Physicians are often conflicted regarding prescription medications for pain, especially pain complicated by insomnia and anxiety. Concerns that patients may become addicted to medications, exacerbated by limited time available to get to know patients, can lead to underprescribing of needed medications, patient suffering, and needless surgery. At the other extreme, pressure to alleviate patients' distress can lead to overprescribing, needless side effects, and even addiction. These risks can be substantially reduced by forming a therapeutic alliance through careful interviews that are directed toward understanding a patient's potential for addiction. In a trusting alliance, supported by specialized consultation on an as-needed basis, the physician and patient can develop an individualized treatment plan.1 Furthermore, patients who are empowered to take responsibility for their choices will be more likely to avoid addiction, minimize side-effect impairments, and avoid unnecessary surgery regardless of whether medications are prescribed.
Reducing the risk of addiction to prescribed medication
Pain is a key sign of illness and is more likely than any other complaint to bring a patient to the doctor.2 Yet studies show that patients' concerns about pain are all too often at odds with those of their treating physicians.3,4 Patients describe how their pain affects them functionally and spiritually. In response, physicians use biomedical models to "solve" the pain. However, physicians sometimes worry that the patient may become addicted to prescription medications.
From 1992 to 2002, the number of prescriptions for controlled drugs increased by 150%. The number of Americans who abused controlled prescription drugs nearly doubled from 7.8 million to 15.1 million from 1992 to 2003; more Americans abuse prescribed drugs than abuse cocaine, hallucinogens, inhalants, and heroin combined. A 2004 survey of physicians showed that 59% blamed patients for prescription drug abuse. Patients can manipulate the system to obtain controlled prescription drugs by faking symptoms that are commonly treated with opioids, depressants, and stimulants; by visiting and obtaining prescriptions from many doctors; and by altering prescriptions.5
Much is at stake in this relationship. If patients cannot trust their physicians, their pain may be compounded by feelings of isolation and fear.1 Furthermore, if these differences cannot be negotiated, there is a greater chance that attempted treatment could lead to a poor result—both in terms of medical outcome and liability.
This article presents strategies that help physicians overcome misunderstandings with their patients and provides support to physicians in their journeys through the shoals of clinical uncertainty and medical liability.6 Instead of a formula, the goal is to provide a framework to help clinicians focus on structuring a beneficial relationship with their patients by integrating good care with complementary rather than unduly burdensome risk management.
Addiction: defining without disempowering
What is addiction? Its meaning has varied over time and in different settings (eg, clinical vs social). The adopted definition guides clinicians' and patients' treatment choices. For potentially addictive prescribed medications, a useful definition would state that addiction is the overuse of a drug leading to impairment in social function and judgment.
This definition does not disempower or stigmatize the patient; rather, it acknowledges that the patient has legitimate pain. This definition also allows physicians to broaden their thinking while they consider prescribing potentially addictive medication: first, do no harm; then, improve functioning; and finally, relieve suffering.
According to study data, empowering patients with choice when prescribing potentially addictive substances appears to limit the use of such drugs immediately following surgery. Compared with patients who were given as-needed doses by nursing staff, patients who were allowed to self-administer pain medication took the same amount or lessof the drug.7,8
Fixed-schedule administration to avoid pain breakthrough can be the most appropriate manner of pain treatment. However, on an outpatient basis, it requires mutual trust between physician and patient, as well as the ability for the patient to follow a fixed schedule. Thus, assessment of patient competency to form and maintain a therapeutic alliance and follow a fixed-dosage schedule is essential in pain management on an outpatient basis.
What types of medications raise the specter of addiction among prescribing physicians? Opiates, such as oxycodone and hydrocodone, as well as sedatives and antianxiety drugs, such as benzodiazepines and barbiturates, cause concern. These medications are prescribed for pain and for the sleep and anxiety problems that may accompany pain.9
How can legitimately prescribed medications get a patient into trouble? Functional MRI shows addiction as a change in the brain's reward pathway, which involves the ventral tegmental neurons that secrete dopamine in the nucleus accumbens, leading to compulsive drug seeking.10 However, addiction cannot be reduced simply to the notion of repetitive stimulation of a reward pathway.