Tag Archives: opioid

Opioid SOS

By Laurie Meyers May 31, 2017

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During a single afternoon this past August, 26 people overdosed on opioids in Huntington, a small city in West Virginia with a population of approximately 50,000. Bolstered by naloxone — an opioid antidote that often can revive overdose victims who have stopped breathing — and too much practice in overdose scenarios, police and paramedics were able to save all 26 people. However, the danger of overdosing is so great — and so common — that many of those 26 individuals are likely to overdose again, some fatally.

Scenes of opioid overdoses are playing out again and again in cities, towns and rural areas across the United States. So many Americans are in thrall to opioids — which encompass both prescription pain relievers and the illegal drug heroin — that the Centers for Disease Control and Prevention (CDC) has declared opioid abuse an epidemic. According to the CDC, in 2015 (the latest year data were collected) more than 33,000 Americans died from opioid overdoses, a number that is quadruple the rate of deaths in 1999. In fact, from 2000 to 2015, more than half a million deaths were attributed to opioid overdose. West Virginia, New Hampshire, Kentucky, Ohio and Rhode Island are the states with the highest rates of opioid deaths, but no state, no socioeconomic status and no racial or ethnic group can claim to remain untouched by the opioid epidemic.

“We’re in danger of losing a generation,” asserted Carol Smith at an April congressional briefing on Capitol Hill sponsored by the American Counseling Association to raise awareness about the opioid epidemic and the role professional counselors can play in stemming the tide. Smith, a member of ACA and a past president of the West Virginia Counseling Association, is a counseling professor and the coordinator of the violence, loss and trauma certificate of studies at Marshall University — which happens to be located in Huntington.

Birth of an epidemic

The CDC numbers show that the opioid epidemic has been gathering steam for a long time. Public awareness of the epidemic has grown gradually with media reports of more fatal overdoses, including the startling 2016 death of music legend Prince by overdose from nonprescribed fentanyl. More than a year later, the full story is not yet known, but the singer and musician had reportedly been taking prescription opioids for chronic pain for many years, which put him at risk for developing an addiction.

In fact, for many of the people who become addicted to opioids, this is how it begins — with a prescription for painkillers. According to the CDC, prescriptions for opioids in the U.S. have quadrupled since the year 2000, despite there being no corresponding overall increase in the amount of pain that Americans report. Experts say a combination of factors has driven the sharp rise in opioid prescriptions. In the late 1990s, in a push to improve pain management, the medical community began considering pain a fifth vital sign, along with body temperature, pulse rate, respiration rate and blood pressure. The prescription drug OxyContin debuted in 1996 and was marketed as less addictive than other opioids. Research that has since been discredited asserted that patients in severe pain had a low tendency to become addicted to opioids.

“That was simply not true,” says Kirk Bowden, a licensed professional counselor (LPC) and ACA fellow in Phoenix who has specialized in addictions for almost 30 years. “They found that [severe pain] patients did start to become addicted — very early on. You can become addicted even if you follow the physician’s directions.”

Experts say that certain populations are particularly at risk for becoming addicted to opioids, including individuals who have a history of trauma, mental illness or other substance abuse. Medical professionals such as doctors, nurses, dentists and veterinarians are at increased risk because they have easy access to opioids through their work. Those in the military are also at greater risk because they are so often treated for pain.

As Smith points out, opioids are particularly addictive because of the effect they have on a person’s mind and body. “We are all biologically vulnerable,” she says.

Opioids attach to opioid receptors in the body to reduce the sensation to pain. As they do this, they cause physical changes in the body’s own opioid system. Over time, the body may become physically dependent on opioids. Even a weeklong prescription for opioids can cause withdrawal at cessation. In addition, opioids affect the brain’s reward system and can cause a feeling of euphoria. This combination of effects means that long-term use is itself a risk factor for physical dependence and addiction. A study reported in the March 17 issue of the CDC’s Morbidity and Mortality Weekly Report found that in patients prescribed opioids for the first time, the likelihood of them still being on the opioid within a year’s time increased after just six days of use and then again at 31 days.

Unfortunately, Smith Says, doctors and dentists commonly prescribe 30-, 60- or 90-day supplies of opioids to help patients alleviate instances of even short-term pain, such as the removal of wisdom teeth.

Some people who become addicted while on painkillers turn to heroin once their prescription runs out or when other opioids become too expensive, says ACA member Kevin Doyle, an LPC who has a private practice that specializes in group work for clients who have substance use disorders. It is becoming more common for heroin to be mixed with fentanyl, which is a much stronger opioid. Frequently, he notes, users either don’t know about the fentanyl or misjudge the dose and end up overdosing.

Addiction as a lifelong illness

There is a common misconception, not just on the part of the average person but also by many health professionals, that “getting sober” (clearing the body of the addictive substance) and recovery are the same thing. Nothing could be further from the truth, say substance abuse experts.

All of the counseling professionals interviewed for this article say that the standard for addiction treatment for both inpatient and outpatient programs is typically 30 days to get biologically clean. Clients are then sent back into their home environments, where they can easily become addicted again in the absence of follow-up support.

“You hear numbers about treatment programs that have outrageous treatment success rates, like 98 percent, but they don’t say where people are five years later,” Bowden notes. “People new to [addiction and recovery] don’t realize how addiction encompasses your whole life. … Long-term support is critical.”

ACA member Larry Ashley, an LPC with more than 40 years in the field of addictions, agrees. He says that as hard as getting “sober” or physically clean may be, it is actually the easiest part of recovery. “Recovery is a lifestyle change,” he says. “It’s important that people understand the difference between sobriety and recovery.”

Smith adds that addiction is most often treated like an acute disease when it is actually a chronic one, and the challenges don’t just stem from staying off the substance.

