Demask the Patient Prone to Develop Illicit

When the physician has the suspicion of a possible abuse of prescription analgesics, he should gather information from multiple sources to validate patient responses or concerns of others. An unanticipated positive urine drug screen or worsening results are often indications that drug abuse is occurring [42]. However, contrary to belief, no behavior is absolutely predictive of aberrant drug use or addictive disease, so a differential diagnosis must be made. These behaviors may be appropriate responses to either under-relieved or well-relieved pain [36]. In the former, drug-seeking behaviors arise when a patient cannot obtain tolerable relief with the prescribed dose of analgesic and seeks alternate sources or increased doses of analgesic - pseudoaddiction [36, 3]. Alternatively, a patient receiving good pain relief may take steps to ensure adequate medication supply, as they fear not only reemergence of pain, but also the emergence of withdrawal symptoms [36]. Psychiatric factors, such as anxiety or depression, a personality disorder, or changes in cognitive state, such as mild encephalopathy due to the treatment regimen or their underlying psychiatric problems, may be responsible for the behaviors identified. Responses of family members and others in the patient's environment may also affect a patient's perception of their pain [5]. These behaviors may be the result of increasing pain due to disease progression, or development of a new medical condition. Non-restorative sleep has also been associated with worsening pain [43]. Criminal activity - diverting the medications to the "street" - may also be an explanation for these behaviors. Although none is pathognomonic, the following behavior patterns could indicate an addiction:

1. Pseudoaddiction

2. Psychiatric diagnosis with a. Depression b. Personality disorder, and/or c. Anxiety

On the other hand there are other traits, which might mislead the supposition of an addiction:

1. Mild encephalopathy

2. Social stressors

3. Other medical diagnosis

4. Inadequate instruction by healthcare provider

5. Non-restorative sleep

6. Criminal activity

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