Chronic Pain in America: Consequences, Addiction and Treatment

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1 Chronic Pain in America: Consequences, Addiction and Treatment September, 2014 Betty Ford Center Bob Hope Dr. Rancho Mirage, CA bettyfordcenter.org 1

2 Introduction This report will document that chronic pain has reached epidemic proportions in the United States, with treatment largely based on drug therapies that usually do not work. The research cited in this report demonstrates that these drug therapies often add drug dependency to the problems of chronic pain sufferers. According to the Institute of Medicine on June 29, 2011, more than 100 million Americans suffer from chronic pain at a cost of around $600 billion a year in medical treatments and lost productivity. The enormity of the problem and lack of solutions makes chronic pain an endless epidemic of quiet and desperate sufferers. The Betty Ford Center in Rancho Mirage has pioneered an alternative treatment to chronic pain that is drug-free and actually re-shapes and re-trains the pain center of the brain. Some 73% of its patients are pain-free and drug-free a year after treatment. The Betty Ford Center approach combines a unique pain treatment and Twelve Step support. It is drug-free. The program is unique in the country. As part of the Betty Ford Center commitment to advancing the treatment of chronic pain and addiction, the center conducted a national survey of chronic pain suffers in July, 2014, and also reviewed over 200 patient histories for data about causes and the impact of the Betty Ford Center treatment plan. The Betty Ford Center Chronic Pain and Addiction Program The Betty Ford Center has a unique chronic pain management and addiction program that goes well beyond the traditional approach of symptom relief. People who use alcohol and other drugs to cope with chronic pain enter our treatment in a state of chronic stress. We help them relearn how to focus and how to de-stress. When the mind is relaxed and this is key to our treatment it will go to a place of healing. The clinically-based program addresses recovery and also includes Qi Gong, Tai Chi and Yoga as part of the chronic pain treatment paradigm. Rather than dealing with the physical cause of pain, the pain management program is based on neurocognitive enhancement reshaping how the brain reacts to pain. Findings from that survey and from the internal review of Betty Ford Center pain patients are presented in this report. About the Betty Ford Center The Hazelden Betty Ford Foundation helps people reclaim their lives from the disease of addiction. It is the nation s largest nonprofit treatment provider, with a legacy that began in 1949 and includes the 1982 founding of the Betty Ford Center. With 15 sites in California, Minnesota, Oregon, Illinois, New York, Florida, Massachusetts, Colorado and Texas, the Foundation offers prevention and recovery solutions nationwide and across the entire continuum of care for youth and adults. A new outpatient treatment center will open in Los Angeles in December

3 About the National U.S. Survey of Chronic Pain The Betty Ford Center wanted to better understand chronic pain sufferers in terms of their treatment, consequences of living with pain, and addiction. The goals of the survey were to determine: 1. Length, frequency, severity and causes of chronic pain. 2. Percentage of chronic pain sufferers with a history of abuse or trauma. 3. Quality of life and consequences of living with chronic pain. 4. Satisfaction with current treatment. 5. Use of medications in treatment. 6. Patients perceptions regarding dependence or addiction to medications. 7. Willingness to eliminate medications to try alternative treatments. Survey Methodology Data was collected using an online survey from U.S. respondents aged 18 to 65 who indicated they were in chronic pain. Within the survey, filters were put in place to make sure that those who responded fit the definition of chronic pain. Chronic pain was defined as any pain that has lasted for three months or more and that the pain was present at least 15 times per month. Only those who met the pain duration and frequency requirements were allowed to complete the survey. Data Collection The survey was conducted from June 27th to July 18th. 1,009 responses were gathered that met the requirements outlined in the Survey Method section above. Responses are fairly distributed in terms of age, geography and income, but contain a larger percentage of females than in the general U.S. population. Overall results obtained from the survey are statistically valid (at a 95% confidence level) to within +/- 3.0%. The survey was conducted by Q Market Research, Eagan, Minnesota. 3