Doyle agrees. “There is a tendency to think of this [addiction treatment] as a single episode — that once you take care of that, we are done,” he says. “But, unfortunately, it’s a lifelong disease, and like any other disease, there may be episodes when a person doesn’t take as good of care of themselves as [other times]. I tell the client upfront, ‘We don’t see a cure, but this is something that can be managed.’”

The cost of not seeking help for addiction is high, and the opioid epidemic has been particularly devastating. ACA member Rick Carroll, a counselor who helped develop the substance abuse certification program at Lindsey Wilson College, has seen many people lose everything to opioids. And like a bomb blast, the destruction from addiction is not limited to the person hooked on opioids — it spreads outward.

In fact, the fallout from opioid abuse is what spurred the state of Kentucky, where the main campus of Lindsey Wilson College is located, to fund Carroll’s certification program. Currently, 1 in 4 babies born in Kentucky is diagnosed with neonatal abstinence syndrome — a range of physical problems that result from being exposed to opioids in the womb. The babies and mothers receive any needed addiction treatment and health care at the hospital, but there is also a need for clinicians who can help mothers cope with bonding and other family issues while undergoing detox.

Carroll also does parental assessments in Virginia for social services and the local court system. He sees many parents who have lost their children to foster care because of opioid abuse and estimates that a third of these clients will never regain custody of their children.

Many problems associated with addiction cannot be addressed with a 30-day program because recovery involves rebuilding a life, say the counselors interviewed for this article. In many instances, these clients have a lot to “relearn,” Carroll says.

“In our program, we talk about meeting people where they are at,” he says. “Which stage of change are they in? Do they say that they have a [substance abuse] problem? Where are they in recognizing the problem?”

People often take substances such as opioids as a way to cope, so counselors can help these clients by teaching them healthy coping skills, Carroll says. This starts by teaching them to be mindful and pay attention to their emotions, particularly becoming aware of when they are experiencing negative emotions such as anxiety and depression. Journaling can be helpful as a kind of daily log of thoughts and feelings, says Carroll, adding that some clients feel more connected to their emotions when they write them down.

As clients learn to be mindful of their emotions, they also need to be presented with new ways to cope, Carroll says. Among the tools he shares with clients are relaxation techniques and systematic desensitization. Carroll says that counselors should talk to clients about the events and everyday situations that are most stressful for them and have them practice breathing and other relaxation techniques that they can continue to use on their own. Counselors can also teach clients how to better deal with conflict through role-play and empty chair exercises, he says.

People who struggle with addiction are also often dealing with significant cognitive distortions, such as thinking that they are damaged goods, Carroll explains. Counselors can help clients examine these beliefs to see either that the beliefs aren’t valid or to clearly identify problems that clients can work on.

It is also important for counselors to understand the dynamics of these clients’ family systems, Carroll says. In some cases, family relationships have been broken or the client’s family members are struggling with addiction themselves. In either case, the client is faced with a lack of support and a potentially triggering environment, he says.

Carroll advises the use of genograms to explore family dynamics, looking in particular for toxic relationships or indications of a multigenerational history of substance abuse or mental illness. Through the use of genograms, “clients can see the roots [of their difficulties] and ask, ‘What can I create in my life right now to break the cycle?’” Carroll says.

Ashley, who also specializes in combat trauma, says that clients struggling against addiction also need to learn different ways to alter their consciousness and feel good. “People who have been addicted for a long time don’t know how to have fun,” he says. Ashley advises asking these clients about the activities that they used to enjoy and encouraging them to find or rediscover hobbies because they need alternatives to getting high.

“Exercise is good as long as they don’t overdo it,” he says. “Reading, bowling, going for a walk, art — it just depends. If you never had any experience [with hobbies], you have to try. If it doesn’t work, keep on trying.”

Ashley says clients also need to develop a plan to stay sober. These plans address elements such as how to stay away from situations or people that trigger or encourage substance use and abuse, how to handle stress and other emotions without opioids or other drugs, what to do when the urge to use strikes and how to occupy the time that previously went to scoring and taking drugs. Although counselors can assist clients with these plans, Ashley says it is equally important that they help clients find additional support through avenues such as group therapy, 12-step support meetings and other treatment programs if necessary.

Carroll agrees. “Counselors need to work closely with other health providers, medical professionals, social workers and school personnel,” he says. “It’s very imperative that you don’t work within a bubble. Get the individual the best help that you can.”

Necessary knowledge

Counselors can serve as a vital source of support for clients in recovery, but many practitioners have little or no training in addictions work. Bowden firmly believes that counselors need intensive training to work with those struggling with addictions.

Smith asserts that the grip of the opioid epidemic is so strong that all counselors must learn how to work with these clients. Likewise, counselors who specialize in substance abuse issues note that all practitioners will encounter clients who are struggling with addiction, even if addiction isn’t the presenting issue. Smith adds that clients may not reveal substance abuse problems right away, meaning that by the time the subject of addiction comes up, a therapeutic bond likely will have been established already with the counselor.

That is not to suggest, however, that the proper training isn’t important. Counselors should seek out additional courses on addictions work, either locally or online. Bowden and Ashley urge counselors to undergo supervision and to find a specialist with whom they can work. Counselors can also get involved with professional organizations such as the International Association of Addictions & Offender Counselors, a division of ACA.

“No matter what your practice is based on, most of your people are going to have addiction issues, whether obvious or not,” Ashley says. “So get to know people in the 12-step community. Look in the Yellow Pages or go online and Google ‘support groups,’ including options that aren’t [connected to] AA [Alcoholics Anonymous].”

When working with individuals who are battling addiction, Smith says, counselors also shouldn’t forget to simply call on the fundamentals of counseling. “A person needs to know that they are in safe company, with someone who is empathetic and who understands at least a little bit what they are going through and is willing to act as a guide.”

