Addiction Free Solutions for Managing Chronic Pain with Dr. Stephen Grinstead

#089 [CEU Podcast]- The opioid crisis has highlighted just how harmful opioid-based pain management approaches can be. In this continuing education podcast you will learn the unique challenges and obstacles that face patients suffering with chronic pain and coexisting disorders, including medication misuse abuse or addiction and mental health concerns.

You will discover that treatment for chronic pain requires an integrated concurrent team approach to achieve successful treatment outcomes. You will obtain the proper understanding, skills and treatment techniques you need to address the neurobiological psychological/emotional, social and spiritual aspects of chronic pain when potentially addictive medications are no longer a viable option.

See the show notes page for more resources. 

Today's guest, Dr. Stephen Grinstead, has  a doctorate in Addictive Disorders (Dr. AD) and was the Co-Founder and Chief Clinical Officer of a Triple Diagnosis Residential and Intensive Outpatient Chronic Pain Management Program in California. He is author of the book Thank You Adversity for Yet Another Test: A Body Mind Spirit Approach for Relieving Chronic Pain Suffering

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Transcript

Dr. Regina Koepp  
If you've been listening to this podcast for a while, you know, we've been talking a lot about managing chronic pain, and the unique concerns and experiences of older adults related to chronic pain. Today will be the final pain episode for a while on the podcast. But today is a fantastic interview with Dr. Steven Grinstead, who's here to talk about addiction free pain management solutions for older adults and others who are living with chronic pain. So let me tell you a little bit about Dr. Steven Grinstead. Dr. Grinstead has a master's degree in counseling psychology and a doctorate in addictive disorders. He's a licensed marriage and family therapist, a past California certified alcohol and drug counselor, and a certified denial management specialist and an advanced relapse prevention specialist. From 2015 to 2018. Dr. Grinstead, was Co Founder and Chief Clinical Officer of a triple diagnosis residential and intensive outpatient chronic pain management program in California. He's author of many books and most recently, the book Thank you adversity for yet another test a body mind spirit approach for relieving chronic pain suffering. Dr. Grinstead is an internationally recognized expert in preventing relapse related to addiction and chronic pain disorders, and is the developer of the evidence based addiction free pain management system. He has been working with chronic pain management, substance use disorders, eating addiction, and coexisting mental and personality disorders since 1984. And I am delighted to be interviewing him today. So let's jump in to the interview. Steven Grinstead, thank you so much for joining us. Today on the podcast. Today, you're here to talk with us about the new rules of treating chronic pain, addiction free solutions in the era of opioid crisis. This is such a timely topic, and I'm really looking forward to this conversation.

Dr. Stephen Grinstead  
Yeah, me too.

Dr. Regina Koepp  
This will be exciting. I'm curious if we could start at what inspired you to pursue a career in addictive disorders.

Dr. Stephen Grinstead  
Well, it actually goes back a long, long, long way. My childhood. I grew up in a family system that had alcoholism on both sides of the family. And then when I was 12 years old, that was back in 1962. That I got exposed due to an injury playing sandlot football with my cousins, to being rushed to the emergency room. I lived in Pueblo, Colorado, I'm the oldest of nine boys. So the hospital knew the Grinstead boys, one or the other is always there. So they rushed me in, I had gotten knocked down, hit my lower back on a concrete post. And I was hurting. And they gave me an injection of something. At the time, I had no idea what it was it was probably Demerol. But what I do know is what they sent me home with, they sent me home with a prescription for Tylenol codeine three. And I'll tell you what, I didn't I never used it first for the physical pain. But what it did for me was took away all the psychological emotional pain of being the over responsible oldest child in a very dysfunctional family system. And for the first time in my young life, I felt at peace. And so for the next 15 or more years, I found a way to get pain meds, but that wasn't the big piece. The next piece was I noticed there was a warning label on the medication bottle says don't use alcohol with this medication. Yeah. And then I looked underneath at the fine print. It said alcohol may intensify the effect. Yes, right on. So I was off and running. I was I had a very active hyperactive adolescence. My junior and senior year in high school, I ran with rough gang and my hometown. And then a little bit later, I joined a professional gang called the United States Marine Corps and went into their special services force recon Marine. And I learned how to be even more violent and have more reasons to get pain meds because we were always doing incredibly crazy things like jumping out of airplanes. So on and on, and on it went and then the big turning point was one evening, back in 1980. I was a single parent at this time with my young daughter and I was at home getting ready to have dinner and the phone rang and and it was my daughter's school counselor. said, Mr. Grinstead, we have a problem, I may need to report you to Child Protective Services. But it's a matter of what's going on. So as well, we had an alcohol and drug awareness day at school today. And your daughter told us that you know about how a lot of nights when you're having dinner, you have a bottle of wine, and then you take your pain pills with it, and then you get really silly. And we don't think that's a good role model. And right then that was a wake up call. Now I was high functioning. I was a black belt in karate. I was running multimillion dollar electrical construction jobs. So he's very high functioning, not the type of person usually think of as an addict. But I was. And so I promised that I would stop I never use again, I promised my daughter I promised myself, I promised since a Richard Kim, who was at the time the most important mentor in my life. And about a year later, I broke that promise, and it was devastating.

