As we begin to gain an understanding of the prevalence of substance-use disorders within the chronic pain population, it has become clear that no one behavior is pathognomonic of addiction. With this in mind, the importance of carefully inquiring into drug and alcohol histories in all patients becomes evident. This information is vital to any clinician treating complex medical and psychological problems. Alcoholism, for example, is a disease that intrudes into many aspects of the care of affected patients seeking medical treatment. Unresponsive hypertension, intractable mood disorders, difficult interpersonal relations, and poor sleep are all part of the life of an untreated alcoholic. While the use of potent medications including opioids in such cases is likely to be more complicated than in a similar patient who is not afflicted with this disorder, the need for the treating health-care professional to explore issues related to drugs and alcohol is not because of a choice to prescribe any particular medication. It is simply because an undiagnosed substance-use disorder, when it exists, can make even routine health care difficult.
Surprisingly, some clinicians struggle with the idea of taking a drug and alcohol history in all patients. Even asking about drug and alcohol misuse is seen as minimizing or dismissing the patients' complaints of pain. In no other area of medicine would such an attitude exist. The fact is that alcohol and drug addiction is present in virtually all areas of medicine, without particular respect for socioeconomic status, race, age, or sex. While the nature and distribution of these problems vary, it is unwise to limit one's inquiry into substance use based on classical societal stereotypes.
Since it is difficult to determine in advance, with any degree of certainty, who will become a problematic patient, there should be a uniform and respectful way of assessing all patients within the health-care setting. Of course, for those patients who are at increased risk for substance-use disorders, this basic level of inquiry can be expanded.
While the majority of pain patients who present to family practice offices are unlikely to be complicated by substance-use disorders, it may be useful to triage these patients into three groups, according to risk and recommended management strategies (27).
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