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7 Articles in Volume 1, Issue #5
Accidentally Speaking
Breaking Down the Barriers of Pain: Part 5
Cancer Pain: Successful Management of Patients’ Fears
Emergency Medicine: Emergency Department Protocols
Magnets & Medicine
The Neural Plasticity Model of Fibromyalgia Theory, Assessment, and Treatment: Part 3
Thinking About Pain

Breaking Down the Barriers of Pain: Part 5

The final installment of this series reviews prescribing schedule II-III drugs: practical definitions and strategies

Drug Addiction

In pain management, the medical definition of addiction is less useful than the legal definition. In California and many other states, an addict is defined as a person who is breaking the law to obtain habit-forming medications. In the context of pain management, law breaking is not typically buying drugs on the street, prescription forging, or calling in prescriptions pretending to be the physician or office staff member. In California it is also illegal to obtain habit-forming medications from one physician without informing that physician that other physicians are also prescribing such medications. Clinical judgment is required in this latter situation. For example, a patient with multiple medical problems may see several physicians and obtain controlled substances from each without recognizing this is dangerous. On the other hand, a patient may obtain controlled substances from his or her primary physician and one or more specialty consultants as a means of increasing the total amount received beyond what any individual physician had intended or recommended. Before determining that such a patient has “crossed the line” the patient should be formally warned that this is unacceptable and that only one physician should manage the controlled substance, in consultation with the other physicians as appropriate. If the patient then continues to “doctor shop” after understanding this warning, then that patient has crossed the line and is properly considered an addict. There is one other meaning of addiction that occasionally arises — occasionally the patient him or herself will state that he or she is an addict or is addicted.

Once a patient is identified as an addict, he or she should be referred to a chemical dependency program and should not receive habit-forming medications except under the supervision of the chemical dependency unit. This is so even if the primary treating physician believes the patient has a legitimate medical condition causing pain in addition to the addiction. In this situation, after a chemical dependency evaluation has been performed, the chemical dependency specialist and the physician managing the underlying painful condition can consult with each other and set up a plan. The documentation of this consulting relationship should be carefully documented because this is the most frequent situation in which physicians get in trouble with their state boards — prescribing to “known addicts.” The same patient who is begging the physician for opiates today is the one who will state tomorrow, “The doctor kept giving me more even though he knew I was addicted.”

Drug Dependence

Drug dependence is used to describe patients who have an underlying documented condition causing pain, those obtaining habit-forming medications from their physicians for the purpose of relieving pain, and who are unable to obtain pain relief without habit-forming medications. It is legal, ethical, and appropriate to prescribe opiates or other habit-forming medications to such patient even on a chronic basis.

It is imperative nevertheless that physician records clearly document the underlying medical condition causing pain, alternative treatments or therapies that have or will be tried, and the quantities and intervals of prescribing. The second most common situation that gets physicians in trouble with medical boards is failure to document adequately. If the physician’s office authorizes pharmacy refills over the phone, it is imperative these refills be clearly documented in the chart.

Drug tolerance is best defined as the taking of higher and higher doses of habit forming medication, resulting in less and less pain relief.

Drug Tolerance

Drug tolerance is conveniently defined as the taking of higher and higher doses of habit-forming medication, resulting in less and less pain relief. Patients typically do not realize that when they develop a tolerance to one narcotic or benzodiazepine, they develop a tolerance to all medications in that class. They also tend to believe the reason they are having more pain is that their underlying conditions are getting worse, rather than the tolerance itself. One frequently hears pain-management physicians state that they have many pain patients who never developed tolerance. If one defines non-tolerance as a stable quantity that has not changed in more than a year, this is a rare occurrence.

If in initial history taking it is determined the patient is taking more than a few per day (a good rule of thumb is more than 20 per week or 100 per month) then a plan must be negotiated to avoid the inevitable “I ran out” desperate weekend emergency calls. The patient should be asked something like, “Would you like me to take over prescribing these medications for you.” If the patient is taking daily narcotics, then the pain-managing physician should take over the responsibility of prescribing. Therefore, if the patient says, “I don’t know,” it is best to say something like, “Well then let me go ahead and set up a plan so you’ll be sure to have what you need, and I’ll let your previous prescriber know.” If the patient says, “No, my other doctor will keep prescribing,” the other physician should be contacted to make sure it is what he or she wants, since often the reason for the referral is discomfort with the frequency or escalation of refills. This call will also ensure that only one physician is prescribing. If the patient wants the pain-managing physician to take over, set up an initial plan. Say something like, “So let’s see, it looks like you’re taking on average four a day which averages out to 28 per week or 56 per two weeks. Why don’t I call in 56 to your regular pharmacy with one refill in two weeks. Then, let’s meet again to see how this is going.”

If the patient sticks to this simple plan, the interval can be increased to, for example, 112 tablets every four weeks. Unfortunately, many patients will not be so reliable. The treating physician will often get phone calls requesting refills. He or she has the choice of spending just a few moments on the phone saying ‘yes’ to a request for a refill or spend many minutes listening to the patient explain why ‘no’ was the wrong answer. Faced with this, the physician frequently “caves-in” out of frustration or simple time constraints. A frequent trigger of the referral to a pain-management physician is when the primary physician gets fed up with the requests for refills. To deal with these concerns a comprehensive medication management program should be available.

Medication Management Program

A medication management program should have at least the following three components: 1) fixed interval dosing; 2) a plan for “running out early;” and 3) a long-term plan.

An individual in the clinic should be identified as the medication manager. This should not be the physician due to time-constraints and because the physician should be free to focus on the diagnostic and treatment plan, rather than be consumed with endless debates about the quantity of pain medications. The medication manager is responsible for keeping track of how much medication the patient is receiving and calling in the refills. The plan should document the quantity of medication per time interval, what will be done if the patient “runs out early,” and what the plan will be if the patient has or is developing tolerance. A useful plan for running out early is the “half-rule” by which the patient receives half the usual daily quantity until the next scheduled refill date. The problem of tolerance can be eliminated by non-daily use of the habit-forming medication. If the patient is not taking the medication every day, then he or she will obtain pain relief when taking it. To achieve non-daily use requires a taper plan, which should be very gradual, typically not more than a couple of tablets decrease by week. A faster taper, or “going cold turkey,” inevitably fails for patients with chronic pain. As an example, for the patient taking three to four Vicodin per day, this equates to 28 tablets per week. An initial agreement would be to call in 28 tablets on the same day of each week and agree to taper this quantity by two per week beginning one month after starting treatment. If the patient “runs out early,” half the usual quantity per day would be called in until the next scheduled refill date. (See Table 1 for a sample Medication Management form to help organize and document the plan.)


Most pain clinics in the United States are anesthesiology-based, with the predictable result that most pain treatment consists of anesthetics and analgesics, regardless of underlying diagnosis. These are often administered via invasive procedures. Anesthetics and analgesics are at best temporary palliation and at worst, carry the risk of complications, drug dependence, and chronic disability. The great majority of musculoskeletal and chronic pain conditions can be treated directly and specifically. The guidelines offered in this series of articles have outlined specific treatments for certain conditions, based on a source-of-pain approach to diagnosis, treatment, and management.

Last updated on: January 10, 2012
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