Identifying Pain-Drug Abusers and Addicts
by Forest Tennant, MD, DrPH; Laura Herman, RN, NP; Leah Silliman, BS, RN; and Jeffrey Reinking, MD
 There is nothing more disheartening and disrupting to a pain
practitioner than a drug abuser or addict who manages to gain entry into the practice and
subsequently exhibits noticeable addictive or deviant behaviors.1-3 The
national drive to eliminate under-treatment of pain and relieve the suffering of thousands
of bed and house-bound pain patients has given the abuser and addict an opportunity to
enter many new and embryonic pain practices. To date, little was known about the profile
of abusers and addicts who prey upon pain practices.4-6 In contrast to the
heroin addict who is relatively easy to identify by criminal records, presence of needle
marks, and morphine in body fluids, most abusers and addicts who frequent pain practices
use oral opioids and may have few obvious characteristics to identify them.5-7
Fortunately, the movement to provide opioid treatment to legitimate, non-abusers in pain
has now matured enough to allow profiling of oral, opioid abusers and addicts so that some
guidance in spotting these individuals can be provided. To assist in preparation of this
article, the authors reviewed twenty patients in their practices who entered pain
treatment and later demonstrated deviant, addictive behaviors and had to be forcibly
discharged.
Drug Abuser and Addict Defined
There appears to be a general consensus on definitions utilized in the practice of pain
management.8,9 Fundamentally, a legitimate pain patient uses opioids and other
medications to relieve pain while abusers and addicts use the drugs for psychologic,
ill-defined reasons other than pain relief. Table 1 lists the definitions used by the
Federation of State Medical Boards which are similar to those used in a joint consensus
statement of the American Pain Society and the American Society of Addiction Medicine.8
Of special significance to pain practitioners is the definition of
“pseudo-addict” who is a patient who frequents emergency rooms and multiple
physicians to obtain additional pain relief medication, because their primary pain
practitioner is under-treating them.
The authors recommend the use of the term “addictive characteristics and
behaviors” because the pain practitioner needs a checklist or set of specific
behaviors and characteristics to help methodically identify the abuser or addict. These
behaviors are known to occur in abusers and addicts, and when enough deviant behaviors
occur, it is a signal to refer, discharge, or take other measures to control and/or
eliminate the behaviors.1,3,5,7 The authors recommend the use of an
“Addictive Characteristics and Behaviors Checklist”3 (see Table 2) which is
initiated when a patient enters treatment. As addictive characteristics or behaviors are
observed over time they can also be noted on the checklist.
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— Nov/Dec 2002
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