A TreATmenT ImprovemenT proTocol

Managing Chronic Pain in 

Adults With or in Recovery 

From Substance Use Disorders

TIP 54
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment

1 Choke Cherry Road 

Rockville, MD 20857

A TreATmenT ImprovemenT proTocol

Managing Chronic Pain in 

Adults With or in Recovery 

From Substance Use Disorders 

TIP 54 
ii 

Acknowledgments 

This publication was prepared for the Substance Abuse and Mental Health Services 

Administration (SAMHSA) by the Knowledge Application Program (KAP), a Joint Venture 

of The CDM Group, Inc., and JBS International, Inc., under contract numbers 270-04-7049 

and 270-09-0307, with SAMHSA, U.S. Department of Health and Human Services (HHS).

Christina Currier served as the Government Project Officer. 

Disclaimer 

The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views, opinions, or policies of SAMHSA or HHS. 

public Domain notice 

All materials appearing in this volume except those taken directly from copyrighted sources are 

in the public domain and may be reproduced or copied without permission from SAMHSA 

or the authors. Citation of the source is appreciated. However, this publication may not be 

reproduced or distributed for a fee without the specific, written authorization of the Office of 

Communications, SAMHSA, HHS. 

electronic Access and copies of publication 

This publication may be ordered from SAMHSA’s Publications Ordering Web page at 

http://www.store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 

(1-877-726-4727) (English and Español). The document can be downloaded from the KAP 

Web site at http://www.kap.samhsa.gov. 

recommended citation 

Substance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults 

With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) 

Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 2011. 

originating office 

Quality Improvement and Workforce Development Branch, Division of Services Improvement,

Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services 

Administration, 1 Choke Cherry Road, Rockville, MD 20857. 

HHS Publication No. (SMA) 12-4671

Printed 2012 
iii 

contents 

Consensus Panel ............................................................ vii
 

What Is a TIP? .............................................................. ix
 

TIP Format ................................................................. ix
 

TIP Development Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
 

Foreword ................................................................... xi
 

1—Introduction ............................................................. 1
 

Chronic Pain Impact .......................................................... 1
 

Audience.................................................................... 2
 

Purpose..................................................................... 2
 

Definitions ................................................................. 2
 

Pain and Addiction Basics ...................................................... 4
 

Neurobiology of Pain .......................................................... 4
 

Chronic Pain ................................................................ 6
 

Pain’s Effect on Health ........................................................ 7
 

Neurobiology of Addiction ..................................................... 7
 

Risk Factors for Addiction ..................................................... 8
 

Cross-Addiction.............................................................. 9
 

The Cycle of Chronic Pain and Addiction ......................................... 9
 

Summary of TIP ............................................................ 11
 

Key Points ................................................................. 11
 

2—Patient Assessment ....................................................... 13
 

Elements of Assessment....................................................... 13
 

Assessment Tools ............................................................ 13
 

Assessing Pain and Function ................................................... 15
 

Screening for Substance Use Disorders ........................................... 20
 

Referring for Further Assessment ............................................... 23
 

Psychiatric Comorbidities ..................................................... 24
 

Assessing Ability To Cope With Chronic Pain .................................... 27
 

Evaluating Risk of Developing Problematic Opioid Use ............................. 28
 

Ongoing Assessment ......................................................... 30
 

Treatment Setting ........................................................... 31
 

Key Points ................................................................. 32
 
iv 

3—Chronic Pain Management ................................................ 33
 

Overview of Pain Management ................................................ 33
 

The Treatment Team ......................................................... 33
 

Treating Patients in Recovery .................................................. 35
 

Nonpharmacological Treatments ................................................ 37
 

Treating Psychiatric Comorbidities .............................................. 39
 

Opioid Therapy ............................................................. 40
 

Treating Patients in Medication-Assisted Recovery ................................. 43
 

Tolerance and Hyperalgesia ................................................... 44
 

Treating Pain in Patients Who Have Active Addiction............................... 45
 

Acute Pain Episodes.......................................................... 46
 

Assessing Treatment Outcomes ................................................. 46
 

Key Points ................................................................. 48
 

4—Managing Addiction Risk in Patients Treated With Opioids ..................... 49
 

Promoting Adherence ........................................................ 49
 

Urine Drug Testing .......................................................... 51
 

Inclusion of Family, Friends, and Others ......................................... 54
 

Nonadherence .............................................................. 54
 

Tools To Assess Aberrant Drug-Related Behaviors.................................. 56
 

Documenting Care........................................................... 58
 

Managing Difficult Conversations............................................... 59
 

Workplace Safety ............................................................ 59
 

Discontinuation of Opioid Therapy ............................................. 61
 

Key Points ................................................................. 63
 

5—Patient Education and Treatment Agreements................................. 65
 

The Value of Patient Education................................................. 65
 

Providing Effective Education .................................................. 66
 

The Internet as a Source of Patient Education ..................................... 68
 

Education Content........................................................... 69
 

Opioid Information .......................................................... 69
 

Methadone Maintenance Therapy Information..................................... 71
 

Treatment Agreements ....................................................... 71
 

Key Points ................................................................. 74
 
v 

Contents 

Appendix A—Bibliography .................................................... 75
 

Appendix B—Assessment Tools and Resources .................................... 87
 

Appendix C—CFR Sample Consent Form and List of Personal Identifiers .............. 91
 

Appendix D—Resources for Finding Complementary and Alternative Therapy Practitioners. 93
 

Appendix E—Field Reviewers.................................................. 95
 

Appendix F—Acknowledgments................................................ 97
 

Index...................................................................... 99
 

exhibits 

Exhibit 1-1 Statistics on Substance Use and Chronic Pain in the United States ............ 1
 

....................................................... 6


Exhibit 1-2 The Pain Pathways .................................................. 5


Exhibit 1-3 Pain Types. .

Exhibit 2-1 Elements of a Comprehensive Patient Assessment ........................ 14


Exhibit 2-2 Tools To Assess Pain Level........................................... 17
 

Exhibit 2-3 Tools To Assess Several Dimensions of Pain ............................. 18
 

Exhibit 2-4 Tools To Assess Pain Interference With Life 


 Activities and Functional Capacities........................................... 19


Exhibit 2-5 Items To Include in Substance Use Assessment........................... 20
 

Exhibit 2-6 DSM-IV-TR Criteria for Substance Abuse 


 and Substance Dependence ................................................. 21
 

Exhibit 2-7 Steps Following Substance Abuse Assessment. . .......................... 22


Exhibit 2-8 Tools To Screen for Substance Use Disorders ............................ 22
 

Exhibit 2-9 Elements of Screening, Brief Intervention, and Referral to Treatment ......... 23


Exhibit 2-10 Federal Protection of Patient Health Information . . ...................... 24
 

Exhibit 2-11 Tools To Assess Emotional Distress, Anxiety,


 Pain-Related Fear, and Depression............................................ 26


Exhibit 2-12 Tools To Assess Coping ... ......................................... 27


Exhibit 2-13 Risk of Patient’s Developing Problematic Opioid Use..................... 28


Exhibit 2-14 SOAPP–R Questions ............................................. 29
 

Exhibit 2-15 ORT ........................................................... 30
 

Exhibit 2-16 Elements To Document During Patient Visits .......................... 31
 

Exhibit 3-1 Algorithm for Managing Chronic Pain in Patients With SUD. . ............. 34


Exhibit 3-2 Summary of Non-Opioid Analgesics .................................. 35
 

Exhibit 3-3 Talking With Patients About Complementary 


 and Alternative Medicine ................................................... 38
 

Exhibit 3-4 Steps To Take If Opioid Therapy Is Indicated............................ 41


Exhibit 3-5 Methadone Titration ............................................... 42
 

Exhibit 3-6 Opioid Rotation ................................................... 45


Exhibit 3-7 Treating Patients Who Have Sickle Cell Disease .. ....................... 47
 

Exhibit 3-8 Treating Patients Who Have HIV/AIDS ............................... 47
 
vi 

Exhibit 4-1 Ten Steps of Universal Precautions..................................... 49


Exhibit 4-2 Issuance of Multiple Prescriptions for Schedule II 


 Controlled Substances ..................................................... 50
 

............................... 52


Exhibit 4-3 Talking With Patients About Medication Supply ......................... 51


Exhibit 4-4 POC Testing Benefits and Limitations ..

Exhibit 4-5 Talking With Patients About Aberrant 


 Urine Drug Testing Results ................................................. 53


Exhibit 4-6 Talking With Patients Who Are Resistant 


 to Urine Drug Testing ..................................................... 55
 

Exhibit 4-7 Pseudoaddiction ................................................... 56
 

Exhibit 4-8 Addiction Behaviors Checklist........................................ 57
 

Exhibit 4-9 Current Opioid Misuse Measure ...................................... 58


Exhibit 4-10 Resources for Information on Drug Use Trends . ........................ 60
 

Exhibit 4-11 Exit Strategy..................................................... 62


Exhibit 5-1 Selected Online Sources of Information on Health Literacy ................. 66


Exhibit 5-2 Talking With Patients Following a Teach-Back Approach .................. 67


Exhibit 5-3 Reliable Web Sites With Information 


 on Chronic Pain and Pain Treatment.......................................... 68
 

Exhibit 5-4 Reliable Web Sites With Information 


 on Substance Use Disorders ................................................. 69
 

Exhibit 5-5 Talking With Patients Before Surgery .................................. 70


Exhibit 5-6 Sample Pain Treatment Agreement .................................... 73


Exhibit B-1 Tools To Assess Pain Level .......................................... 87
 

Exhibit B-2 Tools To Assess Several Dimensions of Pain ............................. 87
 

Exhibit B-3 Tools To Assess Pain Interference and Functional Capacities ................ 87


Exhibit B-4 Tools To Screen for Substance Use Disorder. . ........................... 88
 

Exhibit B-5 Tools To Assess Emotional Distress, Anxiety,


 Pain-Related Fear, and Depression............................................ 88


Exhibit B-6 Tools To Assess Coping . . ........................................... 89
 
vii 

consensus panel
 

chair 

Margaret Kotz, D.O.

Professor, Psychiatry and Anesthesiology

Case Western Reserve University School

of Medicine 

Director, Addiction Recovery Services

Case Medical Center 

University Hospitals of Cleveland

Cleveland, Ohio 

panelists 

Michael Clark, M.D., M.P.H.

Associate Professor 

Department of Psychiatry and Behavioral 

Sciences 

Johns Hopkins University School of Medicine

Baltimore, Maryland 

Peggy Compton, RN, Ph.D., FAAN

Associate Professor 

UCLA School of Nursing 

Los Angeles, California 

Edward Covington, M.D.

Director, Neurological Center for Pain

Neurological Institute

Cleveland Clinic Foundation 

Cleveland, Ohio 

Carmen R. Green, M.D.

Associate Professor, Anesthesiology

Associate Professor, Health Management and 

Policy

Director, Health Disparities Research 

Michigan Institute for Clinical and Health 

Research 

Director, Pain Medicine Research

University of Michigan

Ann Arbor, Michigan 

Joseph O. Merrill, M.D., M.P.H.

Clinical Assistant Professor of Medicine 

University of Washington

Harborview Medical Center 

Seattle, Washington 

Steven D. Passik, Ph.D.

Associate Attending Psychologist

Department of Psychiatry and Behavioral 

Sciences 

Memorial Sloan Kettering Cancer Center

Associate Professor of Psychiatry 

Weill Medical College of Cornell 

University Medical Center

New York, New York 

Charles A. Simpson, D.C., DABCO

Vice President, Medical Director

The CHP Group

Beaverton, Oregon 

ix 

What Is a TIp? 

Treatment Improvement Protocols (TIPs) are developed by the Center for Substance Abuse 

Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration 

(SAMHSA) within the U.S. Department of Health and Human Services (HHS). Each TIP 

involves the development of topic-specific best-practice guidelines for the prevention and treatment of substance use and mental disorders. TIPs draw on the experience and knowledge of 

clinical, research, and administrative experts of various forms of treatment and prevention. TIPs 

are distributed to facilities and individuals across the country. Published TIPs can be accessed via 

the Internet at http://www.kap.samhsa.gov. 

Although each consensus-based TIP strives to include an evidence base for the practices it 

recommends, SAMHSA recognizes that behavioral health is continually evolving, and research 

frequently lags behind the innovations pioneered in the field. A major goal of each TIP is 

to convey “front-line” information quickly but responsibly. If research supports a particular 

approach, citations are provided. 

TIp Format 

Most of the research that forms the evidence basis for a particular TIP is not provided in the 

TIP itself. Rather, those who wish to review the supporting research can access a bibliography 

and literature review via the Internet at http://www.kap.samhsa.gov. These online resources 

include links to abstracts; the online bibliography and literature review are updated every 6 

months for 5 years after publication of the TIP. 

TIPs focus on how-to information. Coverage of topics is limited to what the audience needs to 

understand and use to improve treatment outcomes. TIPs increasingly use quick-reference tools 

such as tables and lists in lieu of extensive text discussion, making the information more readily 

accessible and useful for treatment providers. 

TIp Development process 

TIP topics are based on the current needs of behavioral healthcare professionals and other 

medical care practitioners for information and guidance. After selecting a topic, SAMHSA 

invites staff members from Federal agencies and national organizations to be members of a 

resource panel that reviews an initial draft prospectus and outline and recommends specific 

areas of focus as well as resources that should be considered in developing the content for the 

TIP. These recommendations are communicated to a consensus panel composed of experts on 
x 

the topic who have been nominated by their peers. In partnership with Knowledge Application 

Program writers, consensus panel members participate in creating a draft document and then 

meet to review and discuss the draft. The information and recommendations on which they 

reach consensus form the foundation of the TIP. The panel Chair ensures that the guidelines 

mirror the results of the group’s collaboration. 

A diverse group of experts closely reviews the draft document. Once the changes recommended 

by these field reviewers have been incorporated, the TIP is prepared for publication, in print and 

online. 
xi 

Foreword
 

The Treatment Improvement Protocol (TIP) series fulfills the Substance Abuse and Mental 

Health Services Administration’s (SAMHSA’s) mission to improve prevention and treatment 

of substance use and mental disorders by providing best practices guidance to clinicians, program 

administrators, and payers. TIPs are the result of careful consideration of all relevant clinical and 

health services research findings, demonstration experience, and implementation requirements.

A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best 

practices. This panel’s work is then reviewed and critiqued by field reviewers. 

The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly 

participatory process have helped bridge the gap between the promise of research and the needs 

of practicing clinicians and administrators to serve, in the most scientifically sound and effective 

ways, people in need of behavioral health services. We are grateful to all who have joined with us 

to contribute to advances in the behavioral health field. 

Pamela S. Hyde, J.D.

