The Pain Patient With A Suspected Substance Abuse Problem

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Among the most difficult to manage and treat populations of chronic pain patients are the patients who present with a current or past history of addiction to illicit sub stances, alcohol, or prescription drugs.43 Pain patients who are perceived to have addictive disorders are often undertreated. The unwarranted fear of addiction is a misunderstood concept in pain management that can lead to the undertreatment of pain. The increasingly accepted management of chronic nonmalignant pain with opioid therapy underscores the importance of understanding the nature of opioid addiction. As important as the psychological assessment of the chronic pain patient is in gen eral, it takes on added significance with the patient who presents with a history of past or present substance abuse.

Observation, history, monitoring, and being aware of the

"red flags'' are very important in the specific assessment of the chronic pain patient with suspected abuse.

Specific substance abuse/addiction measures that can be of help include the Drug Abuse Screening Test (DAST-20),44 CAGE-AID,45 and the Cyr-Wartman Screen.46 Passik et al.47 has recently developed the Pain Assessment and Documentation Tool (PADT),47 a 41-item tool that assesses four domains: analgesia, activities of daily living, adverse events, and potential aberrant drug-related behavior. The PADT has been formatted for use as a chart note designed to assist clinicians in assessing and documenting these for main outcome domains during long-term opioid use.

A new score by Belgrade et al.48 [V] attempts to predict risk and outcome of chronic opioid prescribing. This score is derived from four factors:

1. diagnosis;

2. intractability;

3. risk (psychological, chemical health, reliability, social support);

4. efficacy.

This score was developed at the request of the Minnesota Board of Medical Practice (www.state.mn.us/portal/mn/ jsp/home.do?agency=BMP), which has information about the management of chronic pain and prescribing rules.

Pain specialists need to educate themselves about standards of care in addictive disease and substance abuse disorders, as well as be knowledgeable about prescribing and practice laws.

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