4 Key Findings of U.S. Survey of Chronic Pain Sufferers Based on the survey, Americans with chronic pain say current treatments don t work, leading to years of intense suffering, thoughts of suicide and often dependence on medications. 1. Top causes of chronic pain identified The top causes of chronic pain in the U.S., based on survey responses, involve problems with the spine and fibromyalgia. The chart at right lists the top causes of chronic pain as reported by survey participants. Top Six Causes of Chronic Pain in U.S. Hazelden Betty Ford Foundation, Chronic Pain in America: Consequences, Treatments and Addiction, Nearly six in ten respondents (59.3%) have endured significant pain (they rate at a mean score of 6.4 on the 10 point pain scale) for five years or more with no permanent relief Degenerative disc Fibromyalgia Osteoarthritis Neck pain Headaches 13.10% 19.70% 21.30% 26.70% 33.30% Many people with chronic pain feel Back pain 55.90% hopeless, said Dr. Peter Przekop, a leading U.S. chronic pain and addiction treatment expert who treats patients at the Betty Ford Center in Rancho Mirage, California. The pain seems unending, traditional treatment often leads to drug addiction, and many wonder if life is worth living. The shortage of pain specialists in the U.S. and a poor understanding of pain by general practitioners remains a major barrier to effective pain management. The survey found that eight in 10 chronic pain sufferers are women (83.6%). Causes of chronic pain differ between men and women, the survey found. Differences are summarized in the chart below. 4

5 63.2% 54.4% Most Common Causes of Chronic Pain: Women vs. Men 36.2% 19.6% 22.0% 7.4% 11.8% 6.7% 10.8% 6.1% 12.9% 3.5% Women Men Back Headaches Fibromyalgia Irritable Bowel Abdominal Work-related 2. Chronic pain sufferers almost always have history of emotional or physical abuse One of the most dramatic findings in the survey is that 97.1% of chronic pain sufferers have had at least one instance of physical or emotional trauma prior to their chronic pain. Early Life Trauma Common Among Chronic Pain Suffers Hazelden Betty Ford Foundation, Chronic Pain in America: Consequences, Treatments and Addiction, % experience emotional of physical trauma prior to chronic pain Doctors at the Betty Ford Center believe that this early pain experience often trains the person s brain to be more receptive to future chronic pain in a way that does not lead to any treatment relief. Sexual abuse Physical abuse Childhood accident Family drug abuse Emotional abuse Loss of loved one 26.7% 29.7% 32.6% 36.8% 48.2% 75.2% Duration of chronic pain is significant Over a quarter of survey respondents reported being in chronic pain for 10 years of more. 5

6 3. Most medications prescribed for chronic pain are highly addictive When those surveyed were asked if their current treatment involved medications, nearly 9 of ten (87.3%) said it did. In fact, nearly half of those surveyed (48.2%) take three or more pain medications. According to the survey, sufferers of chronic pain fear or face addiction to pain medications, with about half (50.5%) saying say they feel dependent on pain medication or are concerned that they will become dependent. The medical system appears to be too reliant on addictive drugs that don t work and lead to costly and long-term liabilities. Most disturbing is that doctors are prescribing addictive medicines to people with a history of addiction! Nearly 5 percent (4.8%) of those surveyed say they ve been treated for addiction in the past and 35 percent taking pain meds are afraid of becoming addicted. Doctors don t seem to be asking pain patients if they have addiction histories or fears, Dr. Przekop said. Medications Americans Take for Chronic Pain Hazelden Betty Ford Foundation, Chronic Pain in America: Consequences, Treatments and Addiction, Marijuana Sedatives Mood Stabilizers Benzodiazepines Muscle Relaxants Anti-Depressants Opiods 5.80% 11.00% 13.30% 19.50% 34.50% 37.00% 38.20% This list of medications is why addiction so frequently accompanies chronic pain and why the Betty Ford Center treats both. Without alternative ways to manage their pain, people end up using more and more medications until they become chemically dependent. Medications taken by men and women vary as shown in the chart below: Drugs Most Likely Taken for Chronic Pain: Women vs. Men 40.4% 37.9% 38.9% 34.8% 30.3% 32.6% 19.9% 16.9% 13.3% 13.5% 10.7% 11.2% 13.8% 7.1% 9.0% 5.2% Women Men 6

