Navigating Pain Management & Addiction

Navigating Pain Management & Addiction

Dr. Kate: Good evening Los Angeles, welcome to Behind Closed Doors heard every Saturday at 6 p.m right here on Talk Radio 790 KABC. I’m Dr. Kate Balestrieri and my co-host Lauren Dummit couldn’t be here today, but together we are the co-founders of Triune Therapy Group, a psychotherapy practice based in Los Angeles. Behind Closed Doors is a show about Sex, Relationship, Mental Health, Addiction, Staying Healthy and other related social issues.

Today, the topic of conversation that we will be focusing on is Navigating Pain Management and Addiction. As I was thinking about how to best prepare and introduce this topic, I couldn’t help but reflect on what we are seeing happening politically. Now I know that doesn’t sound like a very straight forward connection but hear me out for a second.

Often times people who are struggling with chronic pain or who are struggling with addiction issues feel very isolated, very alone and very in fear of what is ahead of them. I couldn’t help but notice the parallels for what’s happening in our country right now as we think about the political divide that has been continuously growing more and more profound in regardless of what side of the political fence you lean on. I think it’s pretty easy for everyone to agree that the polarization that we are seeing in our country is pretty stark.

When I was thinking about why that is and what’s really going on, we then became aware in the new system about what’s happening with the nomination for Supreme Court judge and all of the allegations that are being brought up as the vetting process is happening. Again, this is not a political show, so I don’t want to get into who is right and who is wrong and what side is more merited here but it got me thinking about empathy.

When we are talking about somebody who has had a traumatic experience in their life I think it’s really important to remember that each person defines what is traumatic for them and it can be really easy for all of us on the outside looking in to say well that’s not a big deal or that didn’t happen or it happened so long ago. This person should be over it by now. We get really decided about how other people should feel and how other people should be reacting in their lives and how other people should really be over something. That’s just not the case for trauma survivors. It’s not the case for people who are in recovery from addiction and it’s not the case for people who are managing pain.

Often times a trauma or an addictive symptom or impulse or a chronic pain symptom comes up of nowhere and it can unleash a whole torrent of emotional, cognitive physiological and relational and behavioral situations that really send off a cascade of regression for people. What I am thinking about treating people who are in recovery from addiction or from trauma. I really think about what are the keystone factors for them feeling better and getting more help and that’s community.

We can’t recover if our community is divided. When I think again about the parallels happening politically right now, I think a lot about why are people invested in being so polarized. We all participate in this act and there are a lot of people who say no, no I am a centrist. I don’t have opinions or even if I do have opinions I can hold space for other people’s opinions and that’s great and I think that’s the conduit that allows for people to learn from each other collectively as a whole. We are all representing the same sort of unconscious mind that is happening in our country and in our culture. I think it’s really important that we start listening to each other as opposed to decided that our side is right and then discounting everything that’s being said on the other side.

Surely, we don’t live in the black and white and as we continue to recognize that, it’s imperative that we lean into the gray and start those difficult dialogues even if it means having to admit that hey maybe something that I thought and felt really strongly about, I can challenge that. I can maybe refrain what I think about a particular topic being willing to be in service of a solution as opposed being invested and being right. But I think a lot of people get really stuck on being right because the illusion of being right feels very safe.

Often times when we are in states of political discord, familial discord, relational discord, we get really scared and that’s understandable because human beings are social creatures and we are hard wired for love, we are hard wired for affection and we want so desperately to make sure that there is connections remain intact and that’s great. That’s what’s beautiful about being human. The alternative though is when our relationships or source of love and connection gets compromised we can get very primitive and very regressed from the way that we think. When we couple that with the phenomenon of group think that gets really dangerous because then we go into this more primitive thinking about how to make sure that we are engendering survival of our tribe.

I’m using the word “tribe” very intentionally here because when we get in that regressed state we really embody a kind of us versus them mentality. In the moment it feels very galvanizing to feel like we are part of a group, we are part of organization or a family or a culture that has the answers. We have the blueprint for how to impersonate our species and nobody else does. So we get very protective about our tribe and very protective about the families and the people who align with us because unconsciously that sends signals into our brain about how we are going to survive and not only how we will survive as humans but how we will make sure to continue procreating which is what we are programmed to do, we are animals at the very end of the day.

I think it’s just really key to think about how am I being dismissive of other people’s points of view? How does that serve me? How do I feel safe in putting down someone else’s perspective? What am I invested in that I am not willing to open my mind to the possibility that someone else’s perspective could also be true. It may not even negate my truth. Two truths can exist at the same time even if they are very different and that’s a hard concept for us to wrap our minds around as humans because we often feel like we are in a position of scarcity.

When we have a political system really invested in people being divisive and not supporting one another for in service of supporting their own more acute wants and needs and goals. Then we tend to get more and more held fast on the idea that our resources are in scarcity. That our relational needs will not be met and that we may end up impoverished or whatever our worst case scenario of fears might be. So again, we become more profoundly dismissive of anything that contradicts this illusion of safety that we have created for ourselves in our divisiveness.

Bringing this back to addiction and pain management, as I said earlier people who are struggling with an addiction often feel very alone. Addiction is a disease of isolation and people can make the argument well they are social and they use or they act out in groups of people and that’s true. However, when someone is in an addictive state it is painfully isolative in their minds and often times that is in fact the pain that they are trying to medicate with whatever the substance or behavior is that they are using.

All addiction really tends to be a coping strategy initially. That’s how it starts out. No one wakes up in the morning and says gosh; today I think I’d like to be an addict that sounds like a great idea. So instead they say I am really hurting right now or gosh I really just don’t want to feel this lonely, I’m in so much pain right now, I will give anything to just not feel this for 10 minutes. That’s how desperate they are for relief. When I think about that I think about the stigma of mental illness and addiction that remains in our country. It’s really staggering and it brings me back to the idea of empathy.