 

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Larry Ashley, Kirk Bowden, Kevin Doyle and Carol Smith each served as panelists (along with Dr. Melinda Campopiano of the federal Substance Abuse and Mental Health Services Administration) at the congressional briefing on opioid abuse in April that was sponsored by ACA. For a report on that briefing, read the online exclusive, “‘We’re in danger of losing a generation,’” by Bethany Bray at CT Online (ct.counseling.org).

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association.

Counseling Today (ct.counseling.org)

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Opioid Use Disorder” by Rachel M. O’Neill
  • “Substance Abuse and Addictive Disorders” by Gerald A. Juhnke & Kathryn L. Henderson
  • “Chronic Pain Counseling” by Stephanie T. Burns

Books (counseling.org/publications/bookstore)

Podcasts (counseling.org/knowledge-center/podcasts)

  • “The Latest on Addiction Counseling, Co-Occurring has Replaced Dual-Diagnosis and Why is Crack so Addictive Anyway?” with Ford Brooks and Bill McHenry

ACA divisions

  • International Association of Addictions & Offender Counselors (iaaoc.org)

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Using your integrated behavioral health toolbox

By David Engstrom May 3, 2017

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People with common medical disorders who visit their primary care physicians have high rates of behavioral health concerns, including diabetes, chronic pain, obesity, sleep disorders and heart disease. Obesity is one of the biggest drivers of preventable chronic diseases and health care costs in the United States. Currently, estimates for these costs range from $147 billion to nearly $210 billion per year. The annual cost of chronic pain is estimated to be as high as $635 billion a year, which is more than the yearly costs for cancer, heart disease and diabetes.

Clearly, there are far more serious outcomes and higher health care costs if these problems aren’t addressed in a unified way. This is where counselors can play a very important role. Consider the following scenario.

 

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Alfonso, a 36-year-old Hispanic male, was referred to you for counseling for depression. He has had increasing depression for the past 10 years. He reports a history of severe physical and emotional abuse from both parents when he was young. He is unmarried, has no close relationships and says, “I always feel alone.” He has no suicidal thoughts or plans, but he describes feelings of hopelessness, lack of energy and thoughts of discouragement and despair. He has been on antidepressant medication for seven years and says it “helps a little.”

Alfonso is 5 feet 10 inches tall and weighs 310 pounds. This equates to a body mass index (BMI) of 44.5 (a BMI of 30 or greater is considered obese). He ingests a large amount of fast food each day. Alfonso previously worked in construction but noticed that even with his active job, he was frequently “dog-tired” all day long and felt like he would “just love to sleep.” His average total sleep time is four to five hours per night.

About three years ago, Alfonso fell on his job site and injured his lower back. He has had several back surgeries but claims that they “didn’t help at all.” He reports still feeling moderate to severe pain every day. He is currently taking oxycodone, an opioid pain medication, at 15 milligrams every six hours and is on long-term disability.

Alfonso has no hobbies or interests, and because he is not currently working, he spends most of each day watching television and drinking beer. By his estimate, he drinks “six to eight beers a day.” He is not a smoker and says that he does not use other drugs.

During your initial interview with Alfonso, he appears very tired and generally unmotivated for treatment. He asks, “Why am I seeing a counselor and not a real doctor?” He appears to have average intelligence but very little insight into how his health problems may be affecting his depression and his life in general. He feels very little control over his health and thinks that he just needs “some new medicine” to help him.

The biopsychosocial perspective

How many times have you seen clients such as Alfonso and gotten so involved in their abuse histories, psychological issues and diagnoses that you ignored the obvious? Sometimes the “mental health” or “psychosocial” view of counseling gets in the way of assessing the biopsychosocial aspects of our clients. (For more information on the biopsychosocial perspective developed by George Engel and John Romano, see tinyurl.com/mcqdyqb.)

If you see clients privately or at any facility, you are bound to encounter people with stories similar to Alfonso’s. Although his scenario may seem exaggerated, the reality is that behavioral health problems often have a substantial impact on clients.

Consider the following facts and figures.

Sleep: According to the National Sleep Foundation’s inaugural Sleep Health Index, 45 percent of Americans report disrupted sleep patterns that have negatively affected their daily life over the past seven days. Some of the study’s biggest takeaways: Among 74,571 adult respondents in 12 states, 35.3 percent (more than 26,000 people) reported getting less than seven hours of sleep during a typical 24-hour period; more than 35,000 reported that they snored; and almost 29,000 reported falling asleep during the day at least once over the past month. More than 3,500 respondents acknowledged either drifting off or falling asleep while driving.

According to Harvard Medical School, chronic sleep problems affect 50 to 80 percent of patients in a typical psychiatric practice and are particularly common in patients with anxiety, depression, bipolar disorder and attention-deficit/hyperactivity disorder. Chronic sleep problems may raise the risk for, and even directly contribute to, the development of some psychiatric disorders.

Pain: Nearly 50 million American adults have significant chronic pain or severe pain, according to The Journal of Pain. New research suggests that people who have chronic pain are also more likely to suffer from problems such as depression, anxiety, lack of sleep and trouble focusing.

Obesity: According to the annual report The State of Obesity, a project of the Trust for America’s Health and the Robert Wood Johnson Foundation, 35.7 percent of U.S. adults are considered to be obese, and more than 1 in 20 (6.3 percent) have extreme obesity. For
state-by-state data, see stateofobesity.org/adult-obesity.

Obesity is frequently accompanied by depression. In fact, the two can trigger and influence each other. Although women are only slightly more at risk than men for being obese, they are much more vulnerable to the obesity-depression cycle. In one study, obesity in women was associated with a 37 percent increase in major depression, according to the American Psychological Association. There is also a strong relationship between obesity in women and more frequent thoughts of suicide. For more information on this research, see cdc.gov/nchs/products/databriefs/db167.htm.