And that started me on the journey to recovery and what a year later would have saved my life. Because a year later is where the pain piece kicked in. A year later, I was getting ready to get out of construction and open my own dojo in our style, you had to have a second degree black belt. Now, about three months before the test time, I had herniated my disc l five s one, it was a minor herniation. And it scared the hell out of me because I did not want to do the old way. So I finally went doctor shopping in a healthy way. And I found an orthopedic surgeon who was willing to do at that time 1982 It was a very non traditional approach. He did give me epidurals, which was great, because that allowed me to do physical therapy, hydrotherapy, but he also hooked me up with acupuncture and chiropractic, which was unheard of back then. And my physical therapist, they put me through two or three, and I kept overdoing. And so the last one they put me with was another Marine. And he says, You're in the medical rehabilitation platoon, your job is to get better, not keep hurting yourself. And I listened. And that started my journey of going through voc rehab. And then I found out I really had good people skills, I was really loved working and helping people. So I was taking it a little bit obsessive compulsive. So I went to UC Santa Cruz, and I enrolled in parallel tracks, one was counseling, and the other was addiction. And I got certified in both. And then a local hospital hired me when because I knew the medical directors. One of them was in recovery also with me. And we knew each other's stories. So they hired me to be the primary therapist for their addiction pain track. So they had an addiction treatment program. And they believe people with chronic pain who got addicted, should be treated for both conditions at the same time in the same place. So that started my passion of professionally, working with people that was about 1986. And I really worked hard studied, learned as much as I could. Then I was exposed to the work of Terry Gorski my supervisor in 1988, who was one of the first group of therapists that got Advanced Certified in relapse prevention with Mr. Gorsky. And about three years later, I decided I needed to have it. And we did not get off to a really good start, this man became my best friend and mentor. And but we didn't get off to a good start. Because he had the audacity, the second day of the training, come up and says, Steve, you're in the middle of a relapse, you need to wake up. My first impression was Who the hell does he think he is? But the second one is, wow, I better listen. So I was I wasn't anywhere near even thinking about alcohol or pain pills. But I had stopped good self care. I had started putting all my energy into the pain patients because our hospital got bought out by a national chain. And the bottom line went from patient care to making money. And I was working 6070, sometimes 80 hours a week for 40 hours pay, because my patients needed me. And so he says that's, that's pretty codependent. And I says you're right. So I went back and resigned and went back to grad school. So that started that next chapter. And then in the middle 90s, he challenged me with developing a protocol to help people in recovery, who relapse with medication and pain issues. And so I developed a system I called addiction free pain management. Now, a lot of people confused this because it's not medication free. Like in the subtitle of this course. It's addiction free options. It doesn't say medication free options. But what I do want to talk about today is how to read Evaluate the traditional biomedical model for managing chronic pain. Because it doesn't work for everybody. Yeah.

Dr. Regina Koepp  
Steven, I so appreciate your willingness to talk about your own personal and family life. The oldest of nine boys, I think would cause anybody pain.

Dr. Stephen Grinstead  
Nine boys in 14 years and no twins, my mother was a same belief.

Dr. Regina Koepp  
I, but what I really admire is, I think in mental health care, there's sometimes such a division between what a what a therapist or mental health provider can say about themselves publicly, and for fear that it might taint or somehow influence that therapeutic relationship too much. And as a result, a lot of mental health providers stay very closed about their own experiences, I think that can have the effect of creating division between us and them and creating a sense of do Why does mental health belong to me and from the from the clients or the patient's perspective. And, you know, I personally also with these podcasts will share a lot about my own family experiences and, and different people and including my own experience with mental health. I just so admire your willingness to share with us how your family system and how your genetic loading and how your own personal experience with pain and pain management, and the psychological aspects of pain, how that all has influenced a career that is helping so many people and very fruitful. So thank you very much for bringing your whole self to this conversation. Yeah, and

Dr. Stephen Grinstead  
the other big piece about me, which connects me with a lot of military vets I work with and active duty even is that I also have severe PTSD from adverse childhood events and Marine Corps time. So I'm also in recovery for PTSD, and still have flare ups nightmares and things at times. The thing is, I think appropriate self disclosure is necessary, but over self disclosure can be harmful. So when I teach therapists or counselors, there, I have a whole segment on how to utilize appropriate self disclosure. And then I tell I tell all my students, you know, what's really important is we should never ask our patients to do something we haven't or wouldn't be willing to do ourselves. And so that that's kind of like my mantra. And you know, the other thing Mr. Gorsky, gave me was before he let me join his team, I eventually became a clinical director for Gorsky synapse. But when I first joined his team, he said, You have to have a mission statement. So while I was all excited, I put together a two page mission statement. He sent me back two words, too long. So that freaked me out. Wait a minute, but I put all this time. So I cut it in half. And I sent him back a page. And he sent me back three words, still too long. Man, I was spreading at that point, because how am I going to take this two page document that I poured my heart and soul into it down to less than that, and I put it down to a paragraph. And he says, Steve, let's talk. When I say mission statement, I want a sentence or a phrase that encapsulates those two pages. So my mission statement since 1991, is is I teach people how to help people. And everything I do is geared towards that. And I and then working with people with chronic pain and coexisting disorders, my mission is to help them reevaluate the traditional biomedical model and look at the whole person approach biopsychosocial spiritual approach. So we're working with the whole person, not on the whole person, but with the whole person collaboratively. Yeah,

Dr. Regina Koepp  
we don't apply a treatment. We work toward something together. Yeah.

Dr. Stephen Grinstead  
Yeah. And I always tell my patients, I don't have your answers, but I'm a damn good coach and guide, I'll help you find your answers. And we explore it together. And it's exciting. It's fun.

Dr. Regina Koepp  
And it's so humanistic, and it come, it's coming from them, they're more likely to follow through.

Dr. Stephen Grinstead  
And sometimes I have to use positive strength based challenge with people because, you know, with both addiction, mental health and chronic pain, there's a lot of systemic denial. That sabotage is it's a good healthy psychological defense mechanism, you know, denial, but it gets in the way. It keeps people stuck in a problem longer than they have to be. So we have to find a way to help them work through it. You know, there's a saying you could lead a horse to water you can't make them drink. That denial management model that I co developed with Terry Gorski is designed to make the horse there's See? And that's what we do we help you know and help people see how they're getting in their own way. I I've started calling it now the inner saboteur rather than denial. I like to use a lot of metaphors and stories, but the inner saboteur is much more palatable. Is it possible your inner saboteur is getting your way? Versus is it possible your denial is getting in your way? Oh, yeah. What a big

Dr. Regina Koepp  
difference. Oh, yeah. The other so confrontational one is so person centered. Yeah. Yeah. Yeah. I wanted to ask you about the term addictive disorders. I know, like, yeah, we have shifted in the field using substance use disorders, or what's your take on that?

