A helpful model addresses a triad of factors in understanding addiction. The first includes a patient's biology (brain chemistry and genetics). The second involves "self-medicating," in which patients use medications in response to feeling helpless about emotions generated in interpersonal situations or to treat a psychiatric disorder. The third aspect notes that addictive drugs may serve as a "companion," substituting for meaningful relationships with other people.11 A physician may feel trapped by this combination of factors when the patient behaves in a subtly complex way and attempts to get his or her feeling of helplessness understood by the physician. As a result, the physician may feel compelled to issue a prescription as the only way to immediately disengage from an uncomfortable encounter. Unfortunately, this same process is likely to recur at the next visit.12
This point of view can initially seem to complicate our task: We would aim to treat all patients for pain, even those with histories of addictive behaviors. But this view gives us more tools, too. Helping a patient understand his individual history and what drug use means to him may allow the physician to form a trusting relationship with the patient, thereby helping him find the personal strength to work through vulnerabilities and disorders in a healthy way.13,14
Existing studies leave gaps in our ability to predict future addiction potential—data cannot predict which group of patients with no addictive or substance abuse history will become addicted or abuse opioids. Nonetheless, in some instances, addiction by prescription is both clinically foreseeable and preventable. This underscores the need for a thorough therapeutic alliance and a comprehensive assessment of patient competency before opioid prescription.
How to make the most of limited patient time
Even with limited time, a physician can make it a priority to take a thorough health and social history of a new patient who seeks or apparently needs a potentially addictive drug. Physicians must also be aware that the reliability of this history may be undermined by the lack of time allowed for the development of trust, as well as by the pain and possible stigma experienced by the patient. Therefore, the physician may need to use a variety of methods to obtain information and build trust, from the use of previsit questionnaires to developing indirect interview methods that support a patient's self-esteem and self-control, even in the presence of painful self-disclosure.15
In some cases, a history will not be reliable because a patient is malingering or being deliberately deceptive. In such circumstances, physicians should look for consistencies and inconsistencies in reports and the reporting of symptoms that do not fit into any meaningful diagnostic category; they should also attempt to understand where a patient is getting all of his medical treatment.
Table 1 presents the factors that are associated with an increased risk of addiction. Situations in which complaints of chronic pain are motivated by primary gain (eg, staged automobile accidents) or secondary gain (eg, cases of complex family psychodynamics, where a lack of visible suffering leads to a lack of attention) should raise concerns.16 Other factors that should signal concern include a current addictive disorder,17,18 a current anxiety or mood disorder,19 a family history of addiction,16 and childhood physical or sexual abuse.20
Risk factors for addiction to medication
Chronic pain is often a presenting complaint of unremitting depression.19 The Hamilton Rating Scale for Depression (HAM-D) or Beck Depression Inventory can help uncover mood disorders that may present as somatization, conversion, or part of the patient's baseline personality. These depression-scale instruments need to be used with caution and are not substitutes for a thorough clinical interview. Some of these instruments, especially the HAM-D, contain questions on somatic complaints, so patients with pain and medical illness can receive scores indicating marked depression just by endorsing these items. On the other hand, unrecognized and untreated depression-compounding pain symptoms may drive patients both to overuse prescribed pain medication and to seek unnecessary surgery and grow impatient with conservative measures.