Now, a lot of people confuse empathy with enabling or with condoning. I want to be very clear about what I mean here because to have empathy is not to say hey great idea, sure, go ahead, use the cocaine this weekend, just like you do every day and that’s fine I’m okay with that. Maybe you do feel that way but maybe you don’t and I’m not suggesting that condoning or enabling someone’s behavior is okay, in fact, just the opposite. Sometimes having empathy is about holding space for someone to feel the way they feel and connecting to that feeling within yourself and just being able to sit with that without trying to find a solution without trying to make it go away.

Usually when we are trying to take away someone else’s feeling or saying “hey cheer up it’s not that bad”, it’s not their anxiety or pain that we are trying to get rid of it’s our own. We are faced with the reality that we are helpless in that moment. Helpless to change someone else’s situation and that makes us feel very uncomfortable. And so what ends up happening is people can kind of fall into two camps. They over empathize and then become so in enmeshed in somebody’s addictive process that they can’t pull themselves out of it and create good boundaries that keep themselves emotionally or physically or sexually safe.

Instead they end up becoming involved in the cyclone of the person’s addiction. That doesn’t feel safe for them. The other extreme is that people can become too rigid, too defensive, too dismissive and say well it’s your problem figure it out on your own and should you choose to come back to the land of the living we’ll be around. Sometimes we have to put up really strong boundaries when people have made it very evident that they are not ready for change. The empathy is not the same thing as boundaries. Being able to say well this person that I love so much is in pain and I really can feel that and it’s not okay for me to be around them while they are using. That’s an example of empathy and setting clear boundaries simultaneously.

When I think about pain management I also think about the link between pain management and trauma. Often times people who have experienced a lot of trauma will sympathies their symptoms and so what happens to them and their emotional reactions actually become somatic and they can show up in the body and lots of different kinds of pain and physical symptoms and we’ll talk more about that after the break when we bring on Dr. Petros.

But, thinking about the idea of chronic pain, it’s often an invisible condition and it’s not always happening at the side of the original injury if in fact there was an original injury. It can be very misleading for people on the outside of the experience to understand chronic pain which can leave people who are suffering from chronic pain feeling incredibly alone and feeling sometimes like they are going crazy or out of their mind.

When we become dismissive of someone else’s situation we can unintentionally guess like them or collude with this idea that they don’t know what’s happening in their own bodies and we can become patronizing and minimizing and that creates an exhaust ration of the pain. Then the emotional symptoms that comes along with it. We are going to jump much more in depth about that when we return from the break. When we come back we will be speaking with Dr. James Petros, Stanford Professor and the Founder of the Allied Pain and Spine Institute in the bay area and when we take a quick break we are going to come back and talk more about pain management and addiction.


Dr. Kate: Welcome back. You are listening to Behind Closed Doors, I’m Dr. Kate Balestrieri and my co-host Lauren Dummit is not able to be with us today but today we are going to be talking about Navigating Pain Management and Addiction issues. With us we have a very special guest, the founder of Allied Pain and Spine Institute and multiple board certified physician Dr. James. Dr. Petros thanks so much for joining us today. How are you?

Dr. James: I’m well, thank you for having me, very excited.

Dr. Kate: That’s very exciting to have you on the show. Tell us a little bit about you and your background and how you got into this area of specialty.

Dr. James: Absolutely, for myself I think I have been reflecting on what brought me from my early years to where I am today and usually people ask me that same question and for me it really goes back to my formative years and I will give you a quick history of why that’s important. So I immigrated to this country at the age of 10 and I came from a war stricken country. Just by virtue of that I really was on the fast track for understanding and appreciation for the value of health and wellness. I think I was at a very young age.

When I came to this country granted I had a lot of work to do to catch up. I didn’t speak English but by high school by the age of 13, 14, I had decided that I was going to become a doctor. I thought that was going to be one of the most powerful ways that I could give back to people around me and again growing up in the area those were very high level priorities for me. I was fortunate enough to make it to medical school. I attended too many medical schools in Louisiana, an amazing place to go to Medical School by the way. I graduated at the top of my class and 2003 I guess it was.

There after I took the next 7 years to train at Stanford in multiple fields which is relatively unusual but it’s something that I felt was going to be important for me to be able to really compile a very solid background to do what I wanted to do and I’ll get into that in a moment. Those medical fields included internal medicine, physical medicine, rehabilitation and pain medicine.

Through that cohort I of course obtained a multiple board certifications. I finished my training at Stanford in 2010 and I spent the next couple years actually engaging some groups in the community doing pain management providing consultative services to them but it wasn’t that much longer after working with them that I realize there was definitely a little bit of a deficiency in terms of…This is nothing against my peers but with respect to pain management I thought it was probably going to be a better way of offering pain management than the more traditional way of the black and white. You have pain, you are not feeling, we are going to give you this medication hopefully you feel better.

I thought there were a lot more that we could do for our patients and so that was really the emphasis for myself starting Allied Pain and Spine Institute which really this institute was born in 2012, 2013. I started this institute as the solo provider at one office and through some good work and a lot of high quality talented people we have been able to really grow this institute into one that have multiple geographic locations, multiple providers and the multidisciplinary office really at this point our organization I should say.

We offer our pain patients and interdisciplinary integrated approach to issues and I mean physiotherapy, chiropractic therapy, acupuncture, nutritional health, pain psychology, pain specialty health and even surgical care if it’s necessary. It’s sort of a one stop shop and it’s really for patients and there is a lot of literature that’s really arguing for an integrated approach to pain management as really being the most effective. That’s really the background in terms of how we came from then to today.

Dr. Kate: I remember looking at your website a few weeks ago when we started talking about doing this episode and being completely blown away by the credentials of your team. I mean it seems like you guys are all very dedicated to treating pain and eliminating pain and from so many different perspectives I can see the many benefits that patients might have by coming to Allied Pain and Spine really seems like you are able to collaborate for your patients.