Dr. Stephen Grinstead  
I think there's way too much stigma associated with the word addiction. When people think addiction, they think of people with heroin, methamphetamine in the gutter, homeless, and all this, but what they don't get is that it's a substance use disorder. It's a neuro biologic brain disease. And the American Society of Addiction Medicine has said it impacts people biologically, psychologically, socially, and spiritually, they added spiritual on them. About six years ago, they added the word spiritual. So it impacts the whole person, right? So and it's like any other chronic illness, and it needs to be looked at the same. And mental health is stigmatized in our society to depression, anxiety, PTSD. So all all this stigma is getting in the way of people getting good help. And as people age, it gets even worse, because then you have the stigma. Oh, you're just old, you know, and it's just ageism, it's just so there's a lot of stigma attached. And for some people, there's a lot that develops a lot of internal shame, guilt remorse, and they try to hide it. So they're not willing to be open, honest, because they're afraid they're going to be

Dr. Regina Koepp  
judged. Right? And judged from multiple perspectives, like a moral judgment. Well, you can just, you know, I remember growing up, I got the message about substance use disorders, that well, it's just a choice people can choose to just stop using or drinking or, or whatever the is happening. And, and it took time in grad school and exposure to unlearn that message about oh, it's just a choice and understand that a neurobiological psychosocial, spiritual condition, that's like a medical illness, it is a medical illness. And when

Dr. Stephen Grinstead  
when I teach when I teach students, whether it's medical students or counselors or therapists, I remind them that there's a continuum of developing an addictive disorder. And people that have high genetic risk, and high environmental toxicity are at much more at risk for quickly going from misuse, abuse, pseudo addiction to addiction, and that, we need to take that into account and not stigmatize it. So and but we also don't want to use the best of criteria. A, you know, the ACES adverse childhood events, instrument, it's a very good instrument, but it's been utilized inappropriately, especially with some of the new artificial intelligence screening instruments. Because if you score several of those aces, as well as some other things, it labels you inappropriately, because there's no human interaction to check out the rest of the story.

Dr. Regina Koepp  
Right? Right. We could dive into this all day. I'm just so let's, yeah, well, I do want to follow up for 10. More than 10 years, actually, I did a lot of my graduate school training and then worked at the Atlanta VA Healthcare System for 10 years and did a lot of training at the Palo Alto VA and worked with the National Center for PTSD for a long time.

Dr. Stephen Grinstead  
Oh, I remember those days. Super Chino, Palo Alto, yes,

Dr. Regina Koepp  
right. Yeah, yeah. I just wanted to say I so exactly know what you're talking about with the there is a there are layers of stigma, I think and shame related to substance use and mental health conditions for for various populations. You know, there's stigma and shame for military populations and even era like what era of service were you in where you Vietnam era, there's another layer of of stigma and shame. Versus the World War Two era, there was much more nobility in fighting for

Dr. Stephen Grinstead  
well, and they this those folks, they got praised when they came home, we got things thrown at us spit out called names right after Vietnam.

Dr. Regina Koepp  
Right. And the and the quality of warfare was very different. The the I just the trauma was levels of trauma were very different. And I just so applaud your willingness to talk about that and sort of break down some of those segment barriers. The other thing as we were talking about older adults at the at the VA for more than 10 years, I worked with older adults. So that included like Vietnam era Korean War era world, new era veterans. Yeah. But the other feature about the stigma with mental health and substance use disorders around older adults that I see in my clinical work is the the myth that older adults can't change.

Dr. Stephen Grinstead  
So that you can't teach an old dog new tricks.

Dr. Regina Koepp  
Right? Right. And so if we have that belief system, and we're working with an older adult who might be struggling with a substance use disorder, you know, we're as as mental health providers are going to be less likely to help that person bridge to treatment than we would to somebody who we believed could change or had the capacity to change or was Redemption was available to them. I mean, I really see recovery stories, personally as very redemptive. It's quite beautiful to see the arc of the struggle and the redemption and the hard work to get there. I just have so much admiration for this process. So I just wanted to throw in those sort of reflections that I had, as you were talking about these different populations.

Dr. Stephen Grinstead  
Well, one more stigma population, I just think we need to put in there is homelessness. Yes. There's a bit and do you know that what really irritates me the most is a big percentage of the homeless population are veterans. And that really irritates me.

Dr. Regina Koepp  
Yeah, it's, it's tragic, and heartbreaking in just immoral as a society that we would allow that to happen. Yeah. Yeah. I agree wholeheartedly. All right. Let's move. Transition from that to what we're talking about specifically today. So what you shared a little bit about what inspired your interest in chronic pain and addiction? Can you help us understand the the intersection of chronic pain and addiction and the impact of chronic pain on society?