Given the findings in each of these areas, it is vitally important for counselors to have the tools available to help their clients thrive. Returning to the scenario of Alfonso, we will see how integrated behavioral health care can bring more clarity to his situation.

Best office practices

This is my toolbox of practices that I have found most useful with clients.

Motivational interviewing: Motivational interviewing is loosely defined by the Motivational Interviewing Network of Trainers as “a particular kind of conversation about change.” It refers to a counseling approach developed in part by clinical psychologists William R. Miller and Stephen Rollnick. Motivational interviewing is nonjudgmental, nonconfrontational and nonadversarial. For integrated care, this style of interviewing has many benefits, including instilling hope, confidence and action in our clients. It empowers clients to take a more active role in their health, far removed from the passivity that the usual “doctor’s advice” elicits.

I use motivational interviewing techniques daily in both my office and in hospital settings. I have found them to be very useful for helping clients reduce ambivalence and take more responsibility for important behavior changes. The main goals of motivational interviewing are to engage clients, elicit change talk and evoke motivation to make positive changes from clients. For example, change talk can be elicited by asking the client questions such as “How might you like things to be different?” or “How does ______ interfere with things that you would like to do?”

The spirit of motivational interviewing can be summarized as follows:

1) Motivation to change is elicited from the client and is not imposed from outside forces.

2) It is the client’s task, not the counselor’s, to articulate and resolve the client’s ambivalence.

3) Direct persuasion is not an effective method for resolving ambivalence.

4) The counseling style is generally quiet and elicits information from
the client.

5) The counselor is directive in that he or she helps the client to examine and resolve ambivalence.

6) Readiness to change is not a trait of the client but rather a fluctuating result of interpersonal interaction.

7) The therapeutic relationship resembles a partnership or companionship.

The four general processes involved in motivational interviewing are:

1) Engaging: Used to involve clients in talking about issues, concerns and hopes, and to establish a trusting relationship with the counselor.

2) Focusing: Used to narrow the conversation to habits or patterns that clients want to change.

3) Evoking: Used to elicit client motivation for change by increasing clients’ sense of the importance of change, their confidence about change and their readiness to change.

4) Planning: Used to develop the practical steps that clients want to use to implement the changes they desire.

For more information, go to motivationalinterviewing.org.

The role of self-monitoring: Self-monitoring is an important technique in all of the areas this article discusses because it a) gives clients the responsibility to actively observe and record their behavior, b) makes clients more aware of the effects of interventions on the variable being monitored and c) puts clients more in control.

There is strong research evidence that the mere act of self-monitoring and recording can significantly change behavior. In my practice, I always find something for the client to track (behaviors, thoughts or emotions) on a regular basis. As is the case with motivational interviewing, this gives more of the responsibility for behavior change to the client.

Measuring self-efficacy: Albert Bandura’s concept of self-efficacy can be applied quite well to clients who need to focus on changing some important aspects of their behavior, including exercise, smoking, alcohol use, sleep management and behavior changes, to reduce pain.

Self-efficacy refers to the degree to which a person feels confident, effective and successful in managing his or her health or life. My contention is that motivational interviewing should increase a client’s self-efficacy, so I often use the simple measure shown below (in the box below) to track the client’s motivation, confidence and readiness to change. I frequently request that the client fill this out on a daily basis for two weeks.

Results from this scale can provide a realistic benchmark of client progress and can be shared with other members of the behavioral health care team.

 

Sleep

Sleep problems are often the most common symptoms that clients discuss with their primary care physicians. Optimal sleep duration for adults of all ages is 7.5 to 8.5 hours per night. Adolescents need a bit more and older adults a bit less. The average American adult gets only about six hours of sleep per night.

Poor sleep can be a result of any combination of physical conditions, psychological disorders, work shift changes or poor sleep habits. People who are sleep deprived may have profound daytime sleepiness and often fall asleep immediately when they go to bed.

Integrated health care team: Sleep disorders center, primary care physician, counselor

Alfonso’s view: We already know that Alfonso estimates his sleep at four to five hours per night. He admits to profound daytime sleepiness and feels “tired all the time.” He doesn’t understand the causes of his poor sleep.

Assessment for Alfonso: Many clients presenting with depressive or anxiety disorders have coexisting sleep issues that can easily make their symptoms worse. Alfonso might have insomnia, partly because of his depression or pain, or he might have obstructive sleep apnea (OSA), which is often related to being overweight or obese. In fact, sleep apnea has been observed in as many as 95 percent of obese males. A complete sleep study should be performed for Alfonso.

I always ensure that clients are screened for OSA prior to further intervention. If no OSA is present, it is important to ask these clients a few general questions about their sleep patterns, such as how long they sleep on the average night, whether they feel rested during the day and if they are concerned about sleep. Sleep problems are not that obvious, so it is always important to ask about them, especially during your initial evaluation with clients. Sleep problems can be either a cause or an effect of other biopsychosocial conditions.

To pursue this further, you might suggest that clients keep a simple sleep log. Have them keep daily records of these sleep-related events for one week:

1) Physical exercise (type/duration/timing)

2) Naps (number and total time)

3) Medication for sleep (drug and amount)

4) Time they went to bed

5) Minutes to fall asleep

6) Number of awakenings

7) Wake-up time

8) Total hours asleep

9) Sleep quality rating (on a scale of 0-10, with 0 being the worst possible and 10 being the best possible)

10) Daytime alertness rating (on a scale of 0-10)

11) Obsessing about sleep (on a scale of 0-10)

Potential interventions: After obtaining Alfonso’s data for a week or more, go over it with him, paying particular attention to challenging areas. The most important part of this intervention is to educate Alfonso regarding some rules of healthy sleep, including continuing to self-monitor his sleep, reducing his caffeine and alcohol use, maintaining a regular sleep schedule, increasing his physical activity (especially later in the day), controlling his sleep environment and taking some time to “unwind” his brain in the evening. In addition, the most popular evidence-based intervention for this issue is cognitive behavior therapy for insomnia (for more information, see sleepfoundation.org/sleep-news/cognitive-behavioral-therapy-insomnia).