Dr. James: I appreciate that and I would go a step beyond and I would say credential is one thing. We could go to great schools, get the best training in the world but I think one of the things that really distinguishes a group or our medical practitioner. This is for all of your listeners to really hopefully take home as a message. It’s beyond that. It’s also about empathy. You were mentioning about in your first segment I think for us to be able to provide our patients with what they need and be effective at it and most efficient at it there’s a certain level of empathy.

We have to understand what we are dealing with and the patients have to see that in us so I hope that’s what we are also able to offer at Allied Pain and not just a great credentials or backgrounds where our people come from.

Dr. Kate: I really appreciate you saying that and I think it says a lot about who you are as a practitioner and I love how your bedside manner must be if you can recognize that each person is coming in with their own set of needs and discomforts and really trying to use them as the expert and their experience and gage what their needs might be.

Dr. James: That’s especially important. Again, this is something that you touched on especially important when we are dealing with chronic pain which is in many cases an invisible disease. The number of times that I have patients coming in initial consultation saying as soon as I open the door Dr. Petros most of the time I tell doctors what’s going on with me they don’t believe me. I just wanted to bring that up and get started with that. It’s a very common thing for us to hear that and I am here to say that it’s not in people’s head. Chronic pain is a disease, it’s a syndrome and it just has to be identified and approached the right way.

Dr. Kate: I so appreciate that. At Triune Therapy Group one of the things Lauren and I see very frequently is just what you said, people immediately anticipating that they are not going to be believed, they are not going to be understood and they won’t get the help they need. So in an effort to sort of tell on themselves if you will or obey any reaction they preempt with a warning of nobody believes me or maybe I am crazy and that’s just really hard to hear sometimes but I think when something is an invisible condition like chronic pain often times people don’t understand. They can’t point to a decided event or situation and say that’s the cause of it. It’s really hard for people to get their minds around sometimes.

Dr. James: Absolutely, and that’s basically the definition of chronic pain. There may not be damaged at one point, but it doesn’t really matter because there are nerve impulses that are still reaching the brain if something is being wrong. Again that’s not in the patients mind. It’s something that’s happening on a physiological level and it has multiple different ways right. That’s part of the reason in fact why when we talk about what we were saying earlier about the importance of having that interdisciplinary approach there are so many diverse affection chronic pain and you can’t just take a black and white approach and approach them linearly. It has to be through sort of a group effort. That’s how it begins and it have to be approach in a very unique way.

Dr. Kate: What are some of the medical conditions that you see typically have chronic pain accompany them or contribute to chronic pain?

Dr. James: So the ones that I think there is one that probably stands out head and shoulders above the rest and that’s lower back pain. It’s probable the single most common for disability in this country, I forgot what the percentages are but that’s one of the main ones. Let’s talk about that for a moment because it goes back to that invisible disease idea that we were talking about. For back pain and have a perfectly normal looking MRI for example. Some doctors may look at it and then they quickly they spot there is not much going on and maybe the patient was making it up or they have something else going on that has nothing to do with a physiologic process. That’s not really true. There are so many different aspects.

Sometimes you will feel lower back pain and it might be explained by a herniated disk but regardless of ideology it definitely is one of the most commented editions that we will see. Beyond that arthritis, migraine headaches, fibromyalgia, nerve damage or neuroolothy are all very common scenarios that we see here. A lot of this comes from trauma but some of it doesn’t. There are a lot of reasons for all of this.

Dr. Kate: Interesting. How do you assess for that diagnostically? What kind of tests or procedures do you have to kind of rule out different kinds of conditions and rule in more possible?

Dr. James: Any time we are working a patient off it’s through a very comprehensive consultation so we will begin through all the issues that the patient may have. A lot of times patients are referred to us, sometimes they come on their own, sometimes they are referred to us from hospital organizations, sometimes from primary care physicians. It doesn’t really matter where they are coming in from. Protocols always remain the same. We look through their medical records; we’ll make sure nothing was missed.

I even take up the phone many times and I will call the referring physician and I will ask some additional questions and then it comes down to like you were saying understanding what test would be ideal to be able to get more answers and that runs a full gamut. Sometimes it can be simple x-rays and potentially x-rays that may not have been done before.

We have a specialty group where they are physically trained to understand exactly what someone might need to get the highest yield data, be able to make decisions ourselves or diagnoses off of. MRIs are obviously very important and also we do nerve conduction studies. So those are very important expansions of our physical examinations. Laboratory tests, blood test sometimes are also quite crucial. Sometimes it’s the condition and autoimmune process for example that many of gone invisible let’s say to the family practitioner’s eye.

Dr. Kate: We have to take a quick break but when we come back let’s talk more about navigating pain management and addiction. So stay with us. Follow us on Instagram and Facebook at Triune Therapy Group. Message us with your questions or give us a call at Triune Therapy Group at 3109334088 for 20 minutes consultation. Stay with us we’ll be right back.


Dr. Kate: Welcome back. You are listening to Talk Radio 790KABC. This is Behind Closed Doors. I am Dr. Kate Balestrieri and my co-host Lauren Dummit is not able to be here today. If you are just tuning in we are discussing navigating pain management and addiction with the founder of Allied Pain and Spine Institute, Dr. James Petros. Thanks so much again for being here with us.

Dr. James: Thank you for your time. I appreciate it.

Dr. Kate: Before we went to break we were talking a little bit about some of the medical conditions that often accompany chronic pain and some of the different diagnostic test that you can run. I am curious about some of the lesser known medical conditions that might show up with chronic pain symptoms.

Dr. James: Lesser known professionally, but for the layperson is something that we see very often and I would say within that category specifically in relation to what your implying fibromyalgia and neuropathy would come to mind. Fibromyalgia for example is a very difficult condition to diagnose. It’s one that we usually would say should be a diagnoses of exclusion and it creates pain in different parts of the body again.

