Identifying Pain-Drug Abusers and Addicts
There is nothing more disheartening and disrupting to a pain practitioner than a drug abuser or addict who manages to gain entry into the practice and subsequently exhibits noticeable addictive or deviant behaviors.1-3 The national drive to eliminate under-treatment of pain and relieve the suffering of thousands of bed and house-bound pain patients has given the abuser and addict an opportunity to enter many new and embryonic pain practices. To date, little was known about the profile of abusers and addicts who prey upon pain practices.4-6 In contrast to the heroin addict who is relatively easy to identify by criminal records, presence of needle marks, and morphine in body fluids, most abusers and addicts who frequent pain practices use oral opioids and may have few obvious characteristics to identify them.5-7 Fortunately, the movement to provide opioid treatment to legitimate, non-abusers in pain has now matured enough to allow profiling of oral, opioid abusers and addicts so that some guidance in spotting these individuals can be provided. To assist in preparation of this article, the authors reviewed twenty patients in their practices who entered pain treatment and later demonstrated deviant, addictive behaviors and had to be forcibly discharged.
Drug Abuser and Addict Defined
There appears to be a general consensus on definitions utilized in the practice of pain management.8,9 Fundamentally, a legitimate pain patient uses opioids and other medications to relieve pain while abusers and addicts use the drugs for psychologic, ill-defined reasons other than pain relief. Table 1 lists the definitions used by the Federation of State Medical Boards which are similar to those used in a joint consensus statement of the American Pain Society and the American Society of Addiction Medicine.8 Of special significance to pain practitioners is the definition of “pseudo-addict” who is a patient who frequents emergency rooms and multiple physicians to obtain additional pain relief medication, because their primary pain practitioner is under-treating them.
Substance Abuse: Substance abuse is the use of any substances(s) for non-therapeutic purposes or use of medication for purposes other than those for which it is prescribed.
Pseudo-Addiction: Pattern of drug-seeking behavior of pain patients who are receiving inadequate pain management that can be mistaken for addiction.
Addiction: Addiction is a neurobehavioral syndrome with genetic and environmental influences that results in psychological dependence on the use of substances for their psychic effects and is characterized by compulsive use despite harm. Addiction may also be referred to by terms such as “drug dependence” and psychological dependence”. Physical dependence and tolerance are normal physiological consequences of extended opioid therapy for pain and should not be considered addiction.
Physical Dependence: Physical dependence on a controlled substance is a physiologic state of neuro-adaptation which is characterized by the emergence of a withdrawal syndrome if drug use is stopped or decreased abruptly, or an antagonist is administered. Physical dependence is an expected result of opioid use. Physical dependence, by itself, does not equate with addiction.
The authors recommend the use of the term “addictive characteristics and behaviors” because the pain practitioner needs a checklist or set of specific behaviors and characteristics to help methodically identify the abuser or addict. These behaviors are known to occur in abusers and addicts, and when enough deviant behaviors occur, it is a signal to refer, discharge, or take other measures to control and/or eliminate the behaviors.1,3,5,7 The authors recommend the use of an “Addictive Characteristics and Behaviors Checklist”3 (see Table 2) which is initiated when a patient enters treatment. As addictive characteristics or behaviors are observed over time they can also be noted on the checklist.
It is highly recommended that every pain practitioner establish a set of criteria for admission that will disqualify many abusers and addicts.
Identifying Abusers and Addicts Prior to Treatment
Clinical experience shows that some abusers and addicts can be identified and rejected prior to admission to pain treatment.1,5 Some others may be suspected but admitted to pain treatment to be observed for characteristics and addictive behaviors that will identify them later and render them unsuitable for the pain practitioner’s practice. It is highly recommended that every pain practitioner establish a set of criteria for admission that will disqualify many abusers and addicts. For example, the authors’ practice requires patients to be referred from a physician, be accompanied by a family member, and produce previous medical records that document prior pain treatment and outcomes of the treatment. Typically abusers and addicts, individuals seeking pain-relieving drugs only for abuse purposes, simply “drop in” the practitioner’s office without an appointment, referral, family member, or previous medical records (see Tables 3 and 4).