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.
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.
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
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.
Elements of the best patient care overlap with our recommendations for physician self-protection. There are some patients who present with no risk factors but nevertheless become addicted to appropriately prescribed pain medications. Thus, a comprehensive initial interview, an ongoing therapeutic alliance, and nonjudgmental but careful monitoring of medication use are essential. The patient should have the opportunity to make an informed choice of treatment options, and the process leading to this choice should be documented. The potential adverse outcomes stemming from medication abuse should be discussed with the patient.
The physician should note the conversation on the patient's chart and offer the patient a written summary of their joint decision. Pain and its accompanying anxiety can lead to dissociative states, which may prevent the patient from accurately remembering conversations with a provider. Patients may have trouble concentrating because of their pain and anxiety; occasionally, the level of impairment can rise to clinical dissociation and even frank amnesia.
In the course of developing a relationship with a patient, other issues may arise. Some physicians may feel compelled to prescribe benzodiazepines, for instance, without adequate knowledge of the patient, and may even use drugs as substitutes for listening to and talking with the patient. Physicians should do their best to monitor their feelings toward difficult patients9,21; they can improve their ability to treat patients by seeking further training in addictive disorders. It may also prove helpful to consult with clinicians who have such specialized training or experience, including addiction or pain specialists, or to refer patients for consultation with such experts.
Physicians can ease the potential misunderstanding that patients may have about referrals by educating patients about the complex nature of the problem and by reassuring them that the treating physician will continue to be involved in their care.22 However, the physician must also retain the right to refuse indefinite treatment to a patient who will not accept this process as deemed necessary for proper prescribing.12 An implicit benefit of consultation is that it provides a healthy model for seeking help and shows how a primary treating clinician can seek help without humiliation.
Alternatives to potentially addictive drugs
There are a number of alternatives to benzodiazepines for the treatment of anxiety23 as well as medications other than opiates for the treatment of chronic pain (Table 2).24-26 This is not to say that benzodiazepines and opiates are the most effective treatment options; for example, there are many common pain conditions for which nonopioids may be more effective. Moreover, benzodiazepines are generally contraindicated for patients with chronic pain since their extended use can lower pain threshold. But if a physician decides that a potentially addictive drug is the best choice, the physician needs to explore alternatives with the patient and document that other nonaddictive therapies are less likely to be effective or have greater risks than the potentially addictive drug.
Informed consent and assessment of a patient's capacity to engage in an informed-consent process need to be implemented in tandem. This is true regardless of the intervention, whether medication is being prescribed or surgery is being recommended. Pro forma informed consent is no substitute for the informed-consent process.
In addition, physicians need to be careful that they do not withhold conservative yet comprehensive pain management from patients; and physicians should not make patients vulnerable to the promises of the quick fixes of surgical solutions before conservative alternatives have been implemented (see Table 2).27-29
Those of us willing to treat patients who have pain need to find the time to explore the patient's history and provide options, to listen carefully to patients, and to help patients individualize their treatment plans (Table 3). By attending to the therapeutic alliance with the patient, clinicians will not fall into the trap of automatic prescription or automatic medication avoidance and patients will not be subjected to needless suffering, heightened risk of addiction, or the complications of unnecessary surgery.30