We keep using the term invisible. I would say that fibromyalgia is definitely one of those that qualifies and that secondarily nerve damage, neuropathy which means gone under diagnosed. Sometimes something like neuropathy can arise because of diabetes sometimes through heavy drug exposure exposure including alcohol. It’s just to create a lot of problems throughout the body and until specific nerve study something we call electromyography for example we may not really pick up on it. So those are some conditions that we would see very often.

Dr. Kate: What are your thoughts on chronic fatigue syndrome or endometriosis or some of the other conditions that maybe don’t have external symptoms but certainly can induce longstanding pain?

Dr. James: We typically don’t see too much of that on our side but I’ll go back to chronic pain and I’ll say it has multiple so typically we will see someone with chronic pain syndrome, also have these associated symptoms of chronic fatigue or someone with endometriosis will have a chronic pain syndrome in association with obviously some depressive symptoms and it’s almost like a covert. We will see all of these diseases get crunched up on a very repetitive basis with our patients.

Dr. Kate: How would you describe what it’s like to be a patient or be someone with chronic pain?

Dr. James: That’s a complicated one. It’s a very complex disease process. I would say it is especially if the patient isn’t getting potentially appropriate proper treatment that patient comes in very defeated. They are physically, mentally, socially, professionally, psychologically just down and out. With respect to chronic pain there are different degrees and I don’t want to imply that all chronic pain is the same. I think we have been hitting at that game especially. I just want to make sure that our listeners understand the huge continuum that is chronic pain. In very severe cases when you are at the spectrum people can be literally debilitated from all the different facets that is chronic pain.

Dr. Kate: At Triune Therapy Group Lauren and I often will work with people who are in recovery from some kind of alcohol or drug addiction or behavioral addiction and they often experience a lot of pain in the withdrawal process and that shows up especially if they have been addicted to any kind of opioid or pain killer medication which we’ll talk about in a little bit. One of the things that are most disheartening for them is not knowing how to get through the day and remedy that source of pain that feels completely over encompassing in their lives.

Dr. James: Yeah we see that all the time on our side as well. Patients are trying to cover up something that maybe deeply rooted in a chronic pain syndrome by resorting to possibly treatments on their own that probably they are not the best thing. What I am talking about specifically is substance use disorders. Patients that will come in that will be saying that I drink alcohol to manage my pain. Those are definitely some problems that spring up very quickly with what we see.

Dr. Kate: What other kinds of mental health issues do you see concurrent with the chronic pain patients that you are working with?

Dr. James: I think the two most common ones…I just named off substance use disorders and I will get to two other ones in just a moment. It makes a lot of sense why we see that in our field we see something like that if we are talking about possible resorting the opioids for treatment of pain. It’s a slippery slope on opioids where patients will get potentially tolerant. They will start become dependent. They might be some abuse and ultimately addiction issues with that. We’ll see a lot of substance abuse disorders when it comes to treating chronic pain.

Depression and anxiety would be the other two very big mental health issues that we will see in our patients. It’s probably is a matter of asking what comes first. Is it the chicken or the egg kind of thing? Sometimes patients will have a history of depression and all of a sudden we will see those same patients developing chronic pain which the purpose as pain some kind of pain that’s been going on for at least 3 to 6 months or so. In some cases patients will say a specific trauma scenario won’t get better and ultimately they will be potentially experiencing depression, anxiety, possibly an adjustment disorder for the first time. There are all these different angles of it. I wish it was simpler but it never is its chronic pain.

Dr. Kate: I know there are too many layers for it to be simple. It’s interesting you bring up a really good point. It’s hard to discern if it is a chicken or the egg. Does someone develop chronic pain because of their depression which would make them more susceptible to having reduced coping skills and maybe have them being more lethargic and maybe experience some atrophy and making their muscles or joints, or nerves more immutable to a trauma that then becomes long lasting pain? Or is it the other way around? An injury creates some depression and it becomes a feedback loop that can be very difficult for patients to break out of?

Dr. James: Absolutely. That’s part of the reason why it’s so important for us to have clinical psychologists as part of our pain delivery team, pain management team because they are able to more quickly recognize some of these patterns and implement part of that bio-psychosocial treatment that really help people get identified the right way and maybe if we are doing everything and in a uniform integrated fashion will snap these people out of their feedback loop.

Dr. Kate: It’s really key we have to interrupt those feedback loops in order to get traction whether physically or emotionally or cognitively. As you said if someone is feeling depressed they might be more dejected and feeling more defeated and that does not help our emotional and mental cheerleader parts of our brain and say hey it’s okay, you can get through it, today is going to be manageable. Sometimes we need the help of psychologists, therapists or other people in our lives whose brain power we can borrow for a little while. It tends to get back on line and we retrain it to think more positively which can have some really big impacts on how people manage pain.

Dr. James: Absolutely. I will give an example of the importance of pain psychologist coming to the rescue of us more physicians. It will be a scenario where potentially I’ll see the patient let’s go back to that back pain again and maybe all that they have done, a lot of these patients will see on a repetitive basis because chronic pain is just one of those disease issues that have to be monitored. It’s just like blood pressure management or diabetes. You will be seeing a patient today and maybe outside of cognitive behavioral therapy they wouldn’t have had much more care until the next time comes that I see the patient about a month later.

What we will notice is just by therapy on its own their pain scores will be much lower than the previous times that I may have seen them. They may be from a 7 out of 10 where 10 being severe pain to 3 out 10 and just through the power of what those coping mechanisms, training mechanisms, relaxation techniques and a bunch of other things that our psychologist will do for a patient is how powerful they are. It makes our job easier because we see all of a sudden, we see that our patients don’t require as much pain medications or maybe they don’t need that specific spine procedure that we had intended for them so very powerful.