Pain

It can sometimes be difficult to identify if clients are having sleep problems, but clients with chronic pain are usually much more forthcoming and their issues with pain are obvious. Acute pain is a normal sensation triggered in the nervous system to alert you to possible injury and the need to take care of yourself, but chronic pain is different. Chronic pain persists — pain signals keep firing in the nervous system for weeks, months or even years. This kind of pain often continues well after the normal healing time for any injury or tissue damage that might have occurred.

Chronic pain can be mild or excruciating, episodic or continuous, merely inconvenient or totally incapacitating. The clients we see as counselors are much more likely to have chronic pain. Research suggests that 40 to 50 percent of chronic pain clients suffer from depressive disorders.

In his important analysis, Dr. John Loeser described the four major components of pain: nociception, pain, suffering and pain behaviors. Nociception is the sensory process that provides the signals that lead to pain. This occurs through nociceptors, which are primary sensory neurons that are activated by stimuli that cause tissue damage. Pain, as described by the International Association for the Study of Pain, is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

It is suffering, not pain, that brings patients into doctor’s offices in hopes of finding relief. Chronic pain is far more than a sensory process, however, so we must maintain the biopsychosocial model of chronic pain if we are to provide effective health care to our patients and clients. Pain behaviors may communicate to others that a person is experiencing pain. These behaviors include resting, shifting positions, guarding, grimacing, asking for help, taking medication and other observable behaviors.

As Loeser has pointed out, every client with chronic pain may be unique in his or her presentation. For instance, many chronic pain sufferers demonstrate pain behaviors without having any physical findings of tissue damage. There are also many cases of people who show pain and suffering without nociception (for example, phantom limb pain).

In the case of chronic pain, many studies have shown that gradual increases in physical activity can actually improve a person’s functioning and reduce his or her pain.

Integrated health care team: Pain physician, physical therapist, primary care physician, counselor

Alfonso’s view: Since his injury, Alfonso has undergone several surgeries to his lower back with no apparent benefit. He feels moderate to severe pain “all the time.” Opioid medication and rest seem to be the only things that help. Alfonso is very inactive and isolated and has “nobody to talk to.”

Assessment for Alfonso: Because it sounds like Alfonso has chronic benign pain, it is important to observe him closely as you talk with him. Does he grimace, shift positions, guard parts of his body or look uncomfortable?

Have Alfonso self-monitor his daily pain levels over the next week or two. Does he show variations in that level at different times of the day or during various activities?

You might also have Alfonso assess his level of self-efficacy. A high level of self-efficacy is beneficial when people are confronted with acute or chronic pain. One reason for this is that individuals who are highly self-efficacious may be more motivated to engage in health-promoting behaviors and adhere better to treatment recommendations because they have higher expectations of performance success. They are also less likely to give up an activity when facing barriers (e.g., pain), which may prevent them from becoming trapped in the negative spiral of activity avoidance, physical deconditioning, loss of social support and depression. Finally, perceived self-efficacy can positively affect the body’s opioid and immune systems.

Potential interventions: Given that Alfonso received no benefit from surgery and is stuck on fairly high doses of opioid pain medications, you might consider several options for psychosocial interventions. Weight loss often helps people with pain, so this might be an early goal. You might suggest a strategy to help Alfonso slowly increase his physical activity, perhaps including use of a wearable activity monitor. You could also work with his pain physician to develop a schedule of gradual “fading” or reduction of Alfonso’s opioid drugs, accompanied by training Alfonso in muscle relaxation, imagery and cognitive behavioral strategies for pain reduction. You can assist the health care team by suggesting nonmedical approaches.

Obesity

Obesity may be the most important focus of attention in Alfonso’s complex case. We have seen that obesity affects sleep dramatically, and extra weight only makes pain problems worse. Given that all three of these problems contribute directly to depression, it is important to select one issue for intervention.

Integrated health care team: Bariatric physician, primary care physician, dietitian, counselor

Alfonso’s view: Alfonso shows little concern about his weight, claiming that he comes from a “fat family.” His sedentary habits and consumption of fast food and beer can be important targets here.

Assessment for Alfonso: Asking Alfonso to keep a journal of his eating and exercise patterns would be a reasonable starting point. Weekly monitoring of weight is also important.

Potential interventions: Motivational interviewing is a very powerful tool for discussing areas of change. In Alfonso’s case, this might include taking small steps toward healthier eating and increasing his level of exercise. Because of Alfonso’s isolation, simply developing a helping relationship with him may be beneficial in and of itself.

Putting it all together

Clients who present with primary psychological problems and issues often have underlying behavioral health problems that may have an effect on their psychological functioning. Using the biopsychosocial model, it is possible to identify those problems and offer focused counseling that involves motivational interviewing, client self-monitoring and assessment of self-efficacy.