Dr. Stephen Grinstead  
Sure. So I look at it as a synergistic process. Back when I started developing addiction, pre pain management, Terry says, Well, where do I start, he says, we'll go out and do some research. At the time, I was teaching at Santa Clara University, UC Santa Cruz, UC Berkeley, and Stanford Medical School. So this was pre Google. So research was way different back then. And you had to really get into good turns with the head librarians and their staff in order to do all these big searches. And so after about five, six weeks, I was totally frustrated, because the search parameter Terry told me to look at was people who had chronic pain and addiction, what happened to them when they went and sought help? Well, I found nothing that matched that I found a lot about people with addiction, and what happened when they want help a whole lot more on people with chronic pain, and they want help. And then I realized we added to add, we have to add mental health to this too. So we had to have mental health. So think of it this way, with people who have a substance use disorder, addiction, whatever you want to call it, it impacts our life and four quadrants bio psychosocial spiritual, so they have some symptoms or negative consequences because of their use of alcohol and or other drugs. Now, let's say a person with mental health disorder, whether it be anxiety, depression, PTSD, whatever it is, it also impacts those four quadrants, not in identical ways, but parallel ways, similar ways biologically, psychologically, socially and spiritually. And then let's talk about people that just have chronic pain. Well, living with chronic pain impacts those four areas also. So if I were to draw a Venn diagram, I would have three circles, I would have the chronic pain I would have that overlapped with substance use disorder, and I would have that overlap with mental health. So you would have the Venn diagram, and then in the middle of the circle I would draw was the addiction pain syndrome. The chronic pain syndrome, one plus one plus one equals 456 or more. So there's a synergistic effect. Now here's what happens when somebody that has a triple diagnosis, addiction, mental health, in chronic pain, if they go see an addiction treatment specialists, they're dealing with 1/3 of the problem. If that same person goes to a chronic pain clinic, they're dealing with a different third of the problem. And if they go to a mental health counselor, they're dealing with a difficult third of the problem. They're getting what's called synergistic treatment and they're getting one at a time they're getting one thing addressed at a time. And what they really need is to bring it all together collaboratively, when all three disciplines are working together as a treatment team, with the patient being the captain of the treatment team to develop the appropriate treatment plan. So it just synergistic problem needs a synergistic solution. That's why I developed the addiction free pain management system is to concurrently rather than sequentially address the issues. So it needs concurrent intervention.

Dr. Regina Koepp  
Yes, and I think this really, really fills in a major gap in the mental health system. Because as I was coming up in my training, so I trained at a program at Stanford in the early 2000s. And one of the messages that we would get was that before you could treat a mental health condition, you had to make sure that the substance use disorder was managed or under control or, or the person was in recovery, like, we're not going to start that the message was, we're not going to start depression treatment for depression until the substance use disorder is is knocked out, right. And so the person would have to jump through these hurdles. And the person in you know, is telling us the identified patient, the client is telling us, I am suffering, I am suffering, and I'm using substances and that's an inch reading, my substance use disorder is not going to take away my suffering, I'm suffering, suffering suffering. And the end the the mental health system, at least the most prominent message I received was, nope, you have to treat substance use first. Because I'm not gonna, I'm not going to treat mental health until that's taken care of,

Dr. Stephen Grinstead  
oh, that's a big part of my, that's been a big part of my professional career. I went on the international speaking circuit about 1996, all around the United States, Canada, etc. And I kept running into that same wall, and I told them, that can be very short sighted, what we need to do is do a thorough assessment, evaluation, triage, we need to triage and if you are dealing with somebody with severe depression, what makes depression worse substitutes and pain. And what happens if you're experiencing moderate to severe addictive disorder, substance use disorder? It causes more depression. Yes. So isn't it make sense that we deal with both concurrently. And that was hard for a lot of people to wrap their heads around, because that's not what was being taught in grad schools. I graduated my master's in 1995, my doctorate in 2001. And I had to overcome a lot of stigma and bias. And it was it was very challenging at times. And when you start and the other thing that's changed a lot since the mid 90s, when I started doing this, I always incorporated the spiritual into it. And boy, that was taboo at that time. But I'll tell you what, after my presentations, there was always a lot of people that came up and said, Thank you, that's been a missing piece. That really the way you explain that you need to deal bio psychosocial spiritually, you have to deal with the whole person, it just makes so much sense and it does. But what's happened with chronic pain is we've gone or traditional pills, shots, procedures and surgeries, the biomedical model. If someone has coexisting disorders, coexisting problems, that model doesn't work real well. 20% of the population is using 80% of the healthcare dollars, because it's being delivered inappropriately, and then they blame the patient.

Dr. Regina Koepp  
You're just not getting better, you're in addiction now. Now, you said part of your goal today is to help us reevaluate the traditional medical biomedical model. So can we take some time to do that? So you're, yeah, help us understand the, the you're getting into it right now. But help us really understand what the state is of the biomedical model and then how you would like us to reformulate our thinking,

Dr. Stephen Grinstead  
okay. Traditionally, what happens was people with pain, they first have acute pain. And so they get treated by usually a primary care physician, urgent care, emergency room, etc. And then when it doesn't get better three or four or five months, then they refer them to pain management, a pain management specialist, and they're always the first approach is let's see what kind of medication is going to help you not suffer with your pain. And they it's better today than it was believe me, but back in the 90s, the early 2000s. It was we had bought into and drank the Kool Aid of Big Pharma, that medication was the solution. That's why we have an opioid crisis. It's exactly why we have an opioid crisis. And we have a lot of research that shows chronic pain responds really well, to cognitive behavioral interventions, hydrotherapy, physical therapy, chiropractic acupuncture, we have research on all that. Do you know there is no level one research that demonstrates opioids are effective for chronic pain management. There's none, there's no level one out there. Because what happens is people exposed to opioids, they don't always, quote, get addicted. But what happens is it starts remodeling the system, and many of them develop what's called opioid induced hyperalgesia, which is put it really simply is they're hypersensitive to pain signals. And so tolerance builds up, we know that with any of the medications, the opioids, especially in the benzodiazepines, and they usually co prescribe those. So we're, we're trying to find a medication. And what they're forgetting is my goal with chronic pain management is twofold, improve quality of life and level of functioning. The biomedical model for people with coexisting disorders cannot and will never do that. So, biomedical model needs to take a look at more than the pills, shots, surgeries, procedures, we need to take a look at some other areas in the biological window are very important to that get overlooked. diet, nutrition exercise the triad, you know, they good hygiene, there's activity, pacing, there's a whole lot of things biologically that needed to be addressed. But we're not done because we need to then concurrently be working on the psychological, we need to assess and see, okay, how's the person functioning psychologically, anxiety and depression are very, very common with people with chronic pain, as is unresolved trauma. That's the people that usually get in trouble and get labeled as addicts with pain addicts, pain pill addicts,