7 Chronic pain sufferers are subject to additional traumas, often due to drug treatment Fears of drug dependency are common, as are actual dependencies. In a third of the cases, chronic pain sufferers have thoughts of suicide. See chart below: 120.0% 100.0% Vulnerability of U.S. Chronic Pain Sufferers Experiences reported by U.S. chronic pain sufferers 97.0% 80.0% 60.0% 40.0% 20.0% 32.7% 35.0% 48.2% 0.0% Thoughts of Suicide Due to Unresolved Pain Drug Dependent Due to Treatment Asked to Take 3 or More Drugs Concurrently for Treatment Had Traumatic Events Prior to Chronic Pain Suicidal thoughts are high for all sufferers of chronic pain, but particularly high for those given opioids as part of their treatment regimen. Thoughts of Suicide Among U.S. Chronic Pain Sufferers 50.0% 32.7% 34.0% 28.4% All Sufferers Women Men Opioid Users Half of chronic pain sufferers in the U.S. taking opioids as part of treatment have had thoughts that life is not worth living. 7

8 In total, half (50.5% of chronic pain sufferers) feel dependent or are concerned about being or becoming dependent on their medications. See chart below: Dangers of Taking Drugs for Chronic Pain Experiences reported by U.S. chronic pain sufferers Sought Illegal Drugs 4.9% Feel Overmedicated 6.3% Exceeded Dosage 23.6% Fear Drug Dependency 24.1% Became Drug Dependent 35.0% 4. The negative impact on chronic pain sufferers of taking opioids is significant Opioid users have greater drug addiction issues and fears, as shown below: Opioid User Have Greater Addiction Issues, Fears Experiences of U.S. Chronic Pain Sufferers Treated for drug addiction in past Think of suicide Want an alternative treatment Say they are drug dependent Fear drug dependency Feel over-medicated 47.3% 50.0% 28.4% 44.8% 38.0% 42.1% 29.5% 31.9% 19.2% 8.4% 4.8% 68.4% Use Opioids Don't Use Opioids Those taking opioids for pain treatment are much more likely to suffer greater personal and social problems: 8

9 Opioids Cause Greater Personal and Social Problems Experiences of U.S. Chronic Pain Sufferers Need more time off work Family friction Need public assistance Lost their job Make mistakes at work Divorced 6.60% 3% 32.80% 22.40% 20.70% 25.80% 17.80% 54.00% 39.50% 51.50% 46.50% Use Opioids 45.70% Don't Use Opioids 5. Societal costs of chronic pain are huge As stated earlier, according to the Institute of Medicine on June 29, 2011, more than 100 million Americans suffer from chronic pain at a cost of around $600 billion a year in medical treatments and lost productivity. Chronic pain affects the ability to work, productivity, costs for medical care, worker s compensation costs, disability costs, and social services costs due to divorce or other family problems. The chronic pain epidemic is damaging families and placing a huge burden on employers, the mental health system and public assistance. Survey respondents, when asked about the consequences of their chronic pain, reported: 50.4% experienced lost productivity 42.3% took time off work 36.5% faced problems with family relationships 27.2% needed public assistance 19.3% made mistakes on the job 6. Chronic pain patients want an alternative to drug treatment Facing the consequences of drug addiction, thoughts of suicide and troubles at work and home, chronic pain sufferers want an alternative treatment: 9

10 Chronic Pain Sufferers Want Alternative to Drugs U.S. chronic pain sufferers taking drugs as part of treatment Not Satisfied With Drugs As Basis For Treatment 88.5% Would Reduce or Eliminate Medications for Alternative Treatment 79.5% Betty Ford Center Chronic Pain and Addiction Program Shows Highly Successful Outcomes A study of 202 patients over a three-year period ending in 2014 shows these findings and results: Of the 202 cases reviewed, 65 % were women and 35% were men. On average, they had endured chronic pain for 15 years. Women in the program rate their pain at 7.2 when entering the program (on the 10-point pain scale) compared to an average rating of 6.3 by men. In 94% of cases, medications were prescribed by physicians as part of treatment of chronic pain. 71% report having taken more medication than was prescribed by a physician. The average patient has had 5 relapses (back into addiction) before entering the Betty Ford Center Chronic Pain and Addiction program. This may suggest that untreated chronic pain is associated with recurrent relapse. Almost all patients (97.5%) were using multiple drugs to deal with their chronic pain. In 50% of the cases, one of the drugs included alcohol. 87% of patients had traumatic events in their lives prior to experiencing chronic pain. 73% of former patients (n=202) report sobriety and little to no pain one year after release from the Betty Ford Center Chronic Pain and Addiction program. 73% of former patients in the past three years report little to no pain and sobriety one year after release from the Betty Ford Center chronic pain and addiction program. 10

