxiety, it is important to really get a deep understanding of what chronic pain syndrome is and to be able to offer complementary therapy to clientele. Commitment therapy is a highly useful tool as is mindfulness based therapy. It is very important for psychologists to do what they do best, which is to look at whole person and to come from a place of asking not what is wrong with this person but what is not wrong with them.
By Catherine Robertson Souter