Administrator 

Substance Abuse and Mental Health Services Administration 

Dr. H. Westley Clark, M.D.,

J.D., M.P.H., CAS, FASAM

Director 

Center for Substance Abuse 

Treatment 

Substance Abuse and 

Mental Health Services 

Administration 

Francis M. Harding

Director 

Center for Substance Abuse 

Prevention 

Substance Abuse and 

Mental Health Services 

Administration 

A. Kathryn Power, M.Ed.

Director 

Center for Mental Health 

Services 

Substance Abuse and 

Mental Health Services 

Administration 

In This Chapter

1 

Introduction 1 

In ThIs chApTer 

•	Chronic Pain Impact 

•	Audience 

•	Purpose 

•	Definitions 

•	Pain and Addiction 

Basics 

•	Summary of TIP 

•	Key Points 

chronic pain Impact 

Chronic noncancer pain (CNCP) is common in the general population

as well as in people who have a substance use disorder (SUD) (Exhibit

1-1). Chronic pain is not harmless; it has physiological, social, and

psychological dimensions that can seriously harm health, functioning,

and well-being. As a multidimensional condition with both objective

and subjective aspects, CNCP is difficult to assess and treat. Although

CNCP can be managed, it usually cannot be completely eliminated.

When patients with CNCP have comorbid SUD or are recovering

from SUD, a complex condition becomes even more difficult to 

manage. 

exhibit 1-1 statistics on substance Use and chronic 

pain in the United states 

category statistic 

Chronic pain patients who may 

have addictive disorders 

32% (Chelminski et al., 2005) 

People ages 20 and older who 

report pain that lasted more than 

3 months 

56% (National Center for Health 

Statistics, 2006) 

People experiencing disabling 

pain in the previous year 

36% (Portenoy, Ugarte, Fuller, & 

Haas, 2004) 

People ages 65 and older who 

experience pain that has lasted 

more than 12 months 

57% (National Center for Health 

Statistics, 2006) 

Civilian, noninstitutionalized U.S. 

residents ages 12 and older who 

report nonmedical use* of pain 

relievers in past year 

5% (Substance Abuse and 

Mental Health Services 

Administration [SAMHSA], 2007) 

People ages 12 and older who 

report that they initiated illegal 

drug use with pain relievers 

19% (SAMHSA, 2008) 

People with opioid addiction who 

report chronic pain 

29–60% (Peles, Schreiber, 

Gordon, & Adelson, 2005; 

Potter, Shiffman, & Weiss, 2008; 

Rosenblum et al., 2003; Sheu et 

al., 2008) 

*Nonmedical use is use for purposes other than that for which the medication was 

prescribed. 
2 

Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders

Audience 

This Treatment Improvement Protocol (TIP)

is for primary care providers who treat or are

likely to treat adult patients with or in recovery

from SUDs who present with CNCP. Given

the prevalence of CNCP in the population,

this audience includes virtually all primary care

providers. Addiction specialists, psychiatrists,

nurses, and other clinicians may find information here that will help them ensure that

their patients with CNCP receive adequate

pain treatment. By providing a shared basic

understanding of and a common language for

these two chronic conditions, this TIP facilitates cooperation and communication between

healthcare professionals treating pain and

those treating addiction. 

purpose 

This TIP equips clinicians with practical

guidance and tools for treating CNCP in 

adults with histories of SUDs. It does not 

describe how to treat SUDs or other behavioral health disorders in patients with CNCP;

however, it provides readers with information

about SUD assessments and referrals for further evaluation. For patients with histories 

of SUDs, the most controversial and possibly 

hazardous pain treatment in widespread use 

is opioid treatment. For this reason, this topic 

receives significant attention in Chapters 3 

and 4. 

Definitions 

Many terms important to the treatment of 

CNCP in people with SUDs are used inconsistently. Clinicians should not assume that 

their definitions of addiction, CNCP, physical 

dependence, recovery, tolerance, or other terms 

are shared by others, especially by patients 

and their families. 

It is especially important that clinicians clarify 

with their patients terms related to substance 

use. For example, patients with histories of 

SUDs who are no longer using substances 

may or may not consider themselves to be in 

recovery. Likewise, some mutual-help groups 

may not regard patients as abstinent if they 

are treated for SUDs with medications such 

as naltrexone, buprenorphine, or methadone.

Many people equate physical dependence or 

tolerance with addiction. However, if clinicians

prescribing opioids for CNCP equate these 

terms, they may misdiagnose their patients on 

opioids as having an addiction, when in fact 

they do not. 

In 2001, the American Academy of Pain 

Medicine, the American Pain Society, and 

the American Society of Addiction Medicine

formed a Liaison Committee on Pain and 

Addiction to standardize the use of the terms 

addiction, physical dependence, and tolerance 

among pain professionals. Shared understandings of these and other terms facilitate 

research, advance dialog among professionals 

in the fields of addiction and pain, and help 

patients make informed decisions about their 

treatment. 

Definitions used in this TIP are presented

below. 

•	 addiction. A primary, chronic, neurobiologic disease, with genetic, psychosocial,

and environmental factors influencing 

its development and manifestations. It is 

characterized by behaviors that include 

one or more of the following: impaired 

control over drug use or compulsive use,

continued use despite harm, and craving

(Savage et al., 2003); clinicians commonly 

refer to these behaviors as the “3Cs.” 

•	 addictive substance. The phrase addictive 

substance is controversial. The phrase draws

attention to the properties of the substance; however, some experts prefer to 
3 

1—Introduction

emphasize the importance of individual 

variability, environment, and situational 

factors in addiction. Evidence suggests 

that animals will self-administer all drugs 

commonly sought by humans (with the 

exception of hallucinogens). Evidence also 

suggests that, if animals are exposed to a 

sufficient dose for a sufficient time, a substantial percentage will develop behaviors 

remarkably similar to those that suggest 

addiction in humans (e.g., “drug seeking”

despite electrical shocks). Nonrewarding 

drugs (see Neurobiology of Addiction,

below) do not elicit these behaviors in 

animals or humans. In this TIP, drugs 

or medications that elicit “drug seeking”

behaviors are referred to as addictive. 

•	 behavioral health. The term comprises 

substance use issues, mental health issues,

and the prevention of both. 

•	 chronic noncancer pain (CNCP).

Pain that is (1) unassociated with an 

imminently terminal condition, and (2) 

unlikely to abate as a result of tissue 

healing, thus requiring long-term management. The term often refers to pain 

not caused by ongoing tissue pathology 

(e.g., backache, fibromyalgia). The term is 

problematic because it includes pain associated with sickle cell disease or recurrent 

pancreatitis, in which both neurological 

sensitization and tissue damage, at least 

in part, are likely. Inflammatory arthritis,

connective tissue diseases, ischemia, and 

other conditions cause pain that persists 

for years yet are not, at least initially, life 

threatening. 

•	 chronic pain syndrome. Intractable pain 

of 6 months or longer, with marked alteration of behavior; depression or anxiety;

marked restriction in daily activities;

frequent use of medication and medical 

services; no clear relationship to organic 

disorder; and a history of multiple, nonproductive tests, treatment, and surgeries 

(U.S. Commission on the Evaluation of 

Pain, 1987). This term is used casually and

imprecisely to refer to pain, distress, and 

dysfunction that are not fully attributable 

to an identifiable medical condition. 

•	 hyperalgesia. An abnormally intense 

response to a normally noxious stimulus. 

•	 narcotic. Substance used to induce narcosis or stupor. Narcotic is not a synonym for 

the opioid class of medications. 

•	 opioid-induced hyperalgesia.

Hyperalgesia that results from the effects 

of opioids on the central nervous system 

(CNS).

•	 pain. An unpleasant sensory or emotional 

experience associated with actual or potential tissue damage or described in terms 

of such damage (International Association

for the Study of Pain, 1986). Pain is subjective and may not always be corroborated 

by objective data. 

•	 physical dependence. A state of adaptation

that is manifested by a drug-class-specific 

withdrawal syndrome that can be produced by abrupt cessation, rapid dose 

reduction, decreasing the level of the 

drug in the blood, or administration of 

an antagonist (a substance that opposes 

the action of the drug) (Savage et al.,

2003).

•	 pseudoaddiction. A controversial term 

coined to describe aberrant drug-related 

behaviors (e.g., clock watching, drug seeking), that resemble those of patients with 

addiction but that actually result from 

inadequate treatment of pain (Weissman 

& Haddox, 1989). 

•	 recovery. A process of change through 

which an individual with an SUD achieves 

abstinence, wellness, and improved health 

and quality of life (Center for Substance

Abuse Treatment [CSAT], 2007). 
4 

Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders

•	 relapse. A return to substance abuse after 

a period of abstinence. 

•	 substance use disorder (SUD). A condition

that includes alcohol and drug problems.

SAMHSA recognizes that several terminologies (e.g., substance abuse and addiction) can be applied and respects that 

some individuals and communities may 

choose to use different terminologies 

(CSAT, 2007). 

•	 tolerance. A state of adaptation in which 

exposure to a substance induces changes 

that result in a diminution of one or 

more of the substance’s effects over time 

(Savage et al., 2003). 

pain and Addiction Basics 

Studies indicate that CNCP and addiction 

frequently co-occur (Chelminski et al., 2005;

Rosenblum et al., 2003; Savage, Kirsh, & 

Passik, 2008). Chronic pain and addiction 

have many shared neurophysiological patterns.

Most chronic pain involves abnormal neural 

processing, which can occur at various levels 

of the peripheral and CNS. Similarly, the disease of addiction results when normal neural 

processes, primarily in the brain’s memory,

reward, and stress systems, are altered into 

dysfunctional patterns. A full understanding 

of each condition is still emerging, and there 

is much to be learned regarding neurobiologic

interactions between the conditions when they

co-exist. 

Chronic pain and addiction are not static 

conditions. Both fluctuate in intensity over 

time and under different circumstances and 

require ongoing management. Treatment for 

one condition can support or conflict with 

treatment for the other; a medication that may

be appropriately prescribed for a particular 

chronic pain condition may be inappropriate 

given the patient’s substance use history. Other 

commonalities include the following: 

•	 Both are neurobiological conditions with 

evidence of disordered CNS function. 

•	 Both are mediated by genetics and 


environment.
 

•	 Both may have significant behavioral 


components.
 

•	 Both may have serious harmful consequences if untreated.
 

•	 Both often require multifaceted 


treatment.
 

Chronic pain and SUDs have similar physical,

social, emotional, and economic effects on

health and well-being (Green, Baker, Smith,

& Sato, 2003). Patients with one or both

of these conditions may report insomnia,

depression, impaired functioning, and other 

symptoms. Effective CNCP management 

in patients with or in recovery from SUDs 

must address both conditions simultaneously 

(Trafton, Oliva, Horst, Minkel, & Humphreys,

2004). 

neurobiology of pain 

Both pain and responses to pain are shaped

by culture, temperament, psychological state,

memory, cognition, beliefs and expectations,

co-occurring health conditions, gender, age,

and other biopsychosocial factors. Because pain

is both a sensory and an emotional experience,

it is by nature subjective. 

When nociceptors are excited, the stimulus 

is converted through transduction into action 

potentials that travel to the dorsal horn of the 

spinal cord. Signals then continue from the 

dorsal horn to the brain along multiple pathways in the cord: to the somatosensory cortex,

where pain is evaluated; to the limbic system, 
5 

1—Introduction

where emotional reactions are mediated; to 

the autonomic centers that control such automatic functions as breathing, perspiration,

and heart rate; and to other parts of the brain,

where a behavioral response to the stimuli 

is determined. Nociceptive impulses are also 

transmitted to nearby terminals of the same 

nerve, where they may lead to diffuse pain and 

release of inflammatory substances that produce the flare and swelling that is a protective 

response to tissue injury (Exhibit 1-2). 

Nociceptive input triggers a pain-inhibiting 

response. Signals traveling the ascending 

pathways are met by descending signals that 

emerge at various points along the spinal 

cord and brain. This antinociceptive response

involves a panoply of chemicals, including 

endorphins, enkephalins, gamma-aminobutyric 

acid, norepinephrine, serotonin, oxytocin, and 

relaxin. Inhibitory signaling serves to attenuate 

nociceptive input, dampening the formation 

of pain sensation and providing pain relief 

(Brookoff, 2005). 

Pain may be acute (e.g., postoperative pain),

acute intermittent (e.g., migraine headache,

pain caused by sickle cell disease), or chronic 

(persistent pain that may or may not have 

a known etiology). These categories are not 

mutually exclusive; for example, acute pain 

may be superimposed on chronic pain. Acute 

nociceptive or neuropathic pain can transform 

into chronic neuropathic pain in which the 

original sensations are extended and amplified. 

exhibit 1-2 The pain pathways 
6 

Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders

chronic pain 

Chronic pain can be nociceptive, neuropathic,

or a mixture of both (Exhibit 1-3). Pains such 

as migraine and fibromyalgia, in which there 

is no noxious stimulus and no apparent neurological lesion, are attributed to dysfunction of 

a structurally intact CNS. 

Chronic pain often results from a process of 

neural sensitization following injury or illness 

in which thresholds are lowered, responses are 

amplified (hyperalgesia), normally non-noxious stimulation becomes painful (allodynia),

and spontaneous neural discharges occur.

Increased signaling disconnected from nociceptive input can become autonomous, selfsustaining, and progressive, leading to the continuous perception of pain even in the absence 

of ongoing tissue damage. Thus, chronic pain 

is not equivalent to prolonged acute pain and 

for clinical purposes is best considered a distinct disorder (Brookoff, 2005). 

The etiology of the abnormal processing in 

chronic pain is not fully understood. However,

there are two main, nonexclusive causes. First, 

tissue damage can trigger the release of chemicals that sensitize the nerve fibers and alter 

gene expression, causing changes in signaling 

through many different mechanisms. Some 

of these changes enable non-pain-conducting 

fibers to trigger pain in the CNS. Second,

pain can result from injured nerve fibers that 

regenerate in a neuroma, which generates pain 

signals with little or no stimulation. 

When injury occurs to key pain-processing 

sectors of the CNS (e.g., the dorsal horn,

thalamus), neural signals that pass through 

them may be interpreted as pain. Injury may 

also lead to degeneration of pain inhibitory 

cells. Modulation of nociceptive stimuli and 

inhibitory responses can occur at one or more 

locations in the CNS: the peripheral nerves,

spinal cord neurons and tracts, thalamus, and 

cortex (Compton & Gebhart, 2003). Accurate 

identification of the source of the chronic 

pain, and of the neurological processes that 

modulate it, can lead to rational therapeutic 

approaches that target the source of aberrant 

signaling on the CNS pathway. 

exhibit 1-3 pain Types 

Type Description 

Nociceptive Pain Pain that results from suprathreshold stimulation of nociceptors, which 

are neural receptors specialized for the detection of potentially harmful situations. This is an adaptive function of the nervous system. 

Nociceptors can be excited by mechanical, thermal, or chemical stimulation. The immediate physical response is reflexive and protective, 

causing a person to pull a hand away from a hot surface, for example. 

Nociceptive pain persists while the injurious agent remains or until healing occurs. Prolonged nociceptive input can cause central hypersensitization and the experience of spontaneous or amplified pain. 

Neuropathic Pain Pain that results from lesion or dysfunction of the sensory nervous system. A compressed, injured, or severed nerve can trigger neuropathic 

pain, as can disorders that affect the neural axis (e.g., metabolic diseases, 

infections, autoimmune disorders, vascular diseases, neoplasia [Campbell 

& Meyer, 2006]). 