Dr. Kate: It makes all the difference in the world and when we think about again some of the deficits that come along in coping with some different mental health conditions I think about how those deficits actually create a higher level of pain sensitivity and a lower level of pain tolerance. If we can help people increase their coping skills then they learn how to tolerate pain and it does feel more manageable reducing their identification of 0-10 maybe it goes from an 8 down to a 4 chronically and then that can thwart the need for surgical intervention like you said. It’s really amazing the power of our mind and how we can use it to influence what we can tolerate in our bodies.

Dr. James: Absolutely and in 2015 the World Health Organization the pain society started to more specifically recognize psychology as one of the more established issues relating to chronic pain. We always knew that it was a part of it but now it would almost be malpractice for us not to incorporate some level of pain psychology that brings into the CBT relaxation techniques refraining into management of our chronic pain cases.

Dr. Kate: One more reason why you are a multidisciplinary team is such a great resource for people because often times when we are seeking help we don’t know what we don’t know and we rely on the experts to educate us on all the different angles and so it’s great that your team pulls that together. We have to take a quick break but when we come back more discussion about navigating pain management and addiction with the founder of Allied Pain and Spine Institute in the bay area Dr. James Petros. Thanks so much. Stay with us. We’ll be right back.


Dr. Kate: Welcome back. You are listening to Talk Radio 790 KABC. If you have just tuned in you are listening to Behind Closed Doors. I’m Dr. Kate Balestrieri and my co-host Lauren Dummit is not able to be with us today but we are the co-founders of Triune Therapy Group, a psychotherapy practice based in Los Angeles treating all different kinds of trauma, addiction, sex and relationship issues. Today on our show we are talking about navigating pain management and addiction issues and we are here with our very special guest Dr. James Petros, the founder of Allied Pain and Spine Institute in the bay area. So Dr. Petros on the break I was thinking a lot about our listeners and I wonder who do you think would benefit most from the treatment that your clinics provide? If someone’s out there listening right now how would they know that they might be a good candidate to give you a call?

Dr. James: So we have been talking a lot about chronic pain as well. We go well beyond that. We deal obviously if you have injuries or something that can very quickly transform into something much larger and in this case chronic pain. We deal with acute pain, chronic pain. We optimize medications to prevent side effects and it’s on the same point of potential addiction issues that may come from medications. Appropriate diagnoses for conditions that people may still be scratching their heads after seeing multiple physicians.

We take all the complicated cases and hopefully we will make the right treatment recommendations and make a difference for those people. It would be anything in the human body or from an orthopedic standpoint, regenerative standpoint etc.

Dr. Kate: It’s really a full service clinic that you have going. It’s great.

Dr. James: Thank you.

Dr. Kate: So you mentioned addiction and medication management and this is something that Lauren and I encounter often at Triune Therapy Group. We work with people very frequently who are in recovery from some kind of drug, alcohol or behavioral addiction and often times if they are addiction is chemical in nature they really are hesitant to take any kind of medication for pain and we are seeing a huge spike in the country right now in terms of opioid addictions and I was reading some stats in preparation for our episode today and it really was staggering.

In 2016 63,632 people died of a drug overdose in our country. That just blew my mind. It’s so high. When I think about the fear that comes along with getting addicted again if someone is in recovery and then trying to manage pain. That feels like a big syndrome that people are in. How do you work with people who are in recovery to try and manage pain when medication isn’t something they feel comfortable exploring or go against their plan?

Dr. James: Great question I would say. That’s a very large category in terms of consideration. Let me add another step to what you just mentioned. In terms out the number of people today that are dying from issues related to opioid overdoses is about 115 per day at this point. In terms of some of the federal regulations it’s making management of patients in general that are suffering from some level of pain especially on chronic is even more problematic. We are not really able to as physicians do it the the way that it’s necessarily the best approach.

When it comes to taking these complicated cases on and this goes really for people that are in recovery or not. When it comes to consideration of opioids for treatment case we are not going to consider opioids as a first line treatment. There are a lot of other medications. If we are talking specifically about medications I am going to want to manage someone’s first and foremost with the first layer of treatment anti-flammatory medications. Maybe muscle relaxers, antidepressants or medications that treat nerve pain before I start considering opioids. Even if I do consider opioids in some of these cases again, whether it be someone who has had issues with addiction before or not. I am not going rule people in recovery necessarily to getting opioids but I maybe very responsible when I am prescribing them. It’s a balancing act in that so we are going to have to manage the risk associated with that.

We are going to use the minimal effective dose; we are going try to keep those patients on opioids on a very short term basis only. We are going to switch off our opioids very quickly in terms of dosing, the types of opioids that we are using because we are trying for that tolerance. It’s the tolerance that ultimately kicks patients into withdraw and that keeps digging it deeper and deeper. Mind you as we have been alluding to over and over again if we are thinking that someone’s pain whether it’s someone with an addiction background or not should be managed with pain medication we are missing the boat. We have been talking about a multimode of treatment at first being the most effective. Hopefully it’s a new point and that opioids won’t even be necessary in many of these cases. I hope that answers your question more specifically now.

Dr. Kate: It really does and it helps me create a construct for the patients that I am working with that opioids are not going to be the only course of action to handle their pain. I think that’s a big myth when someone is struggling with pain they think oh my gosh I’m going to have to have surgery or I could get addicted to opioids because opioids are one of the more well known categories of pain management medications. That can be a real deterrent for people in getting treatment. I am curious, what are some of the other obstacles or deterrents that you see in preventing people from maintaining a solid pain management plan?

Dr. James: I think sometimes people just know what they have cannot be managed. They got defeated attitude and maybe for them it’s just getting another consultation. We are here to remind people that there are ways to help manage. We are not talking about necessarily providing a cure. From all the different disciplines coming together in an integrated fashion we are able to help more people than not. Going back to the opioids if there is an issue, an obstacle in that respect there are opioids substitutes out there, something called… that can block receptors for opioids and allow us to go beyond that magnetism that opioids will help this is a set of patient. So it opens up the channel to be able to more specifically and able to treat those patients taking their minds off opioids all together. There is different ways of going about and I think socially a lot of patients will have hope after hearing today’s message.