In Alfonso’s case, there were many areas of concern — obesity, sleep problems, pain, social isolation and alcohol/drug misuse — that could be improved through counseling. Regardless of the complexity of the case, these areas are always worth exploring carefully.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

David Engstrom is a board-certified health psychologist in Scottsdale, Arizona. He trained and supervised counselors and counseling psychologists for 20 years at the University of California, Irvine. Currently, he is a full-time core faculty member in counseling at the University of Phoenix, where he teaches integrative health care, motivational interviewing and mindfulness meditation techniques to counseling students. Contact him at drengstrom@email.phoenix.edu.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

‘We’re in danger of losing a generation’

By Bethany Bray April 5, 2017

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When a person is prescribed medicine by a doctor, the common assumption is that it’s best to take the dosage until it’s gone.

In most cases, that’s true. But with opioids, a class of powerful, addictive and frequently prescribed pain relievers, dependence on the drug can begin within five days. Yet doctors often prescribe a 30-day supply, said Carol Smith, a licensed professional counselor (LPC) who spoke at an April 4 congressional briefing on Capitol Hill that was sponsored by the American Counseling Association.

“By the end of the 30 days, [the opioid] is not addressing their pain anymore. It’s a vicious, vicious cycle,” said Smith, a professor of counseling at Marshall University in West Virginia and past president of the West Virginia Counseling Association.

Carol Smith, LPC and professor of counseling at Marshall University, speaks at ACA’s congressional briefing on opioids on April 4. At left is panelist Larry Ashley, LPC, LMSW and professor emeritus of counseling at the University of Nevada, Las Vegas. Photos by Bethany Bray/Counseling Today

Smith, a member of ACA, was speaking as part of a panel that focused on the realities of America’s opioid epidemic and how professional counselors are well-suited to help change that trajectory.

“What counselors bring to the table is essential to any response to this crisis,” said panelist and ACA member Kevin Doyle, a professor of counselor education at Longwood University who also has a private counseling practice in Charlottesville, Virginia. “This touches everyone. … Virtually no element of society is immune to this.”

The opioid class includes heroin as well as prescription pain relievers such as oxycodone, Vicodin and morphine. On average, 91 people across the U.S. die every day from opioid overdoses, according the U.S. Centers for Disease Control and Prevention. The amount of prescription opioids sold in the U.S. has nearly quadrupled since 1999; deaths from prescription opioids have more than quadrupled since 1999.

In the U.S., more than 650,000 opioid prescriptions are dispensed every day, said panelist and ACA member Kirk Bowden, an LPC who chairs the addiction and substance use disorder program at Rio Salado College in Arizona.

Opioids should be for acute, not chronic, pain, Bowden said. He also stressed the need for more training for medical professionals on the dangers of dispensing opioids.

For example, patients who have had oral surgery to remove their wisdom teeth are commonly prescribed a 30-day supply of opioids, when in most cases the drugs are only needed for a few days of pain relief, Bowden said. Patients then leave the remaining pills in their medicine cabinets, easily accessible to anyone in the household.

“[With opioids] if individuals use it, even as prescribed, over time the individual will become addicted,” said Bowden. “Something drastic needs to happen. … Over half a million people died between 2000 and 2015 from opioids. That’s like the city [the size] of Atlanta.”

“We’re in danger of losing a generation,” said Smith, who lives in West Virginia, a state with one of the highest opioid overdose rates in the U.S.

“As [Bowden] succinctly put it, we need to remember that this issue is not a singular crisis but a chronic problem that demands that we marshal all available resources to combat,” said Art Terrazas, ACA’s director of government affairs.

Panelists told congressional staff members attending the ACA-sponsored briefing that solutions need to include more addictions training for medical professionals, better access to care and support programs for people struggling with opioid addiction, and the inclusion of professional counselors in response efforts to the opioid crisis.

Kevin Doyle, LPC and professor of counselor education at Longwood University in Virginia speaks as Dr. Melinda Campopiano of the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) looks on.

Counselors use a strengths-based approach and work to address the underlying reasons, such as past trauma, that individuals may turn to opioids to self-medicate, Smith explained.

“What counselors can bring to all of this is an attention to the whole person,” she said. “We come at it from a wellness perspective, and build on [a client’s] strengths. … We teach self-regulation and how to stay grounded in the here and now. We help people to know how to be sad in a healthy way, how to be angry in a healthy way and what to do with those emotions. Many people come to counseling and they can’t even identify that they’re angry. It’s been trained out of them by life experience.”

Counselors are uniquely skilled to support clients in their recovery goals – and in their possible relapses, Doyle added.

“We stick with them through the ups and downs,” he said. “We know that with treatment, recovery is possible.”

 

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Watch a video of ACA’s Congressional briefing on opioids here: youtu.be/tqcEKMTqsaE

 

Download ACA’s infographic on opioids here: bit.ly/2p0ZJ0N

 

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Dillon Harp of ACA’s Government Affairs team (far right) moderates the panel, from left to right Dr. Melinda Campopiano, Kevin Doyle, Kirk Bowden, Larry Ashley and Carol Smith.

About the panelists

Larry Ashley is a licensed professional counselor (LPC), licensed master social worker (LMSW) and professor emeritus of counseling at the University of Nevada, Las Vegas and addiction specialist at the University of Nevada, Reno School of Medicine. A U.S. Army veteran, he specializes in the treatment of military clients and issues related to combat trauma.

Kirk Bowden, an LPC and ACA fellow, is past president of NAADAC, the Association for Addiction Professionals, chair of the addiction and substance use disorder program at Rio Salado College, and consultant and subject matter expert for Ottawa University.

Dr. Melinda Campopiano is a physician and the chief medical officer of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration. She is board-certified in family medicine and addiction medicine.

Kevin Doyle, LPC, is a professor in the counselor education program at Longwood University and chair of the department of education and special education. He has served three terms on the Virginia Board of Counseling and runs a private practice in Charlottesville, Virginia.

Carol Smith, LPC, is a professor of counseling at Marshall University and coordinates Marshall’s Violence, Loss and Trauma Certificate of Advanced Studies program. She is past president of the West Virginia Counseling Association, a branch of ACA.