Mixed Nociceptive/ 

Neuropathic Pain 

A combination of the two types of pain. For example, patients with 

degenerative disc disease may suffer from mechanical (nociceptive) back 

pain and radicular (neuropathic) pain. 
7 

1—Introduction

pain’s effect on health 

Persistent pain can have significant adverse 

effects on health. When pain stimuli continuously trigger the stress response, the acute 

signs of sympathetic activation (e.g., rapid 

heart rate, sweating) may cease or appear 

intermittently, yet the body continues to be 

stressed. This situation contributes to a sense 

of exhaustion. 

Continued pain can trigger emotional responses,

including sleeplessness, anxiety, and depressive 

symptoms, which in turn produce more pain.

Such feedback cycles may continue to cause 

pain after the physiological causes have been 

addressed. Several studies show that the outcome of pain treatment is worse in the presence of depression, or when depression does 

not respond to treatment, and that the future 

course of pain syndromes can be, in part, predicted by emotional status. The physiological 

and psychological sequelae of CNCP can be 

exacerbated by such factors as inactivity and 

overuse of sedating drugs. Physical inactivity 

and a lack of engagement with life may also 

lead to increased levels of anxiety, depression,

and an increased risk for suicidal ideation;

these increases may lead a person to use substances in an attempt to treat these sequelae 

of CNCP and the losses that occur due to its 

presence. 

neurobiology of Addiction 

A person may use substances initially for 

several reasons, such as to experience the 

euphoric effects, to relieve stress, to overcome 

anxiety or depression (or both), or to blunt 

the pain (National Institute on Drug Abuse 

[NIDA], 2007). With repeated exposure, however, substance use in some people can become 

uncontrollable. The defining characteristics of 

the disease of addiction have been summarized 

as the “3Cs” (see the definition of addiction). 

Changes to the brain occur in a process that is 

mediated by both genetic and environmental 

factors, which result in an overvaluation of the 

substance, a devaluation of other things, and 

impaired control of substance-related behavior.

Evidence indicates that addiction is a chronic 

disease. 

The primary rewarding effects of addictive 

substances occur in the cortico-mesolimbic 

dopamine systems, where several structures 

link to control the basic emotions and connect them to memories, which drive behavior.

These systems produce sensations of pleasure 

in response to actions that support survival 

(e.g., eating, sex) and sensations of fear in 

response to potential dangers. In a cascading 

effect, these sensations trigger the endocrine 

and autonomic nervous systems, stimulating 

bodily responses. The prefrontal cortex also 

plays a role in the formation of addictions,

modifying pleasure and pain signals based on 

other considerations. Thus, the brain’s reward 

and stress systems reinforce life-sustaining 

behaviors. 

Reward Response 

Feelings of reward emerge from the core of 

the limbic system after neurons in the ventral 

tegmental area (VTA) release the neurotransmitter dopamine into the nucleus accumbens 

(NAc). Neural activity within this VTA–NAc 

circuit is necessary to experience reward, but 

other areas within the broader brain reward 

circuit also exert a strong influence. For example, the hippocampus contributes information 

from the past that may be relevant to the 

current experience. The amygdala adds critical 

information about the emotional valence of 

the stimulus that activated the reward circuit,

thus contributing to the overall motivational 

power of the experience. In addition, parts of 

the prefrontal cortex (i.e., anterior cingulate 

and orbitofrontal cortices) help integrate all 

the information, a vital function that allows 

the individual to decide whether to initiate 

or suppress a particular behavior in response 

to the stimulus. 
8 

Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders

Most addictive substances increase the levels 

of dopamine in limbic targets well beyond 

what occurs in naturally rewarding situations 

(e.g., sex, food). Some drugs (e.g., marijuana,

heroin) produce dopaminergic effects indirectly. Amphetamines cause the release of 

dopamine, and cocaine prevents its reuptake;

both effects result in amplified messaging that 

eventually disrupts normal neuronal signaling. 

It appears that the brain adjusts to excess 

dopamine levels by producing less dopamine 

and by reducing the number of receptors that 

respond to it in the receiving (postsynaptic) 

neuron. As a result, the pleasurable effects of 

a drug become diminished with continued use.

The pleasurable effects of normal activities also

are blunted, creating a state called anhedonia 

(an inability to experience pleasure). 

It is commonly believed that continued

substance use is driven by the need to prevent

symptoms of withdrawal; however, this idea 

is misleading. Withdrawal, as commonly 

conceptualized, involves rebound symptoms 

resulting from the drug’s absence. In the 

case of opioids, these symptoms include,

but are not limited to, anxiety, sweating,

tachycardia, diarrhea, piloerection, and chills.

Although unpleasant, these symptoms are 

typically absent after a relatively brief period 

of detoxification or weaning and do not 

explain phenomena such as addiction relapse 

and prolonged craving. Even though detoxification is quick and technically easy, the 

prevention of relapse is extremely difficult 

and, in fact, the majority of those who attain 

abstinence experience at least one relapse 

(Dennis, Foss, & Scott, 2007). These more 

difficult problems are thought to result from 

the prolonged impairment of hedonic tone 

and conditioned responses that lead to intense 

craving. 

Stress Response 

The dysregulation of the brain’s reward system 

that occurs through substance use is paralleled 

by similar dysregulating effects in the stress 

system. Use of an addictive substance increases 

the flow of neurochemicals (e.g., corticotropinreleasing factor, norepinephrine, dynorphin).

These chemicals can produce a negative 

emotional state that manifests as chronic irritability, emotional pain, lethargy, disinterest in 

natural rewards, and other dysphoric conditions. The stress response becomes more sensitive with repeated withdrawal and can persist 

into abstinence (Koob, 2009). 

An individual may seek to avert the stress 

response by again using the substance. This 

negative reinforcement combines with the 

positive reinforcement of the substance’s 

euphoric effects in an operant process that 

creates a compulsion for substance use.

Thus, addiction is reflected in compulsive 

use combined with loss of control mediated 

by memory (cue-induced triggers for reuse),

substance-induced reductions in executive 

functioning that hamper rational decisionmaking, and habit formation (Koob, 2009). 

risk Factors for Addiction 

People who use substances with addictive 

potential may develop tolerance to some of 

their effects and develop some degree of physical dependence. However, only a minority 

develops the disease of addiction. Important 

risk factors for addiction include genetics,

psychological factors, and environmental 

factors. 

Genetics plays a substantial role in risk factors 

for addiction: NIDA (2007) estimates that 

between 40 and 60 percent of a person’s vulnerability to addiction may be genetic. The 
9 

1—Introduction

disease of addiction may be more heritable 

than type 2 diabetes, hypertension, and breast 

cancer (Nestler, 2005). Genes also underlie 

human variability in drug metabolism, susceptibility to psychiatric disorders that commonly 

co-occur with addiction, and response to environmental risk factors (e.g., drug availability,

peer group pressure [Vaillant, 2003]). 

Mental illness is another major risk factor for 

addiction (Volkow & Li, 2009), and the two 

conditions have high comorbidity (NIDA,

2009). One condition can follow the other

(NIDA, 2007). For example, a person may

attempt to relieve depression or anxiety with 

substances, and this behavior may lead to

addiction. Conversely, chronic substance use 

may lead to mental disorders, such as psychosis, or make existing mental illness worse 

(NIDA, 2007). Environmental influences on 

addiction include, but are not limited to, poverty, poor parental support, living in a community with high drug availability, and using 

substances at an early age (NIDA, 2007, 2009;

Volkow & Li, 2009). 

cross-Addiction 

Addiction to one substance can be linked with 

addiction to other substances in a pattern

termed cross-addiction. An individual who voluntarily or involuntarily decreases use of one 

substance may increase use of another substance with similar effects on the brain (e.g.,

the person with an alcohol use disorder may 

use barbiturates for the sedative effects). The 

term cross-addiction is also used to describe 

simultaneous addiction (e.g., co-occurring 

addictions to nicotine, alcohol, and marijuana). 

Cross-addiction is not official diagnostic 

nomenclature; rather, it refers to the observation that a person with an addiction to one 

substance may develop addiction to a subsequent substance, especially if the original 

drug of choice becomes inaccessible or is 

relinquished for other reasons. For example,

a study of patients hospitalized for controlledrelease oxycodone addiction found that the 

majority (77 percent) had previously had a 

non-opioid SUD (Potter, Hennessey, Borrow,

Greenfield, & Weiss, 2004). 

Individuals with chronic pain and histories 

of SUDs may be at increased risk of crossaddiction to any medication that acts on the 

brain as a reinforcing agent (Edlund, Sullivan,

Steffick, Harris, & Wells, 2007). Because of 

cross-addiction, persons who abuse marijuana 

may be at increased risk for opioid addiction.

People with alcohol use disorders have been 

found to be more than 18 times as likely to 

report nonmedical use of prescription medications as people who do not drink (McCabe,

Cranford, & Boyd, 2006). 

The cycle of chronic pain and 

Addiction 

Although multiple factors influence the course 

of addiction, CNCP provides both positive 

and negative reinforcement of substance use.

Positive reinforcement occurs when a behavior 

is followed by a consequence that is desirable—

a donkey’s walking may be rewarded by a 

carrot. Negative reinforcement occurs when 

a behavior is followed by the elimination of 

a negative consequence—a donkey’s walking

may eliminate the blows from a stick. For 

example, euphoria is a positive reinforcer for 

taking heroin, and pain reduction is a negative reinforcer for taking heroin. Prescribed 

opioids, benzodiazepines, or other medications 

may dramatically relieve pain or distress (e.g.,

depression, anxiety). Unprescribed substances 

may be used for similar reasons; for example,

alcohol may promote relaxation or sleep. Such 

relief is a strong reinforcement for repeated 

consumption of the substance. 

Unfortunately, analgesic and anxiolytic efficacy 

may diminish over the course of weeks, months, 
10 

Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders

or years as tolerance develops. This loss of efficacy often elicits dose escalation to recapture 

efficacy. This escalation is rewarded, as the 

increased dose is initially more effective than 

the lower dose. 

If the drug produces physical dependence, the 

person may have not only increased pain when 

the substance is absent, but also withdrawal 

symptoms (e.g., anxiety, nausea, cramps,

insomnia). Withdrawal symptoms may lead to 

an increase in symptoms of depression and an 

increase in the potential risk for suicide. All 

these symptoms are relieved by ingesting more 

of the drug that caused the dependence. A 

similar situation may occur if the drug is one 

that elicits rebound symptoms. For example,

ergot relieves migraine, but excessive use leads 

to rebound headaches that are more persistent 

and treatment resistant than were the original 

headaches. 

An illusion of benefit produced by reinforcing 

drugs can create a paradoxical situation in 

which long-term use of the substance creates

the very symptoms the person hopes to

alleviate. People commonly drink to relax or

“cheer up,” yet chronic alcohol abuse leads to

depression and anxiety. 

In some people, a cycle develops in which 

pain or distress elicits severe preoccupation 

with the substance that previously provided 

relief. This cycle—seeking pain relief, experiencing relief, and then having pain recur—can 

be very difficult to break, even in the person 

without an addiction, and the development of 

addiction markedly exacerbates the difficulty.

The propensity to develop this cycle is influenced by genetic and environmental factors;

some people will experience greater degrees 

of analgesia than others, and some will have 

more severe or prolonged abstinence symptoms. Genetic variability in susceptibility to 

these experiences may explain some cases 

of iatrogenic addiction. 
11 

1—Introduction

summary of TIp 

The management of CNCP in patients with a comorbid SUD is challenging for both 

patients and clinicians; however, it can be done successfully. This TIP advises clinicians 

to conduct a careful assessment; develop a treatment plan that addresses pain, functional 

impairment, and psychological symptoms; and closely monitor patients for relapse. Even 

the best treatment is unlikely to completely eliminate chronic pain, and efforts to achieve 

total pain relief can be self-defeating. Patients may benefit when clinicians team with other 

professionals ( e.g., psychologists, addiction counselors, pharmacists, holistic care providers).

Patients must also assume a significant amount of responsibility for optimal management of 

their pain. Educating patients, family members, and caregivers in this process, and helping 

patients improve their quality of life, can be gratifying for everyone involved. 

Key points 

•	 CNCP and the disease of addiction involve neurophysiological processes. 

•	 Both genetic and environmental factors contribute to and influence the development 

and course of CNCP and addiction. 

•	 Clinicians must understand CNCP, addiction, and other behavioral health issues to best 

serve the chronic pain patient with or in recovery from an SUD. 

•	 Despite the complexities of CNCP and SUDs, patients with these co-occurring,

chronic conditions can be treated effectively. 

In This Chapter

2 patient Assessment 

In ThIs chApTer 

•	Elements of Assessment 

•	Assessment Tools 

•	Assessing Pain and 

Function 

•	Screening for Substance 

Use Disorders 

•	Referring for Further 

Assessment 

•	Assessing Ability To 

Cope With Chronic Pain 

•	Evaluating Risk of 

Developing Problematic 

Opioid Use 

•	Ongoing Assessment 

•	Treatment Setting 

•	Key Points 

elements of Assessment 

Researchers and clinicians agree that, because chronic noncancer 

pain (CNCP) is a multifaceted condition, assessment must include 

more than measures of pain intensity (Brunton, 2004; Haefeli & 

Elfering, 2006; Karoly, Ruehlman, Aiken, Todd, & Newton, 2006;

Sullivan & Ferrell, 2005). Some elements are essential to assess;

others, ideal. In many cases, even after a thorough assessment, the 

clinician may not detect the nociceptive source of a patient’s chronic 

pain. 

Collateral information is an important part of the assessment.

Clinicians need to communicate with families, pharmacists, and 

other clinicians after the patient has given full consent for these 

discussions. If the patient declines to give consent, prolonged treatment with controlled substances may be contraindicated. Furthermore,

a clinician who prescribes controlled substances to a patient who 

refuses to permit access to outside information could be considered 

to be ignoring evidence of addiction or substance misuse and, therefore, to be trafficking. Collateral information also helps protect the 

patient from misusing medications. Exhibit 2-1 presents elements of 

a comprehensive assessment. 

Assessment Tools 

Standardized instruments provide ways to assess and track patient 

pain levels, function, substance use, and other factors important to 

managing CNCP. Standardized tools provide supplemental information for treatment planning and assessment of risk and outcomes. If 

used well, tools can reduce clinician bias during patient assessment. 

The sensitivity and specificity of screening instruments vary, and

all can yield false-positive or false-negative results. In addition, no

single instrument has been shown to be appropriate for use with

all patient populations (Bird, 2003; Brunton, 2004). Because of their 

limitations, standardized tools should not be the absolute determinants

of treatments offered or withheld. 