Dr. Kate: Hopefully. I think that’s one of the biggest takeaways I like people to have is that you can in fact feel better. Maybe not 100% but improvement is better than no improvement. What are some of the other biggest deterrents or obstacles that you have seen in helping people treat their pain?

Dr. James: I take it from our standpoint. Sometimes it get a little bit difficult, we are challenging preposition to some level of progress with patient and it kind of very quickly reverses in a way and the patient potentially feel that they are letting the physician down and then it becomes a downward spiral on our patients in those respects and those scenarios need to stay at a more plateau level. I can tell you that if I am seeing a patient, every time that the patient is coming into my office I make sure that I have something new for that patient because I want to revive hope in any specific patient at any specific visit. Even if it means maybe tweaking a medication dose or trying something a little bit different or maybe a different home exercise technique. We are always building forward. We are not allowing the chronic pain syndrome to keep us where we are at.

Dr. Kate: That’s really impressive and I think necessary because a lot of the patients that Lauren and I work with who struggle with chronic pain talk about feeling like a burden. They feel like a burden in their families, with their children, with their partners, with their physician team and you hit it right on the head. Some people feel like they are letting their physicians down if they are not seeing the results that they would like to see. I think that’s a big obstacle that we have identified is that people really struggle with not feeling like a burden or moving forward when it feels like it’s too much for their team to handle. What I am hearing is that your team breathes a fresh breath of life into that fear and says no we actually can get more innovative and more creative and that’s great.

Dr. James: And that’s our calling card and to be able to make sure that we are providing all the evidence based integrated pain solution. I remind the patient that Rome wasn’t built in one day so small victories, 1 bit at a time and reminding the patient that chronic pain syndrome didn’t just creep up overnight, it was chronic accumulative, a staying patient with the recovery process not getting up and staying in tune with the good report that you have with the specialty that’s treating you is going to be beneficial in the long term. It’s a process.

Dr. Kate: It is a process and it’s impacting more people than I think we even know. I was just reading that across the country, the public health problem that has resulted from chronic pain is costing us somewhere between 560 and 635 billion dollars annually in health care and that includes the actual cost of healthcare but also lost productivity due to chronic pain and that number is just mind blowing. As I think about how much more impactful people could feel in their own lives an autonomist they can feel in their own lives when they start to be able to manage their pain a little bit more effectively.

Dr. James: We have been talking about the problem being under diagnosed because it goes down as an invisible condition in many people’s eyes so the number of people that have been now diagnosed somewhere between 50 to 100 million in this country is staggering as well so not surprising to hear that financial burden obviously with that number of patients.

Dr. Kate: It is really remarkable how costly this problem is across our country. Well Dr. Patras thank you so much. This is just been such an insightful interview and I am so grateful for your time today. How can our listeners get a hold of you if they want to learn more or schedule a consultation?

Dr. James: Thank you so much. One of the best ways would be to go straight to the website which is and we can also be contacted by our central number which is 408-528-8833 and we will be happy to help in any capacity.

Dr. Kate: Wonderful, we so appreciate having you as a resource and if you didn’t catch that listeners you can always check out our website Lauren and I are happy to put you in touch with Dr. Patras and is team and answer any questions that you might have. Thank you so much everyone for listening. Tune in every Saturday at 6 p.m for Behind Closed Doors, follow us on Instagram and Facebook at Triune Therapy Group and message us with your questions. You can always call us 310-933-4088. A big thank you again, to Dr. James Patras the founder of Allied Pain and Spine Institute and of course listeners. Thank you. We do this for you. Have a great weekend.


Ask the experts

Often, when anger is the first response, it’s considered impolite, crazy, bitchy or dismissed as overly emotional. Yet, there are many instances in which one’s anger is stirred, and the key is putting it to good use. For instance, when a loved one is unfaithful, or when insensitive remarks are made concerning one’s ambitions or dreams, when feelings are questioned or when a woman is told to be more vulnerable and subservient. Though family and social expectations place unnecessary burdens on women (and men too), they can channel their anger-filled responses into action by going against the grain, pursuing their own interests or business, going to graduate school and much more. In turn, they’re encouraged to surround themselves with like-minded individuals, committed to supporting and cheering on one another, and ultimately helping the other discover their true potential. This system of support will continue to help individuals convert their anger into action, and perhaps enjoy a few laughs, too.

Yes. One hundred percent. Women are socialized to put relationships before themselves, and this often leads to stifling anger or any feeling that might compromise the bond between two people. This is especially the case in their relationships with men, or in competition for men, and over time, women’s anger and aggression has become more user wraps, or covert. Passive aggression seems to be both the only “acceptable” means of communicating anger, but women are also labeled “manipulative” when they attempt to express themselves indirectly. It becomes a vicious circle of anger, denial or minimization of anger, and then make ourselves smaller just to avoid being a “problem.”

While it is becoming more acceptable for women to show anger, progress is slow. Most of the time, female anger is couched in comedy or parody, and only accepted in small soundbites. Those invested in a patriarchal perspective, men and women, hold firm in their beliefs that women ought to act a certain way, or not make waves. The vary act of saying “we’re angry!” is a bold and pioneering move. Further, some women hold more internalized oppressive views, and refuse to participate in a movement that is labeled feminist or angry. For some women, to do so would compromise their social standing, romantic relationships, financial security, etc. It is scary, because the backlash is real. To take a stand is mark of bravery, and not everyone is ready to avail themselves to the fiery response of those in opposition. My opinion is that over time, the backlash will subside and change will take place. Cultural growth is a slow moving process, and with every voice heard, the collective voice of a paradigm shift grows louder and more effective. I don’t think women (or men) should care about acceptability. The more those who are angry attempt to hustle for the approval of their oppressors, the more power is given away. From my perspective, those who are angry a well suited to unite and establish new norms, refusing to tolerate mistreatment any further.

