Walking the Tightrope: Chronic Pain and Substance Abuse

Pain management is a high priority in health care, and pain is a common reason for visits to primary care providers. The most challenging patients to manage are chronic pain patients with substance abuse issues. This article reviews 2 models that assist with making difficult decisions about when to prescribe opiates for chronic nonmalignant pain. A clear understanding of the terms addiction, tolerance, dependence, and pseudo-addiction is necessary. Appropriate precautions include assessing for risks of substance abuse; continual assessment of pain level, daily functioning, and aberrant behaviors; and complete documentation of communication of risks, benefits, and expectations with the patient.