The psychological assessment of the chronic pain patient with a suspected substance use disorder

Abstract

Among the most difficult to manage and treat populations of chronic pain patients is the patient who presents with a current or past history of addiction to illicit substances, alcohol, or prescription drugs. Pain patients who are perceived to have addictive disorders are often undertreated. The unwarranted fear of addiction is a misunderstood concept in pain management that can lead to the undertreatment of pain. The increasingly accepted management of chronic nonmalignant pain with opioid therapy underscores the importance of understanding the nature of opioid addiction. Pain specialists always need to evaluate and distinguish between four different pharmacologic/behavioral occurrences: tolerance, dependence, addiction, and pseudoaddiction. As important as the psychological assessment of the chronic pain patient is in general, it takes on added significance with the patient who presents with a history of past or present substance abuse. Commonly used measures of psychological status include the Beck Depression Inventory, the Spielberger State-Trait Anxiety Inventory, and the Minnesota Multiphasic Personality Inventory. Observation, history, monitoring, and being aware of the “red flags” are very important in the specific assessment of the chronic pain patient with suspected abuse. Specific substance abuse/addiction measures that can be of help include the Drug Abuse Screening Test (DAST-20), CAGE-AID, and the Cyr-Wartman Screen. Pain specialists need to educate themselves about standards of care in addictive disease and substance abuse disorders as well as be knowledgeable about prescribing and practice laws in their state.