Counseling patients who have chronic pain about how to find balance in their lives is important, because patients in pain often seek pleasure and may go too far to find it, according to a speaker at a session here.
“You can go to too far in unregulated indulgence when seeking pleasure, which can lead to all sorts of issues including obesity and addiction,” advised Michael R. Clark, MD, MPH, MBA, who is associate professor and director of the Chronic Pain Treatment Program and the Department of Psychiatry and Behavioral Sciences at The Johns Hopkins Hospital.
In discussing how patients become addicted to medications, either prescription or recreational, Dr. Clark noted that a person must first have the desire to use drugs recreationally. What may start out as an impulsive use of drugs may become habitual, and then “what happens is that the reward-driven behavior becomes a habit. When this happens, you see a shift in brain circuitry from the ventral striatum and nucleus accumbens areas, which are typically associated with reward, to the dorsal striatum region, which has to do with habit behaviors.”1
Dr. Clark said it is important for clinicians to stay aware of addictive behavior and, particularly in those patients who may have ceased abusing drugs, what may trigger a possible relapse.
“What happens with someone who is not currently using drugs but has a history of addiction, if you reexpose them to the drug, it lights up their nucleus accumbens,” he explained. 2
Patients will often relapse back into addiction during periods of stress or when they are exposed to environmental cues, such as visiting friends with whom they engaged in drug activity or visiting an old bar where the patient used to drink.
Dr. Clark noted it is also important for clinicians to understand how pleasure and pain interact. To illustrate his point, Dr. Clark described the idea of being hungry. “Food is more pleasurable when it relieves a state of hunger. Similarly, the relief of pain is more pleasant when the perceived threat of a painful stimulus is greater … In other words, overcoming even a small amount of pain can be pleasurable.”
Much like overindulging in food can lead to obesity, so too can a small amount of prescription drugs, taken to alleviate a painful condition, lead to overindulgence and abuse.
“When you deliver these drugs to the organism, they increase functioning in the reward circuitry areas of the brain and now in addition to pleasure, you are also encoding attention and the expectation of a reward,” Dr. Clark said. “This hedonic dysregulation may lead to addiction. It also poses the question whether patients who abuse may have some dysregulation in these circuits that may push them to seek situations to see if they can feel better.”
Dr. Clark explained that knowing how pleasure and pain interact can help clinicians guide their patients to make better decisions.
“You have to achieve the best outcome by evaluating the importance of competing motivational goals,” Dr. Clark said. Patients can then use these motivational goals to help make better choices about relieving their pain, based on not only their previous experience, but also the advice of their clinician about their best current treatment options.