because they're not addressing the mental health symptoms, they're not developing a treatment plan that designs that. And then we have to take a look at the social family component, cultural family social piece, and we need to see what are the person's assets and liabilities in that area? What what do they need to be doing socially, that's going to help them move out of the problem into the solution. If we don't educate family and friends, in my book, thank you adversity for dinner tests. There's a whole chapter on the role of family and friends that my when I ran a from 2015 to 2018, I ran a residential chronic pain triple diagnosis program in Southern California, the person I hired for the family program, Dale Ryder was a licensed clinical social worker, but I had been following her work with family systems for years on how to deal with families that have substance use disorders. So I trained her to add to the chronic pain piece. So when I was putting the book together, I asked her to co author that fifth chapter with me, because I wanted to bring her wisdom in to the role of family and friends. So that has to be in their self help programs. Well, AAA and na don't work really well for chronic pain people. Because the first thing they're told is if you're on any kind of medication, you're not really in recovery. So that's why there's programs like pills, Addicts Anonymous and chronic pain anonymous. They're my preferred entryway for people with because because they need a social support. And I don't care what the social support is. They need appropriate healthy social support, to be healing that part of the damage that's been done with their pain, addiction and mental health, then we're not done yet. Then we move to the spiritual area. So people who develop these triple diagnoses, they are often isolated from their spiritual values, practices and principles. So one of the one of the assessment instruments we use in our program we use to spiritual assessment instruments to see how people were functioning. We had assessment instruments for all for the domains plus the different mental health conditions, and the physical pain versus psychological pain that I develop. There's all kinds of things we did. But when we got to the spiritual, we wondered improve their spiritual levels of functioning. And we the first trap we fell into was the first thing we better do is differentiate between religion and spirituality. Because that God A lot of blowback. So we did that. So once we have, when are collaborative treatment planning, everybody's treatment plan had to have all four quadrants, they had to be working on improving their levels of functioning. And all four quadrants bio, psychosocial spiritual. And that's what I'm talking about when I said addiction free solutions. And some people needed to be on appropriate medication management for the mental health and the chronic pain. So, you know, it's not stopped the medications, it's let's use them strategically and smartly, while concurrently dealing with the other three domains.

Dr. Regina Koepp  
That's so helpful. I am not a substance use disorder specialist. But I recall years ago, hearing, and I don't know how valid this is, I'm asking you as an expert, is this valid? I recall hearing that when a person is in recovery, like if they go into detox kind of system, an inpatient detox, the more that we can alleviate the withdrawal symptoms and the physiological distress, the better the outcome for recovery. Do you know research on that?

Dr. Stephen Grinstead  
Yeah, that's very true. Because a lot of times, there's the tough love people, the social model detoxes where people just, you know, grin and bear it. But the combination of some of these substances people are using, they really need to use medication assisted treatment ma T, only about a third of the people that need ma T, get it. And it's some people that get it shouldn't be getting it, it's not one size fits all. And here's a resource for you folks would be SAMSA put together what they call chip 84. And it was revised in 2018. And it was medication assisted treatment, and a big part of it talked about not just the three medications they authorized, but also the importance of the psychosocial interventions that need to be concurrently delivered within a tea. So yeah, people that have a better tapered detox, whatever you want to call it. It's the problem is that the insurance companies have sabotaged this, because they're always claiming medical necessity. And that they, we've got into a problem to where medical doctors and health care providers are now being driven by people that don't have medical juries or clinical juries, they're dictating terms of treatment. And that is just so wrong. Because people really sometimes up three to seven days is usually a good for a mild substance use disorder detox, some people need seven to 14, some people need up to 2131 41 days of taper are appropriate medication assisted treatment, paper transition, it's a transition. But they also need to be working on building their levels of functioning and quality of life and all four domains at the same time. So that eventually we take them off the medication assisted training wheels.

Dr. Regina Koepp  
As we were preparing for this, you had shared with me that to your point about who's dictating you know, treatment, and I think you were alluding to that insurance companies are dictating treatment. Longevity, like how much treatment is indicated how long that treatment can last. We're experiencing that with what my six year old right now for a treatment for asthma that anyway, so I'm I'm in the mix of it right now for Yeah, one of my own kids. And and as we were preparing you had shared with me a pretty astounding number that chronic pain caused the insurance company. I think this is back to your 2080 80 kind of principle just a minute ago that 20% of the population is using 80% of healthcare insurance. That's correct. Yeah. And you had shared with me a number of like direct costs and lost productivity. I think it was something like $500 billion or something.

Dr. Stephen Grinstead  
So in 2011, a report came out that talked about chronic pain was costing the insurance industry over a half $1,000,000,000,000.05 100 billion over $500 billion in direct cost and lost productivity. And that at the time was more that was being spent on heart disease, diabetes and cancer treatments combined. And then it just has continued to get worse, to the point to where, like I said 20% of the people were starting to utilize over 80% of the healthcare dollars. They weren't being treated wisely. They were being treated foolishly and a lot of people were suffering and dying because they weren't getting the type of levels of treatment they needed. And what we discovered was when you deliver this kind of concurrent, collaborative biopsychosocial spiritual approach, the outcomes are phenomenal. One of the biggest things that it's it's now becoming standard to be accredited, you have to be outcome data driven, right. But that's relatively new. But I've been encouraging people to do that since the late 90s. I, every time I went in and consulted help programs develop a chronic pain track, for example, says you need to have outcome measures you need to have outcome measures. So in our program, I developed and collaborated with some other psychologists and medical doctors come up with 13 Different pre pre post outcome measures. And so every single person that went through went before we delivered any treatment, we would assess them and get what their measures were anxiety, depression and pain, etc, PTSD, spirituality, family functioning, we the there was a whole level. And then it three weeks we did it again, we did it again at three weeks. So to help better determine whether our original treatment planning was on track or whether we needed to modify it. But we also did it as a way to show the patients how far they've already come in just three weeks, then we did it near the end of treatment, not at the end. But right near the end of treatment, we did it a final time. And that helped us develop their continuing care planning. We can show them okay, you started here, you got here, and now you're here. But you've got more to go. continuing progress, you just can't rest. So the metaphor I use for people is this healing process, recovery process, whatever you want to call it, is like walking up a down escalator and having a mistaken belief. And by stop, I'm going to stay in place. They stopped doing what got them better. And they don't even see that they're going down the inner saboteur is now in control.