13 
14 

exhibit 2-1 elements of a comprehensive patient Assessment 

element Assessment Factor 

Pain and Coping •	Location, character (e.g., shooting or stinging, continuous or 

intermittent) 

•	Pain types (i.e., nociceptive, neuropathic, mixed) 

•	Lowest and highest extent of pain in a typical day, on a 0-to-10 

scale 

•	Usual pain in a typical day, on a 0-to-10 scale 

•	When and how the pain started 

•	Exacerbating factors (e.g., exertion/activity, food consumption, 

elimination, stress, medical issues) 

•	Palliating factors (e.g., heat, cold, stretching, rest, medications, 

complementary and alternative treatments) 

•	Prior evaluations to determine the source of pain 

•	Response to previous pain treatments, including complementary 

and alternative treatments and interventional treatments 

•	Goals and expectations for pain relief 

Collateral Information It is crucial to obtain such information as: 

•	Findings of other clinicians, prior and current 

•	Family concerns, beliefs, and observations 

•	Pharmacist concerns, where relevant 

•	Data from State electronic prescription monitoring programs, 

if available 

•	Medical records, including psychiatric and substance use disorders 

(SUDs) treatment records 

Function Effect of pain on: 

•	Activities of daily living/ability to care for oneself 

•	Sleep 

•	Mood 

•	Work/household responsibilities 

•	Sex 

•	Socialization and support systems 

•	Recreation 

•	Goals and expectations for restored function 

Contingencies •	Family support of wellness versus illness behavior 

•	Vocational incentives and disincentives 

•	Financial incentives and disincentives 

•	Insurance/legal incentives and disincentives 

•	Environmental and social resources for wellness 
15 

2—Patient Assessment

exhibit 2-1 elements of a comprehensive patient Assessment (continued) 

element Assessment Factor 

Substance Use History 

and Risk for Addiction 

•	Current use of substances, including tobacco, alcohol, over-thecounter medications, prescription medications, and illicit drugs 

(confirmed by toxicology) 

•	Focus on opioids to the exclusion of other treatments 

•	Adverse consequences of use (e.g., functional impairment; legal, 

social, financial, family, work, medical problems) 

•	Age at first use 

•	Treatment history, including attendance at mutual-help groups 

•	Periods of abstinence 

•	Strength of recovery support network (e.g., sponsor, sober 

support network, mutual-help meetings) 

•	Family history of SUD 

•	History of physical, sexual, or emotional abuse or trauma 

Co-Occurring Conditions 

and Disorders 

•	Psychological conditions (e.g., depression, anxiety, post-traumatic 

stress disorder [PTSD], somatoform disorders) 

•	Medical conditions (e.g., hepatic, renal, cardiovascular, metabolic) 

•	Cognitive impairments (e.g., dementia, delirium, intoxication, 

traumatic brain injury) 

Physical Exam •	Relevant associated signs of pain disorder 

•	Signs of substance abuse (e.g., track marks, hepatomegaly, 

residua of skin infections, nasal and oropharyngeal pathology) 

Mental Status •	Medication focused 

•	Somatic preoccupation 

•	Mood 

•	Suicidal ideation and behavior 

•	Cognition (e.g., attentional capacity, memory) 

When using standardized tools, clinicians 

should (Bird, 2003): 

•	 Understand the strengths and weaknesses 

of each tool. 

•	 Select a tool appropriate for the patient,

considering memory problems, cognitive 

impairments, eyesight, literacy level, cultural background, gender, ethnicity, and 

other factors. 

•	 Teach patients how to use self-administered tools, even “self-explanatory” tools;

otherwise, the information they provide 

may be invalid. 

Instruments are available to assist with assessment of pain and functioning, SUDs, psychiatric comorbidities, coping skills, and potential 

problems with opioid use. 

Assessing pain and Function 

The assessment of CNCP should include 

documentation of the following: 

•	 Pain onset, quality, and severity; mitigating

and exacerbating factors; and the results 

of investigations into etiology 

•	 Pain-related functional impairment 
16 

•	 Emotional changes (e.g., anxiety, depression, anger) and sleep disturbances 

•	 Cognitive changes (e.g., attentional 


capacity, memory)
 

•	 Family response to pain (i.e., supportive,

enabling, rejecting) 

•	 Environmental consequences (e.g., disability income, loss of desired activities,

absence from desirable or feared work) 

•	 Physical examination 

•	 Partial mental status examination (e.g.,

affect [how pain is experienced], somatic 

preoccupation, cognition, moans, gasps,

lying down during the interview) 

Several factors may complicate an assessment 

of pain levels in any pain patient: 

•	 Some patients may report not only their 

level of pain intensity, but their suffering,

which may be greater than their pain 

intensity. 

•	 Clinicians tend to believe that a patient’s 

pain level is actually lower than the patient

reports, except when the patient reports

low pain (Sloman, Rosen, Rom, & Shir,

2005; Stalnikowicz, Mahamid, Kaspi, &

Brezis, 2005). 

•	 Clinicians are especially likely to underestimate—and, therefore, to undertreat—

pain and disability in women, the elderly,

minorities, people of low economic status,

and people with SUDs (Green, Baker,

Smith, & Sato, 2003; Rupp & Delaney,

2004). 

An assessment of pain and function in 

patients with SUD histories may be further 

complicated by the following factors: 

•	 Some patients with histories of SUDs 

may overreport their pain experience if 

they are afraid that they will be undermedicated or that their symptoms will 

not be taken seriously. 

•	 Others may underreport their pain 

experience if they are afraid they will 

be prescribed medications that will cause 

them to relapse. 

•	 Some patients may exaggerate pain and 

disability levels to get opioids for reasons 

other than pain control. 

The level of functional impairment in patients 

with CNCP is markedly modified by environmental contingencies (e.g., the incentives 

and disincentives for healthful versus so-called 

“sick role” behaviors). For instance, evidence 

shows that pain-related behaviors increase 

in the presence of a solicitous spouse, meaning one who is attentive to and reinforcing 

of such behaviors (Pence, Thorn, Jensen, & 

Romano, 2008). It is also demonstrated that 

work-related functional impairment varies 

with the strengths of reinforcement contingencies for function versus absenteeism. The 

workers’ compensation system may provide a 

special example of this. Studies typically find 

that patients receiving income from this source

respond less well to rehabilitation efforts

than do those not receiving disability income

from this or other sources. The explanation 

is thought to reside in such factors as the 

need to “prove” one is ill to obtain tests and 

specialty consultation and the fear of loss of 

income if one is witnessed engaging in normal

activities. The relative magnitude of rewards 

and punishments for function may thus play 

a determining role in disability. A thorough 

assessment of a patient with CNCP, therefore,

requires a review of the overall consequences 

of resuming healthy function. 

When assessing pain and function in patients 

with histories of SUDs, clinicians should keep 

in mind the following: 

•	 Individuals with similar complaints (e.g.,

low back pain) usually describe and rate 

their pain differently. 

•	 Functional impairments affect patients 

differently. 
17 

2—Patient Assessment

•	 Pain scores do not reflect tissue pathology,

disability, or treatment response. 

•	 Pain reduction is insufficient to judge 

treatment success, which also requires 

optimization of function and normalization of mood. 

Exhibits 2-2 and 2-3 list the strengths and 

weaknesses of common one-dimensional and 

multidimensional pain tools, respectively.

Exhibit 2-4 presents tools for assessing the 

extent to which pain interferes with usual 

functions and activities. Information on how 

to obtain the tools is located in Appendix B. 

Studies show that patients who have chronic 

pain may develop cognitive impairments (e.g.,

changes in attentional capacity, memory, processing speed) that appear to be independent

of other variables (e.g., age, educational level,

pain intensity, pain relief ) (Dick & Rashtiq,

2007; Hart, Martelli, & Zasler, 2000; Hart,

Wade, & Martelli, 2003). Therefore, clinicians

need to be alert to the possibility of these

changes and include an evaluation of mental 

status as part of the patient’s ongoing 

assessment (e.g., the Mini-Mental State 

Examination, [Folstein & Folstein, 2010]) or 

refer the patient to a neurologist as necessary. 

exhibit 2-2 Tools To Assess pain level 

Tool strength Weakness 

Faces Pain Scale •	Easy to use 

•	Usable with people who have 

mild to moderate cognitive 

impairment 

•	Translates across cultures and 

languages 

•	Visual impairment 

may affect accuracy or 

completion 

•	May measure pain affect, 

not only pain intensity 

Numeric Rating Scale (NRS) •	Easy to use if patient can translate pain into numbers 

•	Easy to administer and score 

•	Can measure small changes in 

pain intensity 

•	Oral or written administration 

•	Sensitive to changes in chronic 

pain 

•	Translates across cultures and 

languages 

•	Difficult to administer to 

patients with cognitive 

impairments because of 

difficulty translating pain 

into numbers 

Verbal Rating Scale/Graphic 

Rating Scale 

•	Easy to use 

•	Oral or written administration 

•	High completion rate with 

patients with cognitive 

impairments 

•	Sensitive to change and validated for use with chronic pain 

•	Correlates strongly with other 

tools 

•	Not as sensitive as NRS or 

Visual Analog Scale 
18 

exhibit 2-2 Tools To Assess pain level (continued) 

Tool strength Weakness 

Visual Analog Scale (VAS) •	Easy to use, but must be presented carefully 

•	Precise 

•	Sensitive to ethnic differences 

•	Easily translated across cultures and languages 

•	Some evidence that a horizontal line may be better than 

a vertical (“thermometer”) 

orientation 

•	Visual impairment may affect 

accuracy 

•	Can be time consuming to 

score, unless mechanical or 

computerized VAS tools are 

used 

•	Low completion rate in 

patients with cognitive 

impairments 

•	Difficult to administer to 

patients with cognitive 

impairments 

•	Cannot be administered by 

phone or email 

•	Subject to measurement error 

Bird, 2003; Brunton, 2004. 

exhibit 2-3 Tools To Assess several Dimensions of pain 

Tool strength Weakness 

Brief Pain Inventory •	Short form better for clinical 

practice 

•	Fairly easy to use 

•	Useful in different cultures 

•	Translated into and validated 

in several languages 

•	Not easily used with patients 

with cognitive impairments 

McGill Pain Questionnaire •	Short form easier to 

administer 

•	Extensively studied 

•	Measures pain affect 

•	Not appropriate for patients 

with cognitive impairments 

•	Translation complicated 

•	Meaning of pain descriptors 

may vary across racial and 

ethnic groups 

Department of Veterans Affairs & Department of Defense, 2003. 

Assessing Substance Use and 	

Addiction 

As with assessing pain and function, assessing 

patient self-reports of substance use, whether 

via interviews or structured self-report 

questionnaires, should be corroborated by 

other sources of information (e.g., medical 

records, interviews with family, urine toxicology, information from State prescription monitoring programs) (Katz & Fanciullo, 2002). 
2—Patient Assessment

19 

exhibit 2-4 Tools To Assess pain Interference With life Activities and Functional 

capacities 

Tool purpose 

Katz Basic Activities of Daily Living Scale Rates independence by assessing six areas of daily 

activities 

Pain Disability Index Measures chronic pain and chronic pain interference 

in daily life 

Roland-Morris Disability Questionnaire Measures perceived disability from low back pain 

WOMAC Index Assesses pain, stiffness, and physical function in 

patients with osteoarthritis 

When initiating a conversation about alcohol 

and drug use, clinicians should: 

•	 Approach the topic matter-of-factly,

handling it as part of the overall medical 

history. 

•	 Incorporate questions about drug and 

alcohol use into a general behavioral 

health inventory including discussion 

of other lifestyle behaviors (e.g., diet,

exercise). 

•	 Ask about nicotine and caffeine use;

questions about use of these substances 

provide opportunities to move to assessment of other substances, beginning with

alcohol, the most commonly abused 

substance. 

•	 Assure patients that honest answers to 

questions of substance use are necessary 

to developing a treatment plan and that 

their responses will remain confidential. 

A good prescreening question is, “When did 

you last have a drink of beer, wine, or liquor?”

If the patient reports drinking within the past 

year, the clinician should ask questions to 

determine: 

•	 Frequency (“How many days per week do 

you typically drink alcohol?”) 

•	 Quantity (“How much alcohol do you 

drink on a typical drinking occasion?”) 

•	 Evidence of binge drinking (for men:

“On any day in the past year, have you 

ever had five or more drinks?”; for 

women: “On any day in the past year,

have you ever had four or more drinks?”) 

The clinician should ask the patient to define 

what the patient means by “a drink” (e.g.,

an 8-ounce glass, half a glass). The National 

Institute on Alcohol Abuse and Alcoholism 

(NIAAA) defines one drink as one 12-ounce 

bottle of beer or wine cooler, one 5-ounce 

glass of wine, or 1.5 ounces of 80-proof distilled spirits. According to NIAAA (2005), if 

the male patient drinks more than 4 standard 

drinks in a day (or more than 14 drinks per 

week), or more than 3 drinks in a day (or more 

than 7 drinks per week) for the female patient,

the person is at increased risk for developing 

alcohol-related problems. 

Whether or not the patient reports drinking,

the clinician should probe for the use of licit 

and illicit drugs, starting with the most commonly used illicit drug in the United States:

marijuana. Questions can continue to address 

other major classes of drugs with abuse potential (e.g., depressants, stimulants, opioids), 
20 

 

with particular attention to use related to 

controlling pain or the patient’s anxiety and 

fear of pain (Passik & Kirsch, 2004). Exhibit 

2-5 summarizes the substances that patients 

should be asked about using. 

NIDA provides a Web-based tool that helps 

clinicians screen for tobacco, alcohol, and illicit 

and nonmedical prescription drug use, and

suggests levels of intervention. The tool is at 

http://ww1.drugabuse.gov/nmassist. 

screening for substance Use 

Disorders 

Although the amount of substance used is

significant, it is more important to evaluate 

the consequences of the drug and alcohol

use on life domains, such as family, work or 

school, and involvement with the criminal 

justice system (e.g., arrests for driving under

the influence). When drug or alcohol use

interferes with normal function, addiction is 

likely. Furthermore, addiction is characterized 

by impaired ability to control use of the substance. Asking whether the patient has ever 

attempted to decrease the amount consumed 

is an approach to determining his or her ability to modulate use. In the case of prescription 

medication, a patient’s loss of control may

manifest as the inability to ration pills until 

the next prescription, so the patient’s partner 

may oversee the dispensing of the medications. 

The Diagnostic and Statistical Manual of

Mental Disorders, Fourth Edition, Text

Revision (DSM-IV-TR; American Psychiatric 

Association [APA], 2000) provides criteria for 

determining substance dependence that enable 

the clinician to distinguish between patients 

with at-risk substance use and those whose 

use is consistent with an SUD (Exhibit 2-6).

It is important to remember that, essentially,

all patients taking prescribed opioids or sedatives on a long-term basis will have a degree 

of tolerance and withdrawal and that these 

criteria are not indicative of addiction absent 

the “maladaptive pattern of substance use.” 

exhibit 2-5 Items To Include in substance Use Assessment 
21 

2—Patient Assessment

exhibit 2-6 Dsm-Iv-Tr criteria for substance Abuse and substance 

Dependence 

category criteria 

Substance 

Abuse 

A maladaptive pattern of substance use leading to clinically significant 

impairment or distress, as manifested by one (or more) of the following, 

occurring within a 12-month period: 

•	Recurrent substance use resulting in a failure to fulfill major role obligations 

at work, school, or home (e.g., repeated absences or poor work performance 

related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) 

•	Recurrent substance use in situations in which it is physically hazardous (e.g., 

driving an automobile or operating machinery when impaired by substance 

use) 

•	Recurrent substance-related legal problems (e.g., arrests for substancerelated disorderly conduct) 

•	Continued substance use despite having persistent or recurrent social or 

interpersonal problems caused or exacerbated by the effects of the substance 

(e.g., arguments with spouse about consequences of intoxication, physical 

fights) 

Substance 

Dependence 

A maladaptive pattern of substance use, leading to clinically significant 

impairment or distress, as manifested by three (or more) of the following, 

occurring any time in a 12-month period: 

•	Tolerance, as defined by either of the following: (a) a need for markedly 

increased amounts of the substance to achieve intoxication or desired effect, 

or (b) markedly diminished effect with continued use of the same amount of 

the substance 

•	Withdrawal, as manifested by either of the following: (a) the characteristic 

withdrawal syndrome for the substance, or (b) the same (or closely related) 

substance is taken to relieve or avoid withdrawal symptoms 

•	The substance is often taken in larger amounts or over a longer period than 

intended 

•	There is a persistent desire or unsuccessful efforts to cut down or control 

substance use 

•	A great deal of time is spent in activities necessary to obtain the substance, 

use the substance, or recover from its effects 

•	Important social, occupational, or recreational activities are given up or 

reduced because of substance use 

•	The substance use is continued despite knowledge of having a persistent 

physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of 

cocaine-induced depression, continued drinking despite recognition that an 

ulcer was made worse by alcohol consumption) 

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision 

(Copyright 2000). American Psychiatric Association. 
22 

Although a patient’s former drug of choice is 

the one that is most likely to lead to cravings

and relapse (Daley, Marlatt, & Spotts, 2003;

Gardner, 2000), clinical experience suggests 

that a person with a history of an SUD involving any drug is susceptible to developing a 

cross-addiction with opioids (Covington,

2008; Savage, 2002). 