 

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

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CDC reports drug overdose deaths at ‘epidemic’ levels

By Bethany Bray January 14, 2016

1 Comment

More Americans died from drug overdoses in 2014 than in any previous year on record.

The 2014 statistics, released last month, indicate that U.S. drug overdose deaths have reached an epidemic level, according to the U.S. Centers for Disease Control and Prevention (CDC).

In 2014, 47,055 drug overdose deaths occurred across the U.S., 61 percent of which involved some type of opioid, including heroin. States with the highest rates of drug overdose deaths in 2014 include West Virginia (35.5 deaths per 100,000), New Mexico (27.3), New Hampshire (26.2), Kentucky (24.7) and Ohio (24.6).

Deaths from opioid overdoses, which include prescription painkillers as well as heroin, increased 14 percent from 2013 to 2014. Heroin overdose deaths rose by 26 percent. The CDC reports that the rate of overall opioid overdoses in the United States has tripled since 2000.

Overall, drug overdose deaths increased from 2013 to 2014 in both men and women, in non-Hispanic whites and blacks, and across all adult age groups, according to the CDC’s Morbidity and Mortality Weekly Report.

“The sharp increase in deaths involving synthetic opioids, other than methadone, in 2014 coincided with law enforcement reports of increased availability of illicitly manufactured fentanyl, a synthetic opioid; however, illicitly manufactured fentanyl cannot be distinguished from prescription fentanyl in death certificate data,” writes the CDC. “These findings indicate that the opioid overdose epidemic is worsening. There is a need for continued action to prevent opioid abuse, dependence and death, improve treatment capacity for opioid use disorders and reduce the supply of illicit opioids, particularly heroin and illicit fentanyl.”

 

Graphic via the U.S. Centers for Disease Control and Prevention.

Graphic via the U.S. Centers for Disease Control and Prevention.

 

 

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For more details, and a state-by-state breakdown of data, see the CDC’s Morbidity and Mortality Weekly Report.

 

For counselor resources on addiction, visit the International Association of Addictions and Offender Counselors, a division of the American Counseling Association, at iaaoc.org

 

Related reading: See a review of the book From the Needle to the Grave: My Sister’s Journey With Heroin Addiction as Told Through Her Journals at CT Online: wp.me/p2BxKN-423

 

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday

 

Techniques for counseling clients who have chronic pain

By Betsy Farver-Smith July 27, 2015

13 Comments

Clients or patients facing chronic pain require a special counseling approach that can be applied universally, no matter their source of pain or the number of months or years they have tried to deal with the pain. We have honed and practiced these techniques at the Betty Ford Center in Rancho Mirage, California, because many of the patients we see for addiction treatment also experience chronic pain.

Chronic pain and addiction do not necessarily co-occur, but there are some strong correlations. Unfortunately, because pain medication can be addictive, it is common (but not certain) to find Chronic_Painpatients with the combined condition of chronic pain and addiction. All people who abuse alcohol or other drugs experience chronic emotional pain. According to an article published by Jennifer Sharpe Potter and colleagues in the Journal of Substance Abuse Treatment in 2010, chronic physical pain affects approximately 60 percent of those struggling with alcoholism or addiction.

At the Betty Ford Center, we have a special treatment program, developed by Dr. Peter Przekop, for both chronic pain and addiction. Regarding chronic pain alone, we have learned several critical counseling techniques that help patients move forward.

Determining if an individual has chronic pain issues

Treatment, of course, begins with an assessment and diagnosis. Sometimes clients or patients will not present their chronic pain as a factor in the reason they are seeking counseling. However, certain markers will help you identify whether the person is dealing with chronic pain. Look for:

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 mindset — a belief that if things can go wrong, they will go wrong

A key part of your assessment is to understand any and all physical pain issues. This detailed inquiry will aid the development of your treatment plan.

There is likely to be related emotional pain as well. Often that emotional pain has early life trauma as its origin. Your assessment and treatment must take this into account. In a national survey of 1,009 chronic pain sufferers completed in 2014 by the Hazelden Betty Ford Foundation, we found a disturbing, though not unexpected, correlation between early life trauma and chronic pain. The chart below lists the top incidents of early life trauma among the survey participants.

One of the most dramatic findings in the national survey was that 97.1 percent of chronic pain sufferers had experienced at least one instance of physical or emotional trauma prior to their chronic pain. We believe this early trauma experience often trains the person’s brain to be more receptive to future chronic pain in a way that does not lead easily to treatment relief. Therapy that helps the chronic pain patient understand, accept and forgive these earlier traumas may help heal the pain center of the brain and make it less receptive to chronic pain.

Counseling techniques 

1) Practice being patient with those who are dealing with chronic pain. Inexperienced counselors should know that it is not easy to sit with someone in chronic pain. Many of us in this profession can be caretakers. With clients or patients who have chronic pain, we can tend to want to take away their pain right away. Be prepared instead for a lengthy process. The longer you can comfortably tolerate sitting in session with a client or patient in chronic pain without trying to fix it, minimize it or talk about something else, the more that person will build trust with you. The client or patient will begin to feel that you don’t regard his or her pain as either imaginary or a burden, as the person may have sensed that others have done.

Extended acknowledgment of the pain and listening for the roots of the trauma or concurrent emotional pain builds a capacity within the client or patient for self-exploration and self-awareness. This longer process also helps the client or patient look inward instead of outward, which will benefit the overall therapy process.

2) Offer clients (or refer them to) group therapy in addition to your individual counseling. Unfortunately, a frequent characteristic of people with chronic pain is a tendency to isolate themselves. Because the pain has lingered and feels severe, these individuals talk about it often and intensely with family members and friends. In turn, they have likely eventually experienced being “tuned out.” These clients decide that nobody can relate to what they have gone through. Worse, they may reach an unhealthy conclusion: “My pain is imagined. I’m a wimp. I must be crazy.”