11 Background on Chronic Pain and Addiction and the Betty Ford Center Treatment Program The Betty Ford Center specializes in the treatment of chronic pain and chemical dependency, often to pain medications. This research based program is led by internationally recognized pain management expert Peter Przekop, DO, PhD Dr. Przekop is a board-certified pain and addiction physician with a PhD in neuroscience and a member of the faculty at Loma Linda University School of Medicine, where he holds appointments in psychiatry, pediatrics, and neurology. He has published more than 40 articles. A Q&A with Dr. Przekop follows. What factors make people susceptible to both chronic pain and substance abuse? The predisposing factors that lead to chronic pain are similar to many predisposing factors for chemical dependency: 1. Symptoms of depression 2. A history of adverse events, including physical abuse, emotional abuse, sexual abuse, a bad accident, or a high level of past stress 3. High present stress 4. Anxiety 5. A catastrophizing mind-set a belief that if things can go wrong, they will go wrong How common is the combined condition of chronic pain and addiction? All people who abuse alcohol or other drugs experience chronic emotional pain. Chronic physical pain affects approximately 60 percent of alcoholics and addicts. How does a person enroll in the Betty Ford Center Pain Management Program? We treat chronic pain in people who are dependent on a substance presently or have a history of dependency. If the patient demonstrates significant pain issues, they are offered a 45-day schedule in the Pain Management Program to focus on both addictive disease and developing and implementing a personalized pain curriculum. What effect does chronic pain have on people? People with chronic pain put most of their attention on the pain, the emotions attached to pain, and how they are going to escape pain, even though the plan they are using, which could include chemical abuse, doesn t work as it should. Chronic pain patients have changes in mood, lose the ability to remain calm, lack coping skills, experience the inability to sleep, and lack attention to completing tasks. They suffer from hopelessness, memory loss, and inability to plan. These changes when due to chronic pain are very treatable. What is different about your approach to chronic pain treatment at the Betty Ford Center? The Betty Ford Center has designed a pain management program that goes well beyond the traditional approach of symptom relief. The pain management program follows my unique integrated treatment paradigm for chronic pain patients called neurocognitive enhancement. Our program is based upon two recently discovered findings. First, chronic pain is a disease of the brain. Second, given an optimal environment, the brain of the chronic pain patient retains the ability to heal and return to normal function. 11

12 Does this mean that the pain center is in the brain, not at the site of the physical pain? Yes. If the chronic pain patient s brain function is treated, rather than treating the area of the body where it hurts, the patient will get better. In the chronic pain patient, areas of the brain responsible for things like thinking, planning, paying attention, sleeping, staying calm, getting motivated these areas don t function normally. This dysfunctional brain state, with its various manifestations, constitutes a distinctive disease state referred to as chronic pain syndrome. What is the treatment paradigm? Chronic pain patients begin to deal with pain issues right away, just as they are dealing with chemical dependency. Patients spend time each day becoming aware of how chronic pain has changed their way of thinking, of coping, and of judging themselves and others. Patients spend three hours a day learning how to restore normal brain function. Patients work on planned movement exercises that have been taken from the disciplines of Tai Chi, Qigong, kung fu, and Yoga. Manual medicine and acupuncture are also key parts of the treatment mix. These treatments allow patients to learn to refocus attention, as well as to gain strength, flexibility, and confidence. Also, mindfulness exercises allow the patient to slow down their mind, control their thoughts, and gain a sense of presence. Pain steals this ability from people. What is the ultimate result of this neurocognitive enhancement treatment? If you learn skills you can implement every day, including coping skills that keep you on track, you can regain the use of those portions of your brain that keep you consciously planning the right things in life. You ll do very well. What is the main thing patients tell you after completing treatment? They tell me they feel reborn. They possess the tools to allow them to live a life liberated from drugs and are able to overcome the pain that has crippled them physically, mentally, For the sake of your recovery we are committed to being a world-class organization that pursues excellence and measures our success by the life-changing growth of our patients. We are located in Rancho Mirage, California. VISIT US AT bettyfordcenter.org OR CALL Chronic Pain and Workers Compensation Workplace injury and resulting disability and chronic pain are relatively common and often lead to costly Workers Compensation claims, a significant expense for employers as well as a persistent liability. The injured worker suffers too. For some, the injury causes constant pain. For others, the disability proves devastating to career plans, self-esteem, and hope for the future. And too often, an even worse consequence develops when doctors prescribe opioids or other addictive medications to treat chronic pain which adds dependence and addiction. This can be a complex and costly problem for both the worker and the employer. The Betty Ford Center specializes in treatment of chronic pain and addiction. The Center s unique 12