There are so many way to channel one’s anger constructively. I do not condone any violence (unless in self-defense) and instead think about using anger as a collaborating force within and with others. Being of service to others is one way to channel anger. This is especially relevant because so many women today do not have strong female role models, who they can turn to for advice. Get engaged. Mentor younger women, get a mentor, get creative. How can you pass along the resources (i.e., emotional, financial, logistic, etc) that were not available to you and resulted in your marginalization? What do you wish existed that could have helped you through a particularly challenging experience? Create it. I did, and it changed my relationship with anger and helped me take it for what it is a healthy emotion that lets us know when we feel disrespected or mistreated. This is key information that keeps us psychologically and rationally healthy. Anger is invaluable and an essential part of the human experience. When we embrace that, we can make it work for us in myriad ways.

As a psychologist, patients, friends and family are always asking me advice on their relationships and, let’s be real, everyone else’s relationships. One of the biggest questions they have, is why are there no good men or no good women out there? There are good people out there, I reassure them, but they inevitably come back with some retort about having to settle or face being single forever; for some, a fate worse than death. So herein lies the conundrum stay single forever or settle. Well, let’s back out of the black and white thinking that keeps us stuck for a moment and think about what it means to settle. Most of us have arbitrary ideas or checklists we drag around to assess our swiping situation. Does he make a certain amount of money? Is she pretty enough to take around my friends? Is she/he tall enough/too tall? Is she/he fit enough? What kind of car does he/she drive? Do they like dogs? All-important questions, but what do they really mean about a person’s character or how well you’ll get along? When considering the question of settling, it is important to ask what we:

  1. need in relationships
  2. want in relationships and
  3. won’t tolerate in relationships?

No two relational blue prints will look the same, and there are no right or wrong answers. Let’s look at needs first. We all have intimacy needs, like support, trust, security, communication, touch, respect, etc. They may change over time. That’s okay. Its hardwired in us. We also have relationship wants, the qualities that might ignite our fire a little more intensely. Physical appearance, fitness level, similar hobbies, values, job, financial standing, etc. are examples of wants. There is nothing wrong with wanting whatever you want in a partner. But many times, we mistake our wants for needs and then we feel like we’re settling if the want boxes are not checked, because we’re ignoring the meaning we assign to these traits. For example, consider meeting someone who is two inches shorter than your preferred height in a partner. He or she is funny, witty, charming, consistent, honest, and generous with their time, all of the other wants and needs you’ve identified. They just happen to be a little short-changed in the height department. What does height mean to you? Does it represent strength? Safety? Protection? Status? What does it mean about you if you date this person anyway? Whose judgment do you hear in your head? Why is their judgment so important? Asking these tough questions can help you decide if this is a want or a need, and if the underlying meaning is a need, can that need be met in other ways by this partner or other people in your circle? We often expect our partner to meet all of our needs, and overlook the inevitable disappointment in that expectation. Many people do not know what they need or want in relationships, because they are so eager to be in a relationship that they haven’t stopped to consider what they are looking for in their other half. They accept what is available, to avoid being alone. One day, they wake up and think, “Hey, I think I want more than this. I wish my partner would….” and realize that they might be settling but are afraid to leave. This brings me back to the last point, knowing what you won’t tolerate in relationships. It is just as important to know what doesn’t work for you when considering whether to start, stay in or leave a relationship. For some, deal breakers might include violence or infidelity. For others, perhaps smoking or liking heavy metal is the end of the line. Knowing yourself is key in defining your needs, wants, and deal breakers for relationships. If you don’t know some answers to these three factors, perhaps you’ve been neglectful (and settling!) in the most relationship of all, the relationship you have with yourself. Only when you set intentions and cultivate a relationship with yourself can you invite in the kind of love you are seeking and deserve to have. Until then, you’ll be running in circles, chasing ideas and looking to define yourself in the reflection of another.

Obsession, a thought that continually preoccupies or intrudes on a person’s mind, is often what drives addiction. Obsession is about hypervigilance. When we feel the object of our affection (whether real or in fantasy) may not feel the same way, we perseverate about them, ourselves and the relationship. This rumination and over-focus is an emotional survival strategy that keeps our brain playing out all of the what-ifs and looking for answers to the sometimes unconscious ques- tion, “How can I make sure my partner doesn’t leave me?” A milder version of obsession can look like ruminating thoughts. “What if he likes her more than me?” “Did she talk to her ex-boy- friend last night?” “If only I lost those last 10 pounds…” Perhaps you find yourself checking their social media accounts for proof they are with you, or have moved on. Maybe you enlist your friends or family to investigate or check on your desired. At the extremes, obsession can morph into stalking and domestic violence. If we feel threatened at the loss of someone, and re- taliate with this level of possession, it can be dangerous for everyone involved. Contrary to what may be glamorized in movies, extreme jealously and stalking are not healthy courtship behaviors, and can lead to emotional and physical trouble.

Obsession with another person may be a symptom of love addiction, which is essentially an ad- diction to the experience or “high” of being in love, and generally appears on the form of putting another person on a pedestal, creating the fantasy that they are perfect or the one, ignoring their faults or certain red flags that point to the contrary. Love addicts often expect their partners to care for all of their needs. Love addicts often neglect to care for or value themselves while they in the relationship. There often exists a toxic bond or an obsessive attachment in love addicted relationships. Love addicts often continue to engage in the relationship, trying desperately to connect as they search for their self-worth in the relationship, even if the object of their desire is pejorative, hurtful, or abusive. Inappropriate boundaries, abuse, neglect, intimacy issues, chaos, drama are some of the deleterious characteristics of these relationships. Love addicts suffer from profound feelings of shame, anguish, and fear of abandonment.