Clinicians should try to determine patients’

recovery status, which is crucial in developing 

a treatment plan (Exhibit 2-7). Many patients 

will be forthcoming about past or recent substance abuse during a comprehensive assessment. Some patients who have an SUD lack 

a full appreciation of the effects of substances, 

prescribed or otherwise, on their function;

however, family members can usually provide 

this information. 

Several standardized tools for SUD screening 

are listed in Exhibit 2-8. Information on how 

to obtain the tools is in Appendix B. Most 

tools are short, can be self-administered, and 

can be integrated into the health-screening 

forms the patient completes prior to seeing 

the clinician. Although no tool is a substitute 

for a good clinical interview, screening is 

essential to case finding and a useful complement to the patient interview, the physical 

exam, and ongoing observation (Fishman,

2007). 

exhibit 2-7 steps Following substance Abuse Assessment 

If Then 

Abuse is remote and patient is in long-term 

recovery 

Verify and support recovery efforts 

Patient is on buprenorphine or methadone 

maintenance therapy (MMT) 

Verify and continue buprenorphine or MMT 

Abuse appears active Refer patient to substance abuse specialist for 

further evaluation 

Adapted from Passik & Kirsh, 2004. 

exhibit 2-8 Tools To screen for substance Use Disorders 

Tool Format Administration/ 

scoring Time 

Training 

required 

Alcohol, Smoking, and 

Substance Involvement 

Screening Test 

1 item for lifetime use, 6 

items for each of 10 substances used, and 1 item 

on injection use 

Depends on number of 

substances used 

Yes 

Alcohol Use Disorders 

Identification Test (AUDIT) 

10-item screening 

questionnaire 

2 minutes to administer/ 

1 minute to score 

Yes 

AUDIT-C 3-item screening 

questionnaire 

Less than 1 minute to 

administer and score 

Yes 

CAGE Adapted To Include 

Drugs 

4 yes/no questions Less than 1 minute/ 

not scored 

No 

Drug Abuse Screening 

Test 

20 yes/no questions about 

current and past use 

1–2 minutes to administer/ 

not scored 

No 

Michigan Alcoholism 

Screening Test (MAST) 

(MAST-G for older adults) 

24 yes/no questions 10 minutes to administer/ 

5 minutes to score 

No 
23 

2—Patient Assessment

The Substance Abuse and Mental Health 

Services Administration’s Screening, Brief

Intervention, and Referral to Treatment

(SBIRT) initiative may be helpful in the

primary care context (Exhibit 2-9). More

information can be obtained from the Center 

for Substance Abuse Treatment (CSAT,

1999a). Research findings on SBIRT are 

available from National Association of State 

Alcohol and Drug Abuse Directors (2006). 

referring for Further Assessment 

If the clinical interview, collateral interview,

medical records, and screening suggest an 

unacknowledged SUD in a patient seeking 

treatment for CNCP, the clinician should 

refer the patient to an SUD specialist, if possible. Ideally, clinicians should develop a strong

referral network of substance abuse treatment 

clinicians who can collaborate in the care of 

these high-risk patients, but specialists may 

not always be available or accessible. Referral 

for an SUD does not obviate the need for pain

treatment because addiction treatment facilities rarely have the resources or expertise to 

treat pain. 

Patients may react negatively to a referral to an 

SUD specialist. To avoid surprising the patient 

and putting the specialist in an awkward situation, the clinician should clearly explain the 

purpose of the referral. When referring the 

patient, clinicians should: 

•	 Present the referral to the SUD specialist 

as they would a referral to any specialist,

using a matter-of-fact and unapologetic 

tone. 

•	 Explain to the patient the importance of 

assessing factors that may be contributing 

to chronic pain, including substance use,

and the problems SUDs or substance use 

may present for optimal treatment of 

chronic pain. 

•	 Avoid getting distracted by the patient’s 

explanation of his or her substance use. 

•	 Assure the patient that the referral does 

not mean transfer of care. The patient 

needs to know that care will be coordinated among all professionals involved,

if indicated, and that discussions of shortand long-term treatment will involve 

everyone, including the patient. 

exhibit 2-9 elements of screening, Brief Intervention, and referral to 

Treatment 

category Description 

Screening Identifies individuals with problems related to substance use. Screening 

can be through interview and self-report. 

Brief Intervention Follows a screening result indicating a moderate risk. A successful 

brief intervention encompasses support of the patient’s ability to make 

behavioral change. 

Brief Treatment Follows a screening result of moderate to high risk. Brief treatment 

includes assessment, education, solving problems, introducing coping 

mechanisms, and building a supportive social environment. 

Referral to Treatment Follows a screening result indicating severe abuse or dependence. This 

process facilitates access to care for individuals requiring more extensive treatment than SBIRT provides and ensures access to the appropriate level of care for all who are screened. 
24 

•	 Help the patient make the appointment

or make the appointment for the patient. 

The clinician–patient relationship is especially 

critical for patients who have comorbid pain 

and an SUD. They may anticipate that clinicians will criticize their substance use and 

discount their pain, and they may misinterpret 

a concern about an SUD as a lack of concern 

for their pain. They may blame themselves 

for having developed an SUD and expect 

the clinician to do the same. Therefore, the 

clinician must maintain an attitude of respect 

and concern. The clinician should assure the 

patient that both pain and the SUD are uninvited chronic illnesses and that both need to 

be treated concurrently. 

Federal regulations hold clinicians to a high 

standard of confidentiality regarding patient drug

and alcohol treatment information (Exhibit 

2-10). Appendix C provides elements of a 

written consent and a sample consent form 

from 42 Code of Federal Regulations (CFR). 

psychiatric comorbidities 

Both CNCP and SUDs are associated with 

high rates of psychiatric comorbidities, such as

anxiety, depression, PTSD, and somatoform 

disorders (Chelminski et al., 2005; Dersh,

Polatin, & Gatchel, 2002; Lebovits, 2000;

Manchikanti et al., 2007; Saffier, Colombo,

Brown, Mundt, & Fleming, 2007). Psychiatric

comorbidity can be preexisting, or it can 

exhibit 2-10 Federal protection of patient health Information 

regulation Description 

42 CFR Applies to substance abuse treatment programs. 

Protects the identities and records of patients in federally assisted 

drug and alcohol treatment programs. With few exceptions, clinicians must obtain written consent from a patient before disclosing 

any information regarding his or her identity or the specific type 

and extent of the patient’s health information, including that the 

patient is in an SUD treatment program. 

45 CFR and Health 

Insurance Portability and 

Accountability Act (HIPAA) 

Privacy Rule 

Applies to all clinicians. 

Regulates patient privacy in regard to public health. HIPAA Privacy 

Rule requires clinicians (or their hospitals and clinics) to safeguard 

information regarding patient identification and to: 

•	Notify individuals regarding their privacy rights and how their 

protected health information is used or disclosed. 

•	Adopt and implement internal privacy policies and procedures. 

•	Train employees to understand these privacy policies and procedures as appropriate for their functions within the covered entity. 

•	Designate individuals who are responsible for implementing privacy policies and procedures and who will receive privacy-related 

complaints. 

•	Establish privacy requirements in contracts with business associates that perform covered functions. 

•	Have in place appropriate administrative, technical, and physical 

safeguards to protect the privacy of health information. 

•	Meet obligations with respect to health consumers exercising 

their rights under the Privacy Rule. 
25 

2—Patient Assessment

develop or worsen with chronic pain or SUDs.

Therefore, the presence of comorbid psychiatric conditions should be assessed regularly in 

every patient with CNCP (see CSAT [2005b],

for information on treating SUDs in people 

with co-occurring disorders). 

Adults with chronic pain often exhibit fear 

about the loss of control over routine aspects 

of daily life; apprehension that clinicians

will view their pain reports as exaggerated,

imaginary, or contrived; and catastrophic

thinking (hopelessness based on a conviction that things are worse than they really

are). However, the distress that frequently

accompanies CNCP may or may not signal 

a psychiatric disorder, so the clinician should 

try to make the distinction. Nevertheless, the 

decision to treat is based on the patient’s level 

of suffering and not on whether the symptoms reach the threshold for a DSM-IV-TR 

diagnosis. It is often difficult to differentiate 

a substance-induced condition from a primary psychiatric disorder, and evaluation of 

symptoms over time may be necessary. Where 

indicated, refer patients to a mental health 

provider. Exhibit 2-11 identifies instruments 

to assess distress, anxiety, fear, and depression.

Information on obtaining these instruments is 

in Appendix B. 

Anxiety 

Anxiety is common among people with CNCP

and a current SUD, and it may persist in some 

people recovering from SUDs. It is frequently 

associated with depression but can be present 

without it. Patients who have CNCP, especially those with a history of trauma, have

increased rates of both anxiety symptoms and 

anxiety disorders (Dersh et al., 2002). 

The presence of an anxiety disorder has a 

negative effect on treatment of CNCP. Anxiety

contributes to patient suffering and can make 

patients less able to participate in their pain 

management. Treating anxiety lowers pain 

scores, reduces the need for analgesics, and 

improves quality of life. 

Depression 

Patients who have CNCP and comorbid 

depression tend to: 

•	 Have high pain scores. 

•	 Feel less in control of their lives. 

•	 Use passive–avoidant coping strategies. 

•	 Adhere less to treatment plans than 


patients who are not depressed.
 

•	 Have greater interference from pain,

including more pain behaviors observed 

by others. 

•	 Respond less well to pain treatment,


unless depression is addressed.
 

Clinical depression has been shown to worsen 

other medical illnesses, interfere with their 

ongoing management, and amplify their detrimental effects on health-related quality of 

life (Cassano & Fava, 2002; Gaynes, Burns,

Tweed, & Erickson, 2002). For these reasons,

depression should be treated. It may be difficult to determine whether a patient’s negative 

affect represents clinical depression or the psychological distress of chronic pain, an SUD, or 

other medical conditions. Sleep apnea, hypothyroidism, and hypogonadism can present 

as depression. Hypogonadism is particularly 

relevant because it can result from prolonged 

exposure to opioids. 

Post-Traumatic Stress Disorder 

CNCP and PTSD frequently co-occur;

Asmundson and colleagues (2002) report that 

PTSD symptoms are especially common in 

patients who have CNCP who have high pain 

scores, high pain affect, and high pain interference. Otis and colleagues (2003) recommend 

that patients presenting with either condition 

be assessed for both. 
26 

exhibit 2-11 Tools To Assess emotional Distress, Anxiety, pain-related Fear, 

and Depression 

Tool purpose Format Administration 

Time 

Beck Depression 

Inventory 

Measures depression 21 items 10 minutes 

Brief Patient Health 

Questionnaire 

Measures depression, panic, 

stress, and women’s health 

issues 

9 items on depression, 

1–5 items on panic, 13 

items on stress, and 

6 items on women’s 

health 

Varies 

Center for 

Epidemiologic 

Studies Depression 

Scale 

Measures how a patient has 

felt and behaved in past week 

20 items 5–10 minutes 

Geriatric 

Depression Scale 

Seeks yes/no responses to 

measure depression in older 

adults 

Short form: 15 items 

Long form: 30 items 

5–10 minutes 

Profile of Chronic 

Pain: Screen 

Measures pain severity, interference, and emotional burden 15 items 5 minutes 

Clinician 

Administered PTSD 

Scale 

Assesses for PTSD symptoms, 

the effect of symptoms on 

individual’s life, and the severity 

of symptoms 

30 items 45 minutes or 

more 

Davidson Trauma 

Scale 

Measures frequency and severity of PTSD symptoms 17 items 10 minutes 

Posttraumatic 

Diagnostic Scale 

Assesses for PTSD symptoms 

and severity of symptoms 

49 items 10-15 minutes 

State-Trait Anxiety 

Inventory 

Measures current anxiety and 

propensity for anxiety 

40 items 

Self-administered 

10–20 minutes 

Tampa Scale for 

Kinesiophobia 

Measures pain-related fear 

of movement; may predict 

disability 

17 items 

Self-administered 

5 minutes 

Symptoms for CNCP and PTSD often overlap (Asmundson et al., 2002). These include 

anxiety, hyperarousal, avoidance behavior,

emotional lability, and elevated somatic focus.

Both conditions are also characterized by 

hypervigilance, attentional bias, stress response,

and pain amplification. 

Symptoms may be mutually reinforcing. For 

example, if CNCP resulted from a trauma, the 

pain may trigger flashbacks. 

Somatization 

Somatization refers to inordinate preoccupation

with and communication about physical symptoms. Although a diagnosis of somatization 

disorder is rare in patients who have chronic 

pain, multiple pain complaints are almost

always present in somatization disorder. Many

patients who have multiple unexplained symptoms have subsyndromal forms of somatization

disorder. 
27 

2—Patient Assessment

 

This may be categorized as undifferentiated 

somatoform disorder. When psychological factors are thought to contribute to a pain syndrome, patients may be diagnosed with pain 

disorder with psychological factors or pain disorder with both psychological factors and a general 

medical condition. Patients who have chronic 

pain and medically unexplained symptoms are 

at risk for iatrogenic consequences of unneeded

diagnostic tests, medications, and surgery. 

Suicide 

Studies show an association between CNCP 

and suicidal ideation and suicide attempts 

that is not explained by the presence of cooccurring SUDs (Braden & Sullivan, 2008) 

or co-occurring mental disorders (Braden 

& Sullivan, 2008; Ratcliffe, Enns, Belik, & 

Sareen, 2008; Scott et al., 2010; Tang &

Crane, 2006). In their review of 12 articles on

suicide (including suicidal ideation and suicide

attempts) and CNCP, Tang & Crane (2006) 

found that the risk for suicide “appeared to be 

at least doubled” in patients who experienced 

CNPC (p. 575). (See CSAT [2009a], for 

information on addressing suicidal thoughts 

and behaviors in substance abuse treatment). 