Dr. Regina Koepp  
And and in a circle, a full circle moment because of what you shared about your own recovery process. When you were in that prior to going to grad school or going for your doctorate. Your supervisor had said you're in relapse, and you are skinny. Yeah, yeah. And you hadn't had a drink. And you were on that. You were not doing

Dr. Stephen Grinstead  
it was 10 years. I was 10 years and quality recovery. And I was in relapse. Yes, absolutely.

Dr. Regina Koepp  
Yeah. On that escalator going down.

Dr. Stephen Grinstead  
I was gone down and didn't even see it.

Dr. Regina Koepp  
Yeah. So back back to that full full, full circle point. You have done such a beautiful job, illustrating for us the bio psychosocial, spiritual model of understanding pain, substance use mental health conditions, how they all overlap, and how it requires a holistic treatment, not a one, one than one than one, not a fragmented treatment. Right. Winchell, not sequential Yeah, I'm so curious, because of that spiritual religious piece I can I myself was a skeptic, when I was going through grad school, I am much more open to the spiritual piece than I was ever before. And that's because I'm doing my own work to become more open personally. But I appreciate that you distinguish between religion and spirituality, Dr. Lisa Miller at Columbia, I think she has a spiritual and neuro psychology lab. So they actually look at the brain and spirituality and are doing kind of what you're talking about, but but also creating a foundational of research to support it as well. And that's helped me and my own skepticism to for other mental health providers who might be skeptical like me, who might be like, thinking, Well, I don't do spiritual counseling. How would I include this? Can you just talk a little bit about that?

Dr. Stephen Grinstead  
Well, first of all, there's a great resource on my website, I have an articles page, and one of the articles is the role of spirituality in chronic pain management. And it gives a good foundation of religion versus spirituality. What are the spiritual values, practices and principles people need to develop? Many people have these values and don't even label it as spiritual but their spiritual values. So the first thing is to build a new vocabulary, right? So that article, I don't have time to go in depth on it, but that would be a great free resource. All the articles and video blogs on my website are absolutely free.

Dr. Regina Koepp  
We'll link to that in the shownotes. Of course, you mentioned a couple of other resources that I just want to capture before we move forward. The SAMSA tip 84 Did I get that wrong? Okay, we can link to that. You also mentioned the alternatives to a for some folks with chronic pain. There was chronic pain anonymous chronic

Dr. Stephen Grinstead  
pain Anonymous is one of the biggies that was one every program I've helped developed I've asked them to make available on their campus, a chronic pain Anonymous meeting. We had one in our program ramped to, it's a great way to enhance the social component, because people now will be with a homogenous population, people with chronic pain. So, but were these pain patients go into an NA or an AAA meeting and they're on medication assisted treatment, they're being told you're not really in recovery, right? That's really stigmatizing. It's really stigmatizing. So they need to have their own pills Addicts Anonymous was started by a recovering physician, who knew the importance of an AAA and NA, by the way, have conference approved literature, that states some of our members need to be on appropriate medication for appropriate conditions prescribed by appropriate prescribers. And they're written by recovering physicians. But yet, when it gets down to meeting level, a lot of people say don't use nothing no matter what. And that in a lot of cases, that's good wisdom. But in some cases, it's a death sentence for someone with chronic pain and coexisting mental health. And then if you're if you're elderly, it gets even worse.

Dr. Regina Koepp  
Yes. So let's, let's transition there. So we were talking about that downward escalator. And we kind of have a good frame for how do we approach therapy, and we need those four quadrants. And we need to attend to them synergistically not in a one step approach. And now, you had, I think what's helpful in preparing for treatment and collaborative treatment is understanding some of the obstacles and barriers. And so what are some of the most common obstacles or barriers for positive treatment outcomes?

Dr. Stephen Grinstead  
Great, but And that's always a great question. Because when I do my trainings, my professional trainings on this, the number one primary obstacle to having good outcomes for people with chronic pain and coexisting disorders is our failure to identify and or treat coexisting disorders coexisting problems. That's number one. So it's, they're not being addressed, and that will sabotage the pain management. The other one is family system problems is another very, very big roadblock for a lot of people. But then guess what healthcare providers are also a big problem. Judge mental health care providers. I can't tell you how many people when they get referred to me, one of the questions asked, Why do you think you were sent to me? Because they don't believe me. They said, it can't be that bad. The MRI, the CAT scan says it can't be that bad. It's all in my head. And the stigma and shame and guilt remorse. You know, after I educate people, I said, you know, let's talk about that first day. You know, when they said it was all in your head, well guess what it really is. Because we interpret the pain signals, and then we assign meaning and values to it. And sometimes over time, that system, that processing system gets corrupted, the going in the thalamus, right? The fact of the pain signals go up there to get evaluated. We send messages, prefrontal cortex to the amygdala, limbic systems. So we have thinking and emotional responses to pain signals, and they get distorted or amplified, I call it the amplifier circuit. So that's, that's a big, that's another big obstacle is people are using their medication for psychological and emotional pain symptoms, not for the physiological ones. Yeah. And that's where the non pharmacological and been interventions are really important. They do not have non pharmacological interventions. The other big obstacle is, people being passive recipients, rather than active participants in their healing process. That's a big obstacle. So those are some of the major obstacles I've seen over the years and continue to see with people with chronic pain and coexisting disorders.