Group therapy, particularly in a community of others dealing with chronic pain, can reduce these clients’ or patients’ sense of loneliness, shame and isolation and help them feel they are not alone. By seeing other chronic pain sufferers who are further along in the process of emotional recovery, your client or patient will gain hope that the day might come when he or she will experience less pain.

Individual counseling provides a different benefit, which is why I recommend both types of therapy concurrently. I begin by recognizing with the patient that pain is pain. By this I mean that our minds and bodies are one unit, and pain will register as pain regardless of whether it is physical or emotional. Emotional pain is just as valid and just as much a contributor to chronic pain as is a medical condition that affects the body. For example, chronic knee pain can be influenced by the pain of unresolved emotional pain.

In this way, it becomes the primary focus of individual therapy to gather information from the client about unresolved emotional pain. As a counselor, you must witness that emotional pain and validate it. Out of this discussion emerges a real gift for the client: a new level of positive self-acknowledgment and self-esteem.

3) Consider adding mindfulness exercises. In addition to traditional emotional counseling, we provide mindfulness training to our patients at the Betty Ford Center who are experiencing chronic pain. Patients spend time in group settings each day becoming aware of how chronic pain has changed their way of thinking, coping and judging themselves and others. Patients learn how to restore normal brain function, in part by working on planned movement exercises that have been taken from the disciplines of tai chi, qigong, kung fu and yoga. Manual medicine and acupuncture also are key parts of the treatment mix. These additional treatment approaches allow patients to learn to refocus attention and help them gain strength, flexibility and confidence. Mindfulness exercises also allow the patients to slow down their minds, control their thoughts and gain a sense of presence. Pain literally steals this ability from people.

Group settings for mindfulness exercises can be helpful as chronic pain sufferers share new skills on how not to focus on the physical pain. Mindfulness helps these patients know where in their bodies they tend to carry the emotional pain from the past. Is it in the same place where they feel the physical pain or elsewhere, such as in the stomach? Patients will come to the realization, for example, that they have internalized and physicalized emotional pain.

4) Help clients learn not to judge the pain. Physical pain is intensified by the person’s judgment of the pain. For example, if your client or patient has a “bad back” and suddenly feels a twinge in the back muscle, that person could spend a significant amount of emotional and mental energy assessing or judging that pain. How much did that hurt? Will it come back? How does it compare with past pains? If you teach clients not to judge or assess the pain, but rather to move on and refocus on something positive, it can actually lessen the sensation of physical pain.

5) Look for signs of chemical addiction. As mentioned earlier, there is, unfortunately, a strong correlation between chronic pain and addiction. Often the addiction is attributable to the pain medication. Your clients or patients may be reluctant to address this issue. I have heard patients say, “I can’t possibly be addicted. After all, these medications were prescribed to me by a doctor.” Or they will say to me, “Addicts live under bridges. I am far from that!” Remember, denial and resistance are typical responses of addicted personalities.

In our 2014 national survey, 48.2 percent of those studied were taking at least three concurrent pain medications prescribed for their chronic pain situation. More than one-third (35 percent) thought they were drug dependent because of the chronic pain treatment. Given that people are reluctant to admit addiction, this number likely is underreported.

ChronicPainChartThe most common drugs prescribed for chronic pain are opioids, which are highly addictive. Likewise, there are more negative consequences for opioid use than for any of the other prescribed pain drugs. For instance, our study showed that half of patients taking opioids for chronic pain said they had suicidal thoughts. Opioid use (through legal prescriptions) reportedly caused multiple problems that counselors should understand and address with their clients who are dealing with chronic pain. The chart above, taken from our national survey, lists some of those negative consequences.

6) For follow-up as counseling ends, consider recommending more group therapy. As mentioned earlier, group therapy is an excellent treatment for patients with chronic pain because it puts them in contact with others who are learning ways to cope with the pain. For this reason, after concluding individual counseling with a client or patient, a good ongoing support to suggest would be a chronic pain group.

When making recommendations, avoid two specific types of chronic pain groups. The first is a group in which members are still reliant on medication. We have seen too many patients come to the Betty Ford Center addicted to their pain medication yet still in chronic pain. Medication complicates and often defeats recovery from chronic pain. The second is a group focused on one specific type of pain. In these groups, patients may end up comparing symptoms and aches and pains rather than continuing to move forward with emotional self-exploration and learning new coping skills.

If your clients or patients have chemical addiction issues, I recommend that they participate in a 12-step recovery group. This group will help them focus on recovery from substance abuse, while simultaneously helping them heal related emotional pain issues that pertain to chronic pain.

A proven approach 

We use these counseling techniques at the Betty Ford Center. We possess the benefit of treating the patient daily for anywhere from 45 to 60 days, compared with typical counseling schedules of once or twice weekly. We believe this intensity of treatment leads to exceptional results. Retrospective case reviews show that 74 percent of our pain management patients report being free of pain a year after concluding treatment.

This is why we feel so strongly about these suggested counseling techniques for chronic pain. Even if the counseling sessions you provide are less frequent, we believe these techniques will promote healing of the chronic pain and make your clients more emotionally available to address other issues that are causing them difficulty in life.

 

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Betsy Farver-Smith holds a master’s degree in addiction counseling from the Hazelden School of Addiction Studies. She has been with the Betty Ford Center for 13 years. Her positions include serving as the executive director of clinical services, and she was recently appointed executive director of philanthropy for the Hazelden Betty Ford Foundation. Contact her at bfarver@hazeldenbettyford.org.

Letters to the editor: ct@counseling.org