13 and highly effective program leaves the vast majority of patients chemical free and pain free. A $51 billion employer problem Back pain, overexertion, falls and repetitive-use injuries are among the most common forms of worksite injury, many of which lead to chronic pain and addiction. An estimated 186 million workdays are lost each year to back pain alone. 1 Add the cost of medical claims for treatment of workplace injury, and the total cost of Workers Comp claims is huge. According to the 2012 Liberty Mutual Workplace Safety Index, the cost of the most disabling workplace injuries and illnesses in 2010 amounted to $51.1 billion in direct U.S. Workers Compensation costs, averaging almost one billion dollars per week. 2 When chronic pain stems from a workplace injury, it can be the basis for lengthy and costly workers compensation claims. Betty Ford Center offers a unique solution to reduce Workers Comp claims due to chronic pain. Many times, patients come to us with chronic pain that originated in the workplace. The Betty Ford Center specializes in the treatment of chronic pain and addiction, the latter of which is often dependency on pain medications. The Betty Ford Center program is based on two recently discovered findings. First, chronic pain is a disease of the brain. Second, given an optimal environment, the brain of the chronic pain patient retains the ability to heal and return to normal function. The Betty Ford Center s research-based program is led by internationally recognized pain management expert, Peter Przekop, DO, PhD. Dr. Przekop is a board-certified pain and addiction physician with a PhD in neuroscience. He also serves on the faculty at Loma Linda University School of Medicine, where he holds appointments in psychiatry, pediatrics, and neurology. He has published more than 40 articles. How does a person enroll in the Betty Ford Center s Pain Management Program? The Center treats chronic pain in people who are dependent on a substance presently or have a history of dependency. If the patient demonstrates pain issues, they are offered an inpatient schedule in the Pain Management Program to focus on the addictive disease and on developing and implementing a personalized pain management curriculum. This timeframe assures that both the chronic pain and substance use disorder are successfully evaluated and treated. Patients live on the 20-acre main Betty Ford Center campus in gender-specific residence halls. During their stay, all patients develop a foundation in Twelve Step recovery and are presented with the necessary tools to enhance progress made during treatment. Additionally, family and/or loved ones are encouraged to participate in the Center s Family Program and Children s Program. What is the treatment paradigm? Chronic pain patients begin to deal with pain issues right away, just as they are dealing with addiction. Patients spend time each day becoming aware of how chronic pain has changed their way of thinking, coping, and judging themselves and others. Patients spend three hours a day learning how to restore normal brain function. Patients work on planned movement exercises that have been taken from the disciplines of tai chi, qigong, kung fu, and yoga. Manual medicine and acupuncture are also key parts of the treatment mix. These treatments allow patients to learn to refocus attention, as well as to gain strength, flexibility, and confidence. Also, mindfulness exercises allow the patient to slow down their mind, control their thoughts, and gain a sense of presence. Pain steals this ability from people. Are patients able to return to work? 13