Assessing Ability To cope With 

chronic pain 

Coping and anxiety are closely related, from 

a clinical viewpoint. The patient who has 

CNCP may have anxiety because of maladaptive coping skills, for example. The concept of 

acceptance has been studied in CNCP. This 

concept refers to the patient’s belief that there 

is more to life than pain, that being completely 

free of pain is unrealistic, and that activities 

should be pursued, even at the price of some 

increase in pain (Risdon, Eccleston, Crombez,

& McCracken, 2003). Patients who have high 

levels of acceptance report lower pain intensity, less pain-related anxiety and avoidance,

less depression, less physical and psychosocial 

disability, more daily uptime, and better work 

status than do patients who have not accepted 

pain. 

Patients who have chronic pain who score 

high on measures of self-efficacy or have an 

internal locus of control report lower levels of

pain, higher pain thresholds, increased exercise performance, and more positive coping 

efforts (Asghari, Julaeiha, & Godarsi, 2008;

Barry, Guo, Kerns, Duong, & Reid, 2003).

Exhibit 2-12 lists tools to assess coping skills.

Information on obtaining these instruments 

is provided in Appendix B. 

exhibit 2-12 Tools To Assess coping 

Tool purpose Format Administration 

Time 

Chronic Pain 

Acceptance 

Questionnaire 

Assesses willingness to 

experience pain and engage in 

activities 

20 items 

Self-administered 

5 minutes 

Fear-Avoidance 

Beliefs Questionnaire 

Assesses patients who have 

chronic low-back pain 

16 items 

Self-administered 

10 minutes 
28 

evaluating risk of Developing 

problematic opioid Use 

When any patient with a behavioral health 

disorder is considered for opioid therapy for 

CNCP, the clinician must carefully weigh the 

risks and benefits of opioid use. Risk assessment is made over time and may change over 

the course of treatment (Gourlay & Heit,

2009). A patient’s risk level is a matter of 

clinical judgment. Exhibit 2-13 presents one 

risk assessment schema. All patients who have

SUD histories have some risk, which in many 

cases can be safely managed. However, in some

patients, the risks of opioid use are so great 

and the likely benefit so small that they should

not be treated with chronic opioid therapies. 

Screening tools may be one element of a risk 

assessment. Two commonly used screening 

tools are the Screener and Opioid Assessment 

for Patients with Pain–Revised (SOAPP–R) 

and the Opioid Risk Tool (ORT). Both can 

be helpful for identifying patients at risk, but 

neither has been fully validated. Chapter 4 

describes tools for assessing patients who 

have already begun opioid therapy. 

Screener and Opioid Assessment for 

Patients with Pain–Revised 

SOAPP–R can predict which patients who 

have CNCP are at high risk for problems with 

chronic opioid therapy (Exhibit 2-14) (Butler,

Fernandez, Benoit, Budman, & Jamison,

2008). It is a self-administered questionnaire 

answered on a 5-point scale ranging from 0 

(never) to 4 (very often). The numeric ratings 

are added; a score of 18 or higher suggests 

the patient is at high risk for problems with 

chronic opioid therapy. 

Opioid Risk Tool 

Opioid Risk Tool (ORT; Webster & Webster,

2005) identifies patients at risk for aberrant 

drug-related behaviors (ADRBs) if prescribed 

opioids for CNCP (Exhibit 2-15). Like

SOAPP-R, ORT may help clinicians decide 

which patients may require close monitoring if

opioids are prescribed for them. Most patients 

who have CNCP and histories of behavioral 

health disorders are likely to have elevated 

scores, indicating a high level of risk on opioid

therapy. 

exhibit 2-13 risk of patient’s Developing problematic opioid Use 

risk characteristics of patient 

Low No history of substance abuse 

Minimal, if any, risk factors 

Medium History of non-opioid SUD 

Family history of substance abuse 

Personal or family history of mental illness 

History of nonadherence to scheduled medication therapy 

Poorly characterized pain problem 

History of injection-related diseases 

History of multiple unexplained medical events (e.g., trauma, burns) 

High Active SUD 

History of prescription opioid abuse 

Patient previously assigned to medium risk exhibiting aberrant behaviors 

Analgesic Research, personal communication, October 30, 2009. 
29 

2—Patient Assessment

exhibit 2-14 soApp–r Questions 

1. How often do you have mood swings? 

2. How often have you felt a need for higher doses of medication to treat your pain? 

3. How often have you felt impatient with your doctors? 

4. How often have you felt that things are just too overwhelming that you can’t handle 

them? 

5. How often is there tension in the home? 

6. How often have you counted pain pills to see how many are remaining? 

7. How often have you been concerned that people will judge you for taking pain 

medication? 

8. How often do you feel bored? 

9. How often have you taken more pain medication than you were supposed to? 

10. How often have you worried about being left alone? 

11. How often have you felt a craving for medication? 

12. How often have others expressed concern over your use of medication? 

13. How often have any of your close friends had a problem with alcohol or drugs? 

14. How often have others told you that you have a bad temper? 

15. How often have you felt consumed by the need to get pain medication? 

16. How often have you run out of pain medication early? 

17. How often have others kept you from getting what you deserve? 

18. How often, in your lifetime, have you had legal problems or been arrested? 

19. How often have you attended an Alcoholics Anonymous or Narcotics Anonymous 

meeting? 

20. How often have you been in an argument that was so out of control that someone 

got hurt? 

21. How often have you been sexually abused? 

22. How often have others suggested that you have a drug or alcohol problem? 

23. How often have you had to borrow pain medications from your family or friends? 

24. How often have you been treated for an alcohol or drug problem? 

Reprinted from Butler et al., 2008. Validation of the revised screener and opioid assessment for patients with pain. 

Journal of Pain, 9, 360–372. Used with permission from Elsevier. 
30 

exhibit 2-15 orT 

Item mark each Box 

That Applies 

Item score 

if Female 

Item score 

if male 

1. Family history of substance abuse 

Alcohol 

Illegal drugs 

Prescription drugs 







1 

2 

4 

3 

3 

4 

2. Personal history of substance abuse 

Alcohol 

Illegal drugs 

Prescription drugs 







3 

4 

5 

3 

4 

5 

3. Age (mark box if 16–45)  1 1 

4. History of preadolescent sexual abuse  3 0 

5. Psychological disease 

Attention deficit disorder, obsessivecompulsive disorder, bipolar, schizophrenia 

 2 2 

6. Depression  1 1 

Total ______ ______ 

Total score risk category 

Low risk: 0–3 

Moderate risk: 4–7 

High risk: ≥ 8 

Webster, L. R., & Webster, R. M. (2005). Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of 

the Opioid Risk Tool. Pain Medicine, 6(6), 432–442. Reproduced with permission of Blackwell Publishing, Ltd. 

ongoing Assessment 

Clinicians must assess all patients who have 

CNCP at regular intervals because a variety 

of factors can emerge that can alter treatment 

needs. For example, a patient may develop 

tolerance to a particular opioid, the underlying

disease condition may change another physical or mental health problem, which might 

develop or worsen, or there may be changes 

in the patient’s cognitive functioning. 

Comparative data can be obtained by using

the same assessment tools over time. For 

patients who have SUD histories or other

behavioral health disorders, regular assessments 

should include checking for evidence of medication misuse. Chapter 4 provides a discussion 

on assessing and documenting the behavior of 

patients on opioid therapy. 

The clinician should regularly: 

•	 Assess adherence to all the recommended 

treatment modalities. 

•	 Assess patient reactions to the treatment 

regimen. 

•	 Determine the extent of adherence to the 

prescribed regimen (otherwise, the reported

response may inaccurately reflect on the 

therapies prescribed). 
31 

2—Patient Assessment

•	 Obtain the perspectives of significant 

others on the patient’s relief from pain,

the effects of analgesia on function, and 

adherence to and safety with prescribed 

medications. (Permission to obtain col

lateral information is a prerequisite for 

prolonged opioid treatment.) 

Nicholson and Passik (2007) recommend that 

the elements in Exhibit 2-16 be documented 

and kept current in a patient’s record. The 

frequency with which these areas need to 

be assessed in individual patients is a matter

of clinical judgment. 

­

Treatment setting 

A clinician may conclude that optimal treatment includes more specialized care, such as 

that provided at a pain clinic. Where distance, 

exhibit 2-16 elements To Document During patient visits 

Area elements of Documentation 

History and Physical Evaluation History of present illness 

Pain score/intensity 

Medication history 

SUD/addiction history 

Screening tool assessments 

Medical history 

Physical examination 

Mental status/cognition 

Results of diagnostic studies 

Diagnostic/Clinical Indication for 

Prescribing Opioids 

Most probable pathological explanation of chronic pain 

Treatment Plan Pharmacological treatments 

Nonpharmacological treatments (e.g., physical therapy, 

exercise, behavioral therapy, lifestyle changes) 

Treatment goals and anticipated time course 

Adherence measures (e.g., urine drug testing, pill counts) 

Informed Consent and Agreements 

for Treatment 

Informed consent (e.g., discussion of risks and benefits of 

treatment options) 

Agreement specifying patient’s responsibilities and clinic 

policies 

Periodic Review Pain score/intensity 

Physical, occupational, and overall function; family and 

social relationships; and mood and sleep patterns 

Side effects (including severity) 

ADRBs 

Medication 

Mental status/cognitive changes 

Consultations and referrals As appropriate to provide comprehensive care 

Adapted from Nicholson & Passik, 2007. 
32 

costs, or other factors prohibit such a referral, the clinician must be resourceful, perhaps 

combining various local resources and support groups or suggesting specific electronic 

resources. Chapter 5 provides more details. 

The vast majority of chronic pain syndromes 

(e.g., lumbago, osteoarthritis) in patients 

who do not have major psychopathology or 

histories of SUDs (excluding tobacco) are 

managed by primary care physicians. When 

the pain syndrome is atypical, or when there 

is comorbid psychiatric illness or SUD history,

specialty consultation may be indicated. In the 

presence of current or past SUD, addictionology consultation may be necessary before 

instituting chronic therapy with scheduled 

medications. 

Key points 

•	 Patients should receive a comprehensive initial assessment. 

•	 It is important to discover the cause of a patient’s chronic pain; however, clinicians 

should not assume a patient is disingenuous if the cause is not discovered. 

•	 The patient’s personal and family substance use histories and current substance use patterns should be assessed. 

•	 It is crucial to obtain collateral information on the patient’s pain level and functioning, 

as well as SUD status. 

•	 Comorbid psychological disorders should be assessed and treated. 

•	 Assessment of the patient with co-occurring chronic pain and SUD or other behavioral 

health disorders should be ongoing. 
In This Chapter

 

3 chronic pain 


management
 

In ThIs chApTer 

•	Overview of Pain 

Management 

•	The Treatment Team 

•	Treating Patients in 

Recovery 

•	Nonpharmacological 

Treatments 

•	Treating Psychiatric 

Comorbidities 

•	Opioid Therapy 

•	Treating Patients in 

Medication-Assisted 

Recovery 

•	Treating Pain in Patients 

With Active Addiction 

•	Acute Pain Episodes 

•	Assessing Treatment 

Outcomes 

•	Key Points 

overview of pain management 

Chronic noncancer pain (CNCP) is a major challenge for clinicians 

as well as for the patients who suffer from it. The complete elimination of pain is rarely obtainable for any substantial period. Therefore,

patients and clinicians should discuss treatment goals that include 

reducing pain, maximizing function, and improving quality of life.

The best outcomes can be achieved when chronic pain management 

addresses co-occurring mental disorders (e.g., depression, anxiety) 

and when it incorporates suitable nonpharmacologic and complementary therapies for symptom management. Exhibit 3-1 presents 

the consensus panel’s recommended strategy for treating CNCP in 

adults who have or are in recovery from a substance use disorder 

(SUD). 

The Treatment Team 

Chronic pain management is often complex and time consuming. It 

can be particularly challenging and stressful for clinicians working 

without input from other clinicians. The effectiveness of multiple 

interventions is augmented when all medical and behavioral healthcare professionals involved collaborate as a team (Sanders, Harden,

& Vicente, 2005). A multidisciplinary team approach provides a 

breadth of perspectives and skills that can enhance outcomes and 

reduce stress on individual providers. Although it is ideal when all 

relevant providers work within the same system and under the same 

roof, often a collaborative team must be coordinated across a community. This combined effort requires identification of a designated 

lead care coordinator and a good system of communication among 

team members and the patient. A treatment team can include the 

following professionals: 

•	 Primary care provider 

•	 Addiction specialist 

•	 Pain clinician 

33 
34 

exhibit 3-1 Algorithm for managing chronic pain in patients With sUD 

•	 Nurse 

•	 Pharmacist 

•	 Psychiatrist 

•	 Psychologist 

•	 Other behavioral health treatment specialists (e.g., social worker, marriage and 

family therapist, counselor) 

•	 Physical or occupational therapists 

Addiction specialists, in particular, can make 

significant contributions to the management 

of chronic pain in patients who have SUDs.

They can: 

•	 Put safeguards in place to help patients 

take opioids appropriately. 

•	 Reinforce behavioral and self-care components of pain management. 
35 

3—Chronic Pain Management

•	 Work with patients to reduce stress. 

•	 Assess patients’ recovery support system. 

•	 Identify relapse. 

When the addiction specialist is the prescriber

of analgesics, medical responsibilities (e.g.,

prescribing of analgesics, physical therapy,

orthotics) should be coordinated with the 

clinician responsible for other components of

pain treatment. In some States, consultation 

with an addiction specialist is required before 

scheduled medications can be prescribed on 

a long-term basis to patients who have SUD 

histories. State laws, regulations, and policies 

are available at http://www.painpolicy.wisc.

edu/. 

The more complicated the case, the more 

beneficial a team approach becomes. However,

many clinicians will have to treat complex 

patients who have little or no outside 

resources. 

Treating patients in recovery 

A thorough patient assessment (see Chapter 

2) provides information that allows the clinician to judge the stability of a patient’s recovery from an SUD. Goals for treating CNCP 

in patients who are in long-term recovery 

or whose SUD is in the distant past are as 

follows: 

•	 Treat CNCP with non-opioid analgesics 

as determined by pathophysiology. 

•	 Recommend or prescribe nonpharmacological therapies (e.g., cognitive–behavioral

therapy [CBT], exercises to decrease pain 

and improve function). 

•	 Treat comorbidities. 

•	 Assess treatment outcomes. 

•	 Initiate opioid therapy only if the potential benefits outweigh risk and only for 

as long as it is unequivocally beneficial to 

the patient. 

Non-Opioid Analgesics 

Non-opioid pharmacological options include

acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs), as well as 

adjuvant medications—so called because they 

originally were developed for other purposes 

but have analgesic properties for certain conditions. The primary adjuvant analgesics are 

antidepressants and anticonvulsants. Exhibit 

3-2 presents a summary of these analgesics as 

they pertain to patients who have SUDs. 

Benzodiazepines 

Researchers disagree on the beneficial and 

harmful effects of benzodiazepines and benzodiazepine receptor agonists on chronic pain.

Several studies demonstrate increased pain 

exhibit 3-2 summary of non-opioid Analgesics 

Analgesic Addictive notes 

Acetaminophen No Should normally not exceed 4 g/day; in adults with 

hepatic disease, the maximum dose is 2 g/day. 

Potentiates analgesia without potentiating respiratory 

and sedative side effects. 

NSAIDs No Are used to relieve numerous types of pain, especially bone, dental, and inflammatory, and enhance 

opioid analgesia. May cause gastrointestinal bleeding and renal insufficiency. 