Dr. Regina Koepp  
Yeah, so the failure to identify and treat coexisting disorders that was the number one obstacle Yeah, family system problems. So

Dr. Stephen Grinstead  
there's a biggie well, either they get enabling or codependent or they get burnout and shaming, blaming and blaming the victim or they even leave they abandon, right. So that's the family. The health care providers are judgmental, and not listening, not listening to where the person's really coming from. Right. They're not hearing that. And a big other problem is using medication for psychological emotional reasons. And then another big one is People being passive recipients rather than active participants in their healing process. Right? Those are the biggies.

Dr. Regina Koepp  
Yes, I definitely have seen that. I worked in concert with primary care and the medical system for a long time treating older adults. And I recall, sometimes the person who has been referred would experience the referral as punishment. Yes, they can't help me in primary cares, or whatever the system is they're in. So they they're saying, you know, that I have to go to mental health care. But this is not a mental health problem, this is a physical health problem. And you know, and I am being punished for coming here. And, and the this, even if it would be very helpful to receive mental health care, and that bio, psychosocial, spiritual model, the delivery of the the message and bridging is, I have experienced a lot of harm in that process are patients and clients experiencing a lot of harm in that process?

Dr. Stephen Grinstead  
So Regina, one of the things I don't want to forget to mention, I said, failure to identify and treat or manage coexisting disorders. Well, let's list some of those. For people with chronic pain, I'll list some of the ones that I've seen that are most common. So one is people that have medication misuse, abuse, pseudo addiction, or addiction, that's a coexisting problem. If they're going in for chronic pain treatment that can sabotage it. If they're going in for mental health, or addiction, unresolved trauma is a really big one. Depression is the very common for most people living with chronic pain, anxiety disorders, sleep disorders, cognitive impairment, from living with pain, not from the medication, but from living with pain. And then another one that often gets overlooked is people using food to cope and settle for fuel, and they develop eating problems, eating disorder problems. So those are the most common coexisting disorders.

Dr. Regina Koepp  
That's very helpful. That's an excellent list for us to be mindful of. And we can see how they really overlap. Because disorders affect cognitive functioning, pain affects cognitive front, you know, all all of it really does overlap. So the synergistic approach is key. Yeah. Since our mission is to ensure that older adults have improved access to medic mental health care and reduce stigma for older adults related to mental health and substance use disorders. Will you share what some of the unique challenges are for older adults when it comes to effectively managing pain?

Dr. Stephen Grinstead  
Oh, yeah, well, one of the big ones is, as we age, we're not able to physically do some of the things that will help our pain condition. Because my premises flexibility and mobility are my best friends. That's why four to five days a week, I swim 30 to 50 minutes each time. And that's my major exercise modality, I also bike and walk. So as we age, though, you know, back before my injury, I was probably running eight to 10 miles a day and swimming a mile a day to prepare for my black belt test, my second degree black belt test. But I can't do that now. So And as I'm getting older, I'm finding that it's a little bit more challenging, getting up in the morning and try to take self talk myself out of going. And yet, you know, the benefit of that though, is Yesterday, we were getting ready to have a snow. So we still had a bunch of leaves out in the yard. And I wanted to get all those out. And because of my activity, pacing of keeping myself in physical good shape, I was able to do that without hurting myself. So as we age though, activity, pacing becomes crucial. So that's a big part, appropriate activity, pacing. Some people try to do too little other people try to do too much. So we have to set what are your goals for activities, and I have an assessment I developed for people, they rate themselves where they see themselves and then I want you to watch over the next week, I want you to set a goal for increasing and what a lot of the Type A personalities like me do is they they try to go for 20 30% improvement. I says no, no, we're not gonna go there. You know, 10%. Let's, let's keep it let's keep it low, start low, go slow. That's my motto. Start low, go slow. So having a good appropriate activity pacing plan in place. The next one is as we age is the way we metabolize different medications that's really crucial. And to realize that for most pain, flare ups, non pharmacological interventions are going to be much more helpful than taking oral medication. And a lot of people don't believe this. One of the things when I was consulting with pain clinics in Sacramento, when they had people that they had a policy that they were would not if people ran out of medication, they would not refill until their it was time to refill. And when people started habitually doing that, they would refer him to me for an assessment and treatment planning, and nine times out of 10. And I found out that what they were doing was when they were having pain flare ups, they take an extra dose of their pain meds, and that's all they were depending upon. So helping them see that that activity pacing, and I have another resource, I teach people as I give them a worksheet, it's developing a pain flare up plan, nonpharmacological, pain flare up plan. And in this plan, I describe what it's about and everything. And then there's a checklist of about 40 different interventions. And it says, Look, these are things that my patients have told me that's helped them with flare ups, I want you to pick four or five of these that you're going to add to your plan, and you're going to practice. And so learning these, and then when I would do the assessment with people that were running out of meds, says okay, so you, you took that for a flare up, how long before you started feeling less pain? Oh, 510 minutes. That told me right there, it wasn't the medication. That was the placebo effect. That was the expected placebo effect, because it takes anywhere from 45 to 75 minutes for oral pain medications to start being affected. And yet if they do something like a stem, you know, electro stem unit ice stretching, hydrotherapy, yoga, tai chi, they'll start getting relief in five to 10 months. So it's teaching, especially as we age, we need to find out what is age appropriate. What What can we do. We can't judge ourselves by what other people like if we go to a class or something, we can't judge ourselves by how other people are performing. No, we have to be working on us. We need to challenge improve our goals, right? Not compare ourselves to other people. And for elderly people. That's hard. And definitely there's been a lot of research on elderly, how they definitely change how they metabolize different medications as we age, it definitely changes. And then there's the problem of a lot of elderly people are on multiple medications. And there's that synergistic effect with those. So you know, we need to really be cognizant of that.