14 Patients can and do return to work. As a result of treatment at the Betty Ford Center s Chronic Pain and Addiction Program, most patients who were on leave from work due to chronic pain and substance abuse report they were able to return to work within two months of completing treatment. A Case History A testimonial by Jeanian E. Santa Rosa Mountain Cahuilla Tribal Member, Santa Rosa Indian Reservation near Palm Desert, California. Summer 2014 Betty Ford Center s pain and addiction program saved my life. At eight years old, my childhood was over. My home life consisted of a mother, who was an alcoholic, and two alcoholic step-fathers. For discipline, Mother would whip me, leaving me welted. At age eight I came home from Brownies to learn that my two-year-old sister had died. Shortly thereafter, my grandmother died. My childhood had been stolen from me. Suddenly, I was the new parent in the household. I was expected to care for my remaining five younger brothers and sisters. From time to time over the next four years, Mother sent me by Greyhound bus to San Diego to be with my father, who was in the Navy. I thought I was being punished but later learned she sent all of us children away whenever she had to serve jail time. By the time I was 12, I was drugging and drinking. I didn t know why. I rationalized my behavior, saying it was the seventies. But in truth, I was becoming like my mother, despite my best intentions not to. By age 16, I was a real parent myself; by age 21, I had two more children. I was still drinking. I was an alcoholic. But I was smart, too. Despite my situation, I graduated from high school and earned a general accounting degree with honors at Skradron College in San Bernardino, California. I am Native American and a proud member of the small Mountain Cahuilla Tribe. We believe that the White Man gave us the curse of firewater. Many of our Native American families seem predisposed to alcoholism. My sister, brother, brother-in-law, and son are alcoholics. 14

15 I tried (and tried) to get sober. At age 35, I sought treatment for alcoholism and addiction to methamphetamine at the Native American Indian Eagle Lodge in Long Beach, California. I got a job at the Indian Health Clinic on the Morongo Indian Reservation. For the first time in my life, I learned Indian spirituality. I did sweat lodge and vision quest. But life kept pulling me down. My companion of 20 years physically and mentally abused me. I continued to drink. My oldest daughter died. She left me with two grandsons. Still I drank. I drank to such excess my nose would not stop bleeding. My youngest daughter took the grandsons from me. My life literally came crashing down. While driving on the reservation at an excessive speed, I hit a tree. I broke my hip, pelvis, left leg, and foot. Twice I died on the operating table but was brought back to life. I like to think God brought me back twice once for each of my grand babies. I have a total hip replacement, plus plates, nuts, and bolts in my knee, shin, and heels. The chronic pain became so bad I was delusional. To deal with the pain, I drank more alcohol, on top of taking prescription oxycodone. I was in a wheelchair. I had reached bottom. I called the Indian Health Clinic. In March 2013, they sent me to the Betty Ford Center s Pain Management Program. There is no program in the world like the Betty Ford Center s pain program. The pain and addiction program is run by Dr. Peter Przekop. We call him Dr. P. He is a gifted healer. His program is intense. You learn about mindfulness and meditation. He uses acupuncture and qigong. Dr. P. is joined by Mr. John (Newton), who does the spiritual healing part of the team program. My favorite part of the program is what they call Adverse Thursdays. This is when you speak toward all the people who did you harm in your life, and you tell them: You can t hurt me anymore. You get rid of all the anger, pain, and fear that has been stuffed inside and built up over the years. It s magical. When I began treatment I walked only indoors, not very far, with a cane. I was mad at the world. By the end of the program I walked up to five miles on paths across the campus. I learned forgiveness. I have forgiven my mother. A time in my life to celebrate. I celebrated my year of sobriety last March. This is the longest I have been sober since I was 12 years old. I am 56 years old. I am the tribal librarian. I am spending quality time with my grandsons. I am no longer the letdown grandma. My companion went through the Betty Ford Center family program and then went into treatment. He is sober. My son went through the Betty Ford Center pain program. He is sober and uses acupuncture as part of his aftercare program. We each have our journey. Mine took 56 years. I have learned that by forgiving others and yourself, you become one with yourself. I am starting my own Alcoholics Anonymous and Narcotics Anonymous groups on the Santa Rosa Indian Reservation. I wake up refreshed. 15

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