Serotonin-Norepinephrine 

Reuptake Inhibitors 

(SNRIs) 

No Are used to relieve several nonstructural types of 

pain (e.g., migraine, fibromyalgia, low back pain) and 

probably others. 
36 

exhibit 3-2 summary of non-opioid Analgesics (continued) 

Analgesic Addictive notes 

Tricyclic Antidepressants No Have demonstrated efficacy in migraine prophylaxis, 

fibromyalgia, many neuropathic pains, vulvodynia, 

and functional bowel disorders. Watch for anticholinergic side effects and orthostatic hypotension (fall 

risk in older people). 

Anticonvulsants No Some have demonstrated efficacy in relieving fibromyalgia, migraine prophylaxis, and neuropathic 

pains. 

Topical Analgesics No Comprise several unrelated substances (e.g., 

NSAIDs, capsaicin, local anesthetics). Work locally, 

not systemically, and therefore usually have minimal 

systemic side effects. 

Antipsychotics No Have no demonstrated analgesic effect, except to 

abort migraine/cluster headache. Risks include extrapyramidal reactions and metabolic syndrome. 

Muscle Relaxants Carisoprodol 

(Soma) is 

addictive. 

Some others 

have significant abuse 

potential. 

Have not been shown to be effective beyond the 

acute period. Some potentiate opioids and are not 

recommended. 

Benzodiazepines Yes Not recommended (see discussion). 

Cannabinoids Yes Not recommended (see discussion). 

with benzodiazepines or reduced pain following benzodiazepine antagonist use (Ciccone 

et al., 2000; Gear et al., 1997; Nemmani & 

Mogil, 2003; Pakulska & Czarnecka, 2001).

All benzodiazepines have side effects, including impaired coordination, reduced memory,

and addiction liability. For the following reasons, the consensus panel concludes that benzodiazepines have no role in the treatment of 

CNCP in patients who have comorbid SUD,

beyond very short-term, closely supervised 

treatment of acute anxiety states: 

•	 Guidelines from the American 

Psychiatric Association (2006) and the 

United Kingdom’s National Institute for 

Health and Clinical Excellence (Hughes 

et al., 2004) caution that benzodiazepines 

are not first-line medications. 

•	 Excellent options to benzodiazepines 


for treating anxiety exist (see Treating 


Psychiatric Comorbidities, below).
 

•	 Anxiolytic use in adults with CNCP is 

often protracted. 

•	 Benzodiazepines pose significant risk 


for addiction relapse and functional 


impairment.
 

The consensus panel recommends that clinicians

treat comorbid anxiety and insomnia with 

antidepressants or anticonvulsants. Some 

antidepressants (e.g., trazodone, mirtazapine,

amitriptyline, doxepin) may be useful sleep 

aids. Benzodiazepine weaning can be done 

in consultation with a psychiatrist or SUD 

treatment provider (see Center for Substance 

Abuse Treatment [CSAT], 2006). 
37 

3—Chronic Pain Management

Cannabinoids 

At least two types of cannabinoid receptors are 

present in the human nervous system, and they

interact with systems relevant to pain perception, including the serotonergic and dopaminergic systems. Cannabinoids are anti-inflammatory and increase levels of endogenous opioids. They inhibit glutamatergic transmission 

and antagonize the N-methyl-D-aspartate 

(NMDA) glutamate receptor, both of which 

actions would be expected to inhibit pain 

(Burns & Ineck, 2006; McCarberg, 2006). 

The primary psychoactive chemical in

marijuana responsible for its abuse potential 

is Δ9 tetrahydrocannabinol (THC). Synthetic

THC (Marinol) is approved in the United 

States for chemotherapy-induced nausea and 

AIDS-induced anorexia. Sativex, a mixture of 

THC and cannabidiol, is an oromucosal spray 

that spares the lungs the toxicity of drugs and 

smoke. It is analgesic in neuropathic pain and 

is approved in Canada for the pain of multiple 

sclerosis. Nabilone is a synthetic drug similar 

to THC. Its reported analgesic effects were 

determined to be weaker than codeine in a 

controlled study of neuropathic pain (Frank,

Serpell, Hughes, Matthews, & Kapur, 2008). 

Although it is reasonable to conclude that 

modulating the human cannabinoid system 

shows promise for treating pain, there is no 

reason to believe that inhaled smoke is an 

acceptable delivery mode. The consensus panel

does not recommend smoked marijuana for 

treating CNCP. 

nonpharmacological Treatments 

An approach to pain management that integrates evidence-based pharmacological and 

nonpharmacological treatments can ease pain 

and reduce reliance on medication. 

Nonpharmacological treatments for CNCP 

(Hart, 2008; Simpson, 2006): 

•	 Pose no risk of relapse. 

•	 May be more consistent with the recovering patient’s values and preferences than 

pharmacological treatments, especially 

opioid interventions. 

•	 May reduce pain and improve quality 

of life in some patients who have CNCP. 

•	 Should be included in most pain treatment plans. 

Common nonpharmacological therapies for 

CNCP include: 

•	 Therapeutic exercise. 

•	 Physical therapy (PT). 

•	 Cognitive–behavioral therapy (CBT). 

•	 Complementary and alternative medicine 

(CAM; e.g., chiropractic therapy, massage 

therapy, acupuncture, mind–body therapies,

relaxation strategies). 

Appendix D provides information on how to 

find qualified practitioners who provide CAM. 

Therapeutic Exercise 

A number of practitioners, including physicians,

chiropractors, and physical therapists, frequently include exercise instruction and supervised 

exercise components in CNCP treatment.

Therapeutic exercise can increase strength,

aerobic capacity, balance, and flexibility;

improve posture; and enhance general wellbeing. Fitness can be an antidote to the sense 

of helplessness and personal fragility experienced by many people with CNCP. Moderate 

evidence shows that exercise alleviates low 

back pain, neck pain, fibromyalgia, and other 

conditions. Furthermore, exercise reduces anxiety and depression. Limited evidence suggests 

that exercise benefits individuals undergoing 

SUD treatment (Weinstock, Barry, & Petry,

2008). 
38 

 

 

 

 

 

Physical Therapy 

PT facilitates recovery from a large variety 

of medical conditions, including cardiopulmonary, geriatric, pediatric, integumentary,

neurologic, and orthopedic. Neurologic PT 

and orthopedic PT are most likely to be used 

to treat chronic pain. Physical therapists use 

various hands-on approaches to help patients 

increase their range of motion, strength, and 

functioning. They also offer training in movement and exercises that help patients feel and 

function better. 

Many widely used interventions by physical

therapists lack definitive evidence. For example,

several Cochrane Collaboration reviews of a 

commonly used PT modality—transcutaneous

electrical nerve stimulation—found inconsistent evidence of effectiveness in a variety of 

chronic and acute pain conditions. Despite

this lack of an evidence base, PT interventions

have the advantages of being nonsurgical,

bringing low risk of injury or dependence,

and encouraging patients’ involvement in their 

own recovery. 

Cognitive–Behavioral Therapy 

Several studies have shown that CBT can 

help patients who have CNCP reduce pain 

and associated distress, disability, depression,

anxiety, and catastrophizing, as well as improve

coping, functioning, and sleep (McCracken, 

MacKichan, & Eccleston, 2007; Thorn et al.,

2007; Turner, Mancl, & Aaron, 2006; Vitiello,

Rybarczyk, Von Korff, & Stepanski, 2009). In 

addition to its salutary effects on pain syndromes, CBT also benefits people who have 

SUDs. In a meta-analysis of 53 controlled 

trials of CBT for alcohol or illicit drug disorders, CBT was found to produce a small but 

significant benefit (Magill & Ray, 2009). 

Complementary and Alternative 

Medicine 

CAM includes health systems, practices, and 

products that are not necessarily considered 

part of conventional medicine (National

Center for Complementary and Alternative 

Medicine, 2007). Surveys show that 27–60 

percent of chronic pain patients use CAM 

(Fleming, Rabago, Mundt, & Fleming, 2007;

McEachrane-Gross, Liebschutz, & Berlowitz,

2006; Nayak, Matheis, Agostinelli, & Shifleft,

2001). Clinicians are urged to learn about 

these approaches to pain treatment not only 

because of their therapeutic promise, but also 

because many patients use CAM, raising the 

possibility of interactions with conventional 

treatments (Simpson, 2006). Exhibit 3-3

presents one way to ask patients about their

use of CAM. 

The evidence supporting CAM interventions 

for adults with comorbid CNCP and SUD is 

exhibit 3-3 Talking With patients About complementary and Alternative 

medicine 

Clinician “So many of my patients use alternative medicine that I always ask about it. Are you 

using vitamins, herbs, acupuncture, that sort of thing for pain or for anything else?” 

Patient “Yeah. Acupuncture really helped when I was in rehab, and I still get it now and then. 

She does the needles and gives me Chinese herbs once in a while.” 

Clinician “That’s fine. If it helps, keep doing it. And when you take herbs or anything else she 

gives you, please tell me. I want to make sure that any herbs or medicines that you get 

from your acupuncturist won’t interfere with the treatment that you are getting here, 

okay?” 
39 

3—Chronic Pain Management

 

 

 

ambiguous. These conditions are complex and 

multifactorial and, therefore, difficult to study.

Many systematic reviews of CAM research 

note generally poor-quality reporting and heterogeneous methodology that precludes definitive evidence-based conclusions (e.g., Gagnier,

van Tulder, Berman, & Bombardier, 2006). Of 

the CAM interventions, manual therapies are 

the most widely used and the most studied 

(Simpson, 2006). Chiropractic and massage 

therapies are often covered by health insurance, making these therapies accessible and 

compatible with conventional therapies. 

Treating psychiatric comorbidities 

Research shows well-established associations 

among chronic pain, SUDs, and mental disorders (e.g., depression, anxiety, post-traumatic 

stress disorder [PTSD], somatoform disorders) 

(Chelminski et al., 2005; Covington, 2007;

Manchikanti et al., 2007; Saffier, Colombo,

Brown, Mundt, & Fleming, 2007; Wasan et 

al., 2007). Psychiatric comorbidity is of special 

significance for two reasons. First, it is often 

occult. Second, untreated psychopathology is 

associated with poor pain treatment outcomes 

(Edwards et al., 2007; Williams, Jones, Shen,

Robinson, & Kroenke, 2004). Therefore,

management of patients who have CNCP

must include intervention for co-occurring 

psychopathology. 

Because psychiatric comorbid disorders might 

be preexisting, or they may develop or worsen 

with chronic pain or SUDs, it is important to 

determine the onset of psychiatric symptoms 

during the screening and assessment process 

(see Chapter 2). The psychiatric disorder

needs to be included in the comprehensive

treatment plan that is developed for the

patient in consultation with the patient’s 

treatment team (e.g., primary healthcare

provider, substance abuse treatment counselor, 

pain management provider, mental health 

professional). CSAT (2005b) provides detailed 

information on treatment strategies and models for working with individuals with a wide 

spectrum of psychiatric co-occurring disorders. 

Benzodiazepines are generally indicated for 

short-term treatment of anxiety; however, anxiety associated with chronic pain commonly 

persists for years. Effective options include 

(Van Ameringen, Mancini, Pipe, & Bennett,

2004): 

•	 Psychological and behavioral treatments. 

•	 Selective serotonin reuptake inhibitors 


(SSRIs).
 

•	 SNRIs. 

•	 Tricyclic antidepressants. 

•	 Several anticonvulsants. 

The anxiety that is often comorbid with 

CNCP can often be managed satisfactorily 

with adjuvants prescribed for the pain syndrome. Several anticonvulsants that are used 

for CNCP are strongly anxiolytic. In a review,

Van Ameringen and colleagues (2004) found 

that the strongest evidence was for pregabalin 

(for social phobia and generalized anxiety 

disorder), gabapentin (for social phobia),

lamotrigine (for PTSD), and valproic acid 

(for panic disorder). In addition, many antidepressants are effective for chronic pain and 

may be used to treat comorbid anxiety and 

depression, and both duloxetine and venlafaxine have been approved by the Food and Drug 

Administration for treatment of generalized 

anxiety disorder. Most tricyclic antidepressants 

are anxiolytic. Trazodone has also been found 

to be anxiolytic and is often used as a sedative in patients for whom benzodiazepine-like 

agents are undesirable. Treating comorbidities 

with medications that also alleviate pain can 

reduce polypharmacy, drug interactions, nonadherence, and, at times, financial costs. 
40 

 

The person who somatizes extensively may 

present a plethora of complaints. This situation may lead to the clinician’s inappropriate 

discounting of all the patient’s symptoms as 

trivial or imaginary. Clinicians should take the 

following steps in treating such a patient: 

•	 Complete an inventory of all the patient’s 

complaints. 

•	 Emphasize history and physical examination in the evaluation. 

•	 Validate the patient’s symptoms while 


assuring him or her about the absence 


of worrisome pathology.
 

•	 Minimize expensive or invasive tests and 

treatments. 

•	 Minimize use of medications with abuse 

liability, especially short-acting medications used as needed (PRN). 

•	 Minimize use of passive modalities of 


therapy.
 

•	 Schedule regular appointments rather 


than PRN visits.
 

•	 Adequately treat comorbid Axis I (i.e.,

major psychiatric) disorders. 

•	 Refer patients for counseling or relaxation 

training, as available. 

opioid Therapy 

Limitations 

Opioids are potent analgesics that may provide 

relief for many types of CNCP. However, even 

when effective, they have limitations, such as 

diminished efficacy over time (Ballantyne,

2006; Noble, Tregear, Treadwell, & Schoelles,

2008). Opioids also have adverse effects that 

many patients cannot tolerate (e.g., nausea,

sedation, constipation). Other drawbacks 

include risk of addiction or addiction relapse,

opioid-induced hyperalgesia (OIH), and

many potential drug interactions. Serotonin 

syndrome is a potential adverse effect of both 

opioids and some medications used to treat 

depression, obsessive-compulsive disorder, or 

other behavioral health disorders. Serotonin 

syndrome can cause agitation, confusion, fever,

and seizures, and it can be lethal if undetected 

or untreated. Patients who take SSRIs, SNRIs,

St. John’s Wort, monoamine oxidase inhibitors,

lithium, or HIV medications are at increased 

risk of serotonin syndrome (U.S. Food and 

Drug Administration, 2006). In addition,

patients who take opioids chronically are at 

increased risk of serotonin syndrome if medications such as fentanyl, meperidine, or pentazocaine are needed in emergency or surgical 

care settings. 

Although opioids are an important treatment 

component for many patients, they are rarely 

sufficient. Chronic opioid therapy rarely shows 

more than one-third pain reduction in studies 

extending beyond 18 months, indicating that 

opioids are best used as one part of a multidimensional approach for most patients. 

When an SUD co-occurs with CNCP, the 

benefits of opioids are not well established and

risk of relapse is increased (Reid et al., 2002).

Studies indicate that most patients who are 

currently addicted to prescription opioids had 

a prior SUD, suggesting that people in recovery are at increased risk for relapse (Potter 

et al., 2004; Rosenblum et al., 2003). This 

may be especially true when the prior SUD 

involved opioids, because one of the most 

powerful triggers for relapse is exposure to 

the former drug of choice (Daley et al., 2003;

Gardner, 2000). Trescot and colleagues (2008) 

provide a detailed review. 