Since love addicts typically suffer from an anxious or preoccupied attachment (hypervigilance about their partner or the relationship), some signs to watch out for would be someone who is wanting speedy closeness, says “I love you before the first argument, has poor boundaries, is constantly expressing insecurities and worrying about rejection, is often very unhappy when not in a relationship, plays games to keep your attention, has difficulty with direct communication, struggles to effectively express their wants, needs, thoughts, and feelings, expecting you to guess or read his or her mind, acts out, tries to make you jealous, always makes things about him/her- self in the relationship, lets you set the tone of the relationship, seems preoccupied with the relationship, calls or texts excessively, stops by your home or work unexpectedly, fears that the small acts will ruin the relationship, seems to be trying too hard to keep your interest, and is extremely jealous.

If you suspect that the person you are getting to know has obsessive or love addicted tendencies, this does not mean you have to cut them out of your life completely. However, it is important to take things slowly, establish very clear boundaries, assess what works for you and get consulta- tion from friends and loved ones about your experience, pay attention to any attempts to get you to change or disregard your boundaries or needs, use direct, clear communication, and effectively verbalize your wants, needs, thoughts, and feelings. – Dr. Kate Balestrieri, Psy.D., CSAT-S, Licensed Clinical and Forensic Psychologist, and Lauren Dummit-Schock, LMFT, CSAT, CoFounder

The first step to getting help from this type of toxic relationship is to recognize narcissism in your partner or spouse. This involves identifying the traits and warning signs of this disorder, which you may have been living with for quite some time. At Triune Therapy Group, we have skilled clinicians who are highly trained to treat those that are in a relationship with a narcissist.

To help you understand the condition and how you may or may not have been affected, please explore the following Frequently Asked Questions and Answers provided by Licensed Psychologist Dr. Kate Balestrieri: Read More FAQs About Narcissistic Personality Disorder

Perhaps the greatest hope surrounding the #MeToo movement and other similar movements is that it will generate an awareness of the magnitude of sexual assault and harassment, particularly in the workplace. In doing so, maybe it will initiate and rebirth conversations regarding equality that have since gone underground. This is important, because many people fail to see the ways in which others misuse power and privilege, and how this leads them to engage in predatory behaviors. In another sense, the #MeToo movement could educate people on how to avoid being exploitative, while enlightening them on affirmative consent, power imbalances and how to classify and pursue intimacy and happiness in a authentic, healthy manner.

I work with new mothers and I have on multiple occasions worked with mothers who have experienced a the loss of a pregnancy close to becoming a mother. It is indeed a double whammy. There is so much that gets stirred up, and it intensifies the transition into motherhood and the processing of these loss, exacerbating common life-cycle events, and resulting in undue pressure on new moms, emotionally, physically, spiritually. When we’re trying to understand how motherhood and losses affect us, it is imperative to remember that the transition into motherhood and assimilation of loss are multi-dimensional and encompass physical, social, emotional, spiritual aspects of humanity. Although we mostly associate motherhood with new beginnings and joy, the questions of loss and death and endings actually also come up. Becoming mothers is a definite end to our earlier self, our pre-motherhood bodies and relationships, and mothers must mourn how the idealized fantasy of motherhood is never matched with the reality of the day to day. This is all considered “normal” to go through unless it gets complicated with trauma or major stressors. But if the transition to motherhood coincides with a loss, mothers get all of this thrown at them at the speed of light. It’s like existential pressure overload. – Helena Vissing, M.S., Psy.D. Clinical Associate, Psychological Assistant

The mental health of mothers is a major public health concern. Research demonstrates that depression and anxiety in mothers impact their children. The exact ways children are impacted by their mothers’ mental health involves a complex interplay of factors. We always have to look at the unique combination of risk factors and protective factors for each mother-child couple. If you grew up with a mother who suffered from postpartum depression, you are not necessarily determined to suffer. But we know that on a large public health scale, there is a clear connection between mothers’ mental health and lifelong mental health of their children. The immediate effects of mothers’ depression is that babies become withdrawn and irritable. This is happening at a sensitive time when babies are beginning their lifelong development of emotion regulation. Development is layered and scaffolding throughout life, so a baby who is experiencing these challenges already during their first years will be What we often experience in the consulting room is adults who struggle with feelings of shame and inadequacy or “never being enough”, even when they are normally functioning. They might describe a vague sense of unworthiness that has always “haunted” them. Although it’s widely acknowledged now that our sense of ourselves is rooted in our earliest relationships, it is still overlooked how issues in this area can stem from the emotional pain the child of a depressed mother experienced. This pain does not just disappear as the child grows or if the mother’s mental health improves, as it has influences the very core of the child’s sense of self. Infants and children are developmentally unable to make sense of the intensity of their mother’s depression, but they still feel it. This is because our earliest sense of self is built from our early nonverbal and physical experiences of being cared for. The only way and infant can interpret the signals from a depressed mother is to internalize it, which manifest as a sense of never being enough. Even when the child grows up to be an adult who can rationally separate their mother’s emotions from their own self-worth, the early experiences can still linger and manifest as issues with unworthiness. For each person, it’s a unique story of with all the risk factors and the negative impact on one hand, and then all the mitigating factors and strengths on the other hand. The adult who describes feeling shame and unworthiness might struggle to pinpoint the root of their issues, especially if their mother’s emotional issues were hidden, denied in the family, or minimized. The mother’s emotional state during the crucial early years is often that missing piece to help an adult fully understand their development and life story. Often they are not in a position to communicate about sensitive material with their mothers. This is why it’s crucial that maternal mental health is addressed clearly at all levels of society. The taboo still surrounding motherhood and postpartum emotional issue has devasting consequences for the entire family. I know this is a lot. Feel free to use what makes sense, and let me know if I should clarify things? I tried to use language for laypeople. – Helena Vissing, M.S., Psy.D.