Dr. Regina Koepp  
Yeah, the medication interactions are so dangerous.

Dr. Stephen Grinstead  
And how many medications are the person really needs to be on? You know, I don't play doctor with people about that. But I want to collaborate, I always get releases sign. And I collaborate with their healthcare providers to try to find a way to improve their levels of function and quality of life without hurting them with the side effects. Yeah,

Dr. Regina Koepp  
I think most geriatricians would agree. That's a primary care provider who specializes with older adults for our listeners. But most geriatricians would agree that the bare minimum medications to meet the maximum effect, right, we don't write so many medications in a body.

Dr. Stephen Grinstead  
And let's let's introduce some bio, psychosocial spiritual tools instead. Right? That's right.

Dr. Regina Koepp  
And one of the great things about older adults, and I'm suspecting I don't specialize in, in substance use disorders with older adults, but older adults tend to have higher levels of resilience than younger populations. And so one of the sort of anti ageism techniques, like if we're really dedicated to having an anti ageist practice, is to sort of build on the resilience that the older adult is already bringing into our clinic rooms and therapy rooms,

Dr. Stephen Grinstead  
and all the wisdom they bring with their life experience. And we sometimes forget that that gets discounted in our culture,

Dr. Regina Koepp  
and that higher levels of self regulation and emotion, emotion regulation. Yeah, yeah. Yeah. Stephen, this has been really enlightening and helpful. I am, am curious. One. So you mentioned a book that you had written? And I mentioned that in the intro, can you share a little bit about that and share where people can do about you?

Dr. Stephen Grinstead  
Yeah, my website is www. Dr. Steve grinstead.com. Very simple, Dr. Steve grinstead.com. And on that site, I've got free articles, free video blogs, my publications, my training page to where people can get self paced digital trainings, or how they can work with me directly. I also there's on that same page as a way for people that want to do empowerment coaching with me, or healthcare professionals that want consultation or training, you know, individualize So, those are some of the things I offer through my website. Of course, I highlight my book, my latest book number 16. Thank you adversity for yet another test. body mind spirit approach for relieving chronic pain suffering is the subtitle. And that one was based on my whole years of experience plus those four years running that residential chronic pain program. And in that I composite and four of our pain patients, and demonstrated what their pre outcome measures were, what they did to get to their post outcome measures, which were sent the aggregate was 53% improvement, which is, you know, in the field, anything over 30% is significant, right? We had 53% for our aggregate. And some people were higher than that, of course, some people were lower than that. But that that's what the book walks through. And there's, like I say, there's a whole chapter for family and friends, because family and friends can sabotage effective recovery for not just for the chronic pain, but for substance use or mental health. So the family needs to have a parallel process. So what we did was we had a cyber educational program for the family members, and then a three day personal retreat, to where Dale writer, my family therapist, would spend three full days with them. And it always ended with an equine session with the family and the pain patients. And it was just amazing, some of the healing we got to see. And I'm still doing empowerment coaching with a few of them for their continuing care, because they need tuneups periodically. Sure. So

Dr. Regina Koepp  
quite well, we'll definitely link to, to your website and your book in the show notes. I'm, I'm curious for a private practice clinician who maybe has a 60 something year old individual come into their office with chronic pain over use of opioid meds, and, and mental health concerns. Where How would you encourage them to start? And what would you say that should be their their thought process?

Dr. Stephen Grinstead  
Okay, well, knowledge is power. That's my premise. But a little knowledge that x is worth more than all our head knowledge in the world that lays fallow, right. So that's why I put all the resources on my M on my website, they're free. There's also at the bottom of the articles page in the video blog page, there's an archive page for those. So if people want to educate themselves, you can tell by the titles of each of the articles what you're going to get. One of my latest one that's up there now is looking under the surface of chronic pain. What people usually see is pain behaviors, complaining suffering. But what they don't see is what's going on under the surface, the CO occurring coexisting problems. And the reason people get in trouble with medication, they don't see that that's all that's under the iceberg. All they see is the tip of the iceberg. And that's actually the visual I use with that article as an iceberg.

Dr. Regina Koepp  
Yeah. So clinician deepening her understanding or their understanding of the pain experience, that what you might be seeing in the clinic room is, is the tip of the iceberg to look deeper,

Dr. Stephen Grinstead  
you're just seeing the tip of the iceberg, you need to dive deeper, you need to do a deeper dive. And one of the most important things to do is to identify and manage the psychological emotional symptoms of the pain. And, you know, that's, that's something that an instrument I've developed. I started working on it in the late 80s. And I continued fine tuning it up. And I think it's the last version was finalized in 2019. But it's got 27 items of physical symptoms and 27 items, psychological emotional symptoms. And if people are interested in having a free copy of that they can email me my emails, Dr. grinstead@yahoo.com, because that's what I believe is really that's one of the things I do at every first session with people I want to help them differentiate between the physical and the psychological, emotional. I don't share the results of that until after I do some education about all about pain,

Dr. Regina Koepp  
I guess. So if people are interested, you can email Dr. Grinstead and get that measure. Well, Dr. Grinstead, thank you tremendously for this wealth of information and just a really enjoyable conversation that was easy to digest, and really validating of the human experience.

Dr. Stephen Grinstead  
Please stop the sequential treatment and use concurrent collaborative treatment with the patient being the captain of the team.

Dr. Regina Koepp  
Bravo. I think that's a perfect place to end. Thank you. Thank you so much.