**5. Non-pharmacologic pain management modalities**

In approaching a patient with co-occurring chronic pain and SUD, it is important for the clinician to recognize the multiple functional domains affected: body, brain (CNS), mind, and spirit. Structural and functional changes in the brain have been well-documented and contribute to reorganization of neural networks involved in behavior, emotional regulation, identity formation, and capacity for enjoyment of life. Thinking may be distorted due to chronically focused attention on pain and distress signals, frequently attached to drug-related cues, which biases thoughts and attitudes toward negative, maladaptive patterns of fear, avoidance, catastrophizing, and disengagement. Treatment modalities aimed at improving self-efficacy and coping skills are critical in achieving good outcomes. Below are some categories and examples of such approaches.

Special mention is given to the existence and strong evidence in favor of structured interdisciplinary pain rehabilitation programs [53]. Though not commonly found, these programs provide holistic care to a cohort of patients and typically include medical management, psychological counseling, movement-based therapy, and relaxation training. They are often managed by a nurse or allied health provider. The team of specialists communicates about each patient in the program in a longitudinal and coordinated fashion to optimize individual patient progress and outcomes, emphasizing training the patient in sustainable self-care techniques.

### **5.1 Movement-based therapies**

Ref. [54] At a basic level, exercise and movement are helpful and adaptive for patients with chronic pain, many of whom have developed kinesiophobia, or fear of movement. Physical therapy is often a helpful first step in addressing that fear and

*Management of Co-Occurring SUD and Chronic Pain DOI: http://dx.doi.org/10.5772/intechopen.105721*

gradually improving activity tolerance. Occupational therapy assesses and intervenes to maintain or re-establish meaningful activities or occupations specific to a patient's circumstances, such as working in an office environment or providing care to small children. Tai chi is an evidence-based form of ancient Chinese movement, breathing, and harnessing of energy (chi) that has been used widely in chronic pain treatment, especially in interdisciplinary chronic pain rehabilitation programs. Yoga is another validated technique for combining anaerobic exercise, breathing, mindfulness, and energy movement, and has become very popular both in chronic pain treatment and as an approach for general wellness.

### **5.2 Bodywork treatments**

Ref. [54] Acupuncture is an ancient Chinese technique using specific needle placement, with available modern innovations such as the use of percutaneous electrical nerve stimulation, which has been shown to be effective for a variety of chronic pain conditions, including headache syndromes, chronic low back pain, and other common structural and functional pain syndromes. Chiropractic treatment aims to realign structural abnormalities via manual manipulation of the spine, with evidence most positive for low back pain and less so for neck and upper back pain. Osteopathic manipulation therapy (OMT) similarly uses structural manipulation techniques but in contrast to chiropractic care, OMT is not exclusively focused on the spine as a site for application of gentle pressure on body tissues. Massage therapy is performed by trained, licensed providers using various styles ranging from very gentle to deep tissue techniques, with the goal of reduction of muscle tension as well as general relaxation of body and mind. It has been shown in a host of studies to be useful in chronic pain [55].

### **5.3 Psychosocial treatment for chronic pain**

Ref. [54] Enhancing insight into the role of a patient's thoughts, emotions, and behaviors on functional capacity and subjective level of pain is of paramount importance and may be approached with specific counseling techniques, which are often provided by mental health specialists but may also be used by medical providers such as pain or addiction medicine specialists, or primary care providers [56]. Motivational interviewing is a patient-centered approach that encourages the patient to undergo behavior change in a manner consistent with their own choice and empowerment. Cognitive restructuring aims to increase a patient's awareness of maladaptive thoughts and behavioral patterns and encourages replacing those with more positive, adaptive ones. Cognitive-behavioral therapy (CBT) is a broad category of a wellstudied treatment that, like cognitive restructuring, emphasizes the pursuit of change in maladaptive thoughts and behaviors. Emphasis is on improvement of coping skills, reducing fear of movement and activity, development of techniques for relaxation and enjoyment, and establishing adaptive routines. Acceptance-Commitment Therapy (ACT) is a modification of CBT that emphasizes cognitive flexibility and encourages non-judgmental detachment from the experience of pain, with the goal to engage in meaningful and rewarding activities despite the presence of pain.

### **5.4 Self-directed non-pharmacologic management of chronic pain**

Self-management of chronic pain is a vital component of a successful pain management approach. It is often impractical at best to access the full gamut of evidence-based professional treatment, due to both availability and cost; moreover, self-care tends to enhance the patient's sense of autonomy, self-reliance, and selfefficacy while incorporating activities and techniques that are consistent with the patient's belief system. The following are examples of self-care approaches:


of pain and substance use disorders, using the model and framework that has been so critical and well-trod by individuals who have participated in Alcoholics Anonymous or Narcotics Anonymous programs.