Before Initiating Opioid Treatment 

Exhibit 3-4 shows steps to take before initiating opioid therapy. Information about patient 

education, informed consent, and treatment 

plans is provided in Chapter 5. 
41 

3—Chronic Pain Management

 

Opioid Selection 

For patients who have histories of SUDs, it is 

essential to minimize exposure to the euphoric 

effects of opioids. To reduce the likelihood of 

such effects, clinicians should: 

•	 Select opioids with minimal rewarding 

properties (e.g., tramadol, codeine), when 

effective. 

•	 Avoid prescribing supratherapeutic doses 

(usually demonstrated by presence of 

sedation, lethargy, functional impairment). 

•	 If higher potency opioids are required,

prescribe slow-onset opioids with 

prolonged duration of action (Mironer,

Brown, Satterthwaite, Haasis, & 

LaTourette, 2000). 

Short-acting medications have been recommended to be used preemptively before

activities known to cause pain, such as PT,

or for pain limited to certain times of day.

There is controversy regarding the appropriateness of this suggestion for patients who 

have CNCP (Devulder, Jacobs, Richarz, & 

Wigget, 2009), and the practice is especially 

hazardous in people with current or past 

SUDs. 

The route of administration may influence 

addiction risk, so medications that are injected

or easily convertible to forms that can be 

injected, smoked, or snorted are often avoided 

in patients who have SUDs. Some clinicians 

favor transdermal medication, with an agreement that refills are contingent on the patient’s 

returning the used patches to demonstrate that 

they were not punctured, cut, or diverted. 

Dose Finding 

Dose finding for the patient with an SUD,

especially a history of abuse of or dependence 

on opioids, can be complicated because of 

existing or rapidly developing tolerance to 

opioids. Also, analgesics affect individuals differently. A person who states that a particular 

opioid “doesn’t work for me,” whereas another 

opioid does, may be accurately reporting analgesic response. 

Titration schedules appropriate for the patient 

with no SUD history may expose the patient 

in SUD recovery to a protracted period of 

inadequate relief. Although no schedule can 

be applied to everyone, a general guide is that,

if low doses of opioids (other than methadone) are initiated for severe pain, they should

be titrated rapidly to avoid subjecting the

patient to a prolonged period of dose finding.

However, if relatively high doses are initiated,

titration should be slower and determined to 

a great extent by the half-life of the drug. For 

some patients, increasing the dose may lead to 

exhibit 3-4 steps To Take If opioid Therapy Is Indicated 

Step 1. Educate patient and family about treatment options, sharing the decision about the goal 

and expected outcome of therapy. 

Step 2. Discuss treatment agreement with the patient and family. 

Step 3. Obtain a written opioid agreement. 

Step 4. Determine and document the treatment plan. 

Step 5. Initiate a trial of opioid therapy. 

Step 6. Document details of therapy and results. 

Department of Veterans Affairs & Department of Defense, 2010. 
42 

decreased functioning. It is essential that clinicians understand that dose finding for methadone can be dangerous (see Exhibit 3-5). 

When an effective dose for a given patient 

has been determined, total opioid dose should 

thereafter be escalated very slowly, if at all, as 

tolerance develops. No study has ever shown 

that opioids eliminate chronic pain, other than 

in the very short term, so efforts to achieve 

a zero pain level with opioids will fail, while 

subjecting the patient to potentially intoxicating doses of the medication. 

Relapse 

For patients on chronic opioid therapy who 

have minor relapses and quickly regain stability, provision of substance abuse counseling,

either in the medical setting or through a formal addiction program, may suffice. Opioids,

if their continuation is deemed safe, must be 

very closely monitored, with short dispensing

intervals and frequent urine drug testing.

Unfortunately, many addiction treatment programs are unwilling to admit patients who are 

taking opioid pain medications, interpreting 

their prescription opioid use as a sign of active 

addiction. 

Clinicians prescribing opioids need to establish

relationships with substance abuse treatment 

providers who are willing to provide services 

for patients who need additional support in 

their recovery but do not require extensive 

services. For clinicians who treat a population 

with high levels of comorbid addiction, the 

development of onsite chemical dependence 

counseling services can be extremely helpful. 

For relapse in patients for whom opioid 

addiction is a serious problem, referral to 

an opioid treatment program (OTP) for 

methadone maintenance therapy (MMT) 

may be the best choice. Such programs will 

not generally accept patients whose primary 

problem is pain because they do not have 

the resources to provide comprehensive pain 

management services. Patients who have 

chronic pain likely will not obtain adequate 

pain control through the single daily dose 

of methadone that can be provided through 

an OTP. Such programs may, however, be 

willing to collaborate in the management of 

patients, providing addiction treatment and 

allowing the prescription of additional opioids 

for pain management through a medical 

provider. Such arrangements require close 

communication between the OTP and the 

prescribing clinician so that patients who do 

not respond to SUD treatment can be safely 

withdrawn from opioids prescribed for pain.

CSAT (2005a) provides more information 

about OTPs. 

exhibit 3-5 methadone Titration 

The titration of methadone for chronic pain is complex and potentially dangerous because methadone levels increase during the first few days of treatment. This risk is compounded by the variable 

half-life among individuals and the large number of drug interactions. In addition, cardiac toxicity 

(e.g., QT prolongation, torsade de pointes) is possible. The majority of deaths secondary to methadone occur in the first 14 days of use because: 

•	The initial dose is too high. 

•	It is titrated too quickly. 

•	It interacts with other drugs or medications. 

Chou, Fanciullo, Fine, Adler, et al., 2009; Weschules, Baib, & Richeimer, 2008. 
43 

3—Chronic Pain Management

 

Another option for patients who have comorbid active addiction and CNCP is replacement 

of full agonist opioids with the partial opioid 

agonist buprenorphine (Heit, Covington, & 

Good, 2004; Heit & Gourlay, 2008). Benefits

of this treatment include that dose escalation 

does not provide reinforcement and that 

the effects of other opioid substances may 

be attenuated. Buprenorphine can prevent 

withdrawal symptoms, allowing patients to 

stabilize and facilitating their progression into 

non-opioid and nonpharmacologic forms of 

pain treatment. However, buprenorphine prescribed specifically for pain is currently an offlabel use (see Treating Patients in MedicationAssisted Recovery). 

Opioid Discontinuation 

Opioids should be discontinued if patient 

harm and public safety outweigh benefit. This

situation may be apparent early in therapy,

for example, if function is impaired by doses 

necessary to achieve useful analgesia. Harm 

also may outweigh benefit after a long period 

of successful treatment. Discontinuation of 

opioid therapy is addressed in Chapter 4. 

Treating patients in medicationAssisted recovery 

Goals for treating CNCP in patients who are 

in medication-assisted recovery are the same 

as for patients who are in recovery without 

medications: reduce pain and craving and 

improve function. As with other patients: 

•	 Start with recommending or prescribing 

nonpharmacological and non-opioid 

therapies. 

•	 Treat comorbidities. 

•	 Closely monitor treatment outcomes for 

evidence of benefit and harm. 

Patients receiving opioid agonist treatment 

for addiction require special consideration 

when being treated for chronic pain. In these 

patients, the schedule and doses of opioid agonists sufficient to block withdrawal and craving are unlikely to provide adequate analgesia.

Because of tolerance, a higher-than-usual dose 

of opioids may be needed (in addition to the 

maintenance dose) to provide pain relief. 

Buprenorphine 

Patients who have CNCP and are using 

sublingual buprenorphine treatment of opioid

addiction pose special challenges. The drug 

is a partial mu agonist that binds tightly to 

the receptor. Because it is a partial agonist, its 

dose–response curve plateaus or even declines 

as the dose is increased. Thus, a ceiling dose 

limits both the available analgesia and the 

toxicity produced by overdose. Nevertheless,

buprenorphine is an effective analgesic, and 

some patients who have addiction and CNCP 

may receive benefit for both conditions from 

it. To optimize analgesic efficacy, the drug 

should be given three times a day when pain 

reduction is a goal. High doses of buprenorphine can attenuate the effects of pure mu 

agonists given in addition to it. High doses 

tend to reduce the reinforcing effects of inappropriately consumed opioids but, at the same 

time, may reduce the effectiveness of opioids 

given for additional analgesia in the case of 

trauma or acute illness (Alford, Compton, & 

Samet, 2006). 

Because buprenorphine has such high affinity 

for the mu receptor, it displaces full agonists 

and can induce acute opioid withdrawal; for 

example, if a patient on chronic methadone is 

given a dose of buprenorphine, acute opioid 

withdrawal may be precipitated (see CSAT 

[2004] for more information). 

The use of buprenorphine for pain is offlabel, albeit legal. Whereas clinicians must 

obtain a waiver to prescribe buprenorphine 

for an SUD, only a Drug Enforcement 
44 

Administration (DEA) registration is required 

to prescribe buprenorphine for pain. To clarify 

(for pharmacists) that a prescription does not 

require the special DEA number, it is useful 

to specify on the prescription that the drug 

is “for pain.” 

Methadone 

Patients who have chronic pain do not obtain 

adequate pain control through a single daily 

dose of methadone because the analgesic effects

of methadone are short acting in comparison 

with its half-life. The dosing schedule for

the treatment of opioid addiction does not

effectively treat pain, although the single dose 

often provides transient analgesia. 

Methadone effects vary significantly from 

patient to patient, and finding a safe dose is 

difficult. Methadone’s analgesic effects last 

approximately 6 hours. However, its halflife is variable and may be up to 36 hours in 

some patients. Pain patients may take 10 days 

or longer to stabilize on methadone, so the 

clinician must titrate very slowly and balance 

the risk of insufficient dosing with the lifethreatening dangers of overdosing (Heit & 

Gourlay, 2008) (Exhibit 3-5). It is critical for 

the clinician to advise patients to stop methadone treatment if they become sedated. 

Methadone is an especially desirable analgesic 

for chronic use because of its low cost and 

its relatively slow development of analgesic 

tolerance; however, it is also especially toxic 

because of issues of accumulation, drug interaction, and QT prolongation. For these reasons,

it should be prescribed only by providers who 

are thoroughly familiar with it. 

It is critical that patients starting methadone 

receive a thorough education in the dangers 

of inadvertent overdose with this medication. 

They must understand that a dose that seems 

initially inadequate can be toxic a few days

later because of accumulation. They should be 

advised to keep the medication out of reach 

so that they cannot take a dose when sedated.

Furthermore, they must be informed of the 

extreme danger if a child or nontolerant adult 

ingests their medication. Chapter 5 provides 

more patient education information, and 

CSAT (2009b) describes emerging issues 

in the use of methadone. 

Naltrexone 

Patients taking naltrexone should not be 

prescribed outpatient opioids for any reason.

Naltrexone is a long-acting oral or injectable 

mu antagonist that blocks the effects of opioids.

It also reduces alcohol consumption by impeding its rewarding effects. Because naltrexone 

displaces opioid agonists from their binding 

sites, opioid analgesics will not be effective 

in patients on naltrexone. Increasing the dose 

of opioids to overcome the blockade puts 

the patient at risk of respiratory arrest. Pain 

relief for these patients requires non-opioid 

modalities. 

If patients on naltrexone require emergency 

opioids for acute pain, higher doses are required,

which, if continued, can become toxic as naltrexone levels wane. In this situation, inpatient 

or prolonged emergency department monitoring

is required (Covington, 2008). 

Tolerance and hyperalgesia 

Tolerance develops rapidly to the sedating,

euphoric, and anxiolytic effects of opioids.

It develops more slowly to their analgesic 

effects and seldom develops to their constipating effects. Tolerance can be characterized 

as decreased sensitivity to opioids, whereas 

OIH is increased sensitivity to pain resulting 

from opioid use. In a clinical setting, it may 

be impossible to distinguish between the two 

conditions, and they may coexist (Angst & 

Clark, 2006). Tolerance can develop in chronic 

opioid therapy regardless of opioid type, dose,

route of administration, and administration 
45 

3—Chronic Pain Management

schedules (DuPen, Shen, & Ersek, 2007).

Hyperalgesia has been found to result from 

the use of those opioids thus far studied (i.e.,

methadone, buprenorphine, sufentanyl, fentanyl, morphine, heroin). Patients in MMT experience analgesic tolerance and OIH. Clinical 

implications of these findings are unclear, as 

studies indicate that OIH may develop to 

some measures of pain (e.g., cold pressor test) 

and not to others (e.g., pressure) (Mao, 2002). 

When patients develop tolerance to the 

analgesic effects of a particular opioid, either 

dose escalation or opioid rotation may be 

useful (Exhibit 3-6). Opioid rotation, switching from one opioid to another, is a way to 

exploit incomplete cross-tolerance to achieve 

improved analgesia without an increase in 

(equivalent) doses. 

If a patient requests an increase in opioid dose,

it is important for the clinician to try to discern

whether the patient is experiencing increased 

pain or analgesic tolerance or is seeking some 

other effect (e.g., sedation, reduced anxiety).

In the patient seeking sedation or reduced 

anxiety, a larger opioid dose provides temporary

anxiolytic or sedative effects, but tolerance soon

develops, necessitating another dose increase.

To avoid a cycle of dose increases, the clinician 

should evaluate the patient’s request. When 

nonanalgesic effects seem to be the basis for 

the request, alternative non-opioid medications

should be provided and opioid doses should 

not be increased. 

As with tolerance, OIH appears to require 

increased doses of opioids to achieve previous levels of analgesia. However, with OIH,

increased doses could exacerbate pain. Treating 

pain with a multimodal approach—in addition

to analgesics—may reduce the need for opioids,

thereby decreasing the risk of tolerance and 

OIH. 

Treating pain in patients Who 

have Active Addiction 

The presence of active addiction—whether to 

alcohol, opioids, or other substances—makes 

successful treatment of chronic pain improbable (Covington, 2008; Weaver & Schnoll,

2007). For patients who have active addiction 

and CNCP, it may be impossible for clinicians in the primary care setting to provide 

the comprehensive services necessary to treat 

both conditions. Specifically, an active SUD 

indicates that the patient should be referred 

for formal addiction treatment. The clinician 

should work closely with the patient’s SUD 

treatment provider. 

If the patient refuses the SUD referral, the

clinician can use motivational interviewing

techniques. CSAT (1999b) provides more

information on motivational interviewing. If 

the patient still does not consent to addiction 

treatment, he or she should not be prescribed 

scheduled medications, except for acute pain 

or detoxification. CSAT (2006) provides more 

information on detoxification. 

exhibit 3-6 opioid rotation 

When an opioid is ineffective, becomes ineffective, or produces intolerable side effects, it is common practice to rotate opioids. This practice is based on the observation that particular opioids 

affect people differently, primarily because of intraindividual and interindividual variability among 

opiate receptors, so-called mu-receptor polymorphism. Although most opioid analgesics are mu 

agonists, they affect some mu receptors differently from others. A Cochrane review (Quigley, 2004) 

looked at the evidence supporting the replacement of an opioid to which an individual has developed analgesic tolerance with a different opioid. The conclusion was that although evidence is 

scant, the practice appears to be efficacious. The most common opioid rotation, and most studied, 

is from morphine to methadone. 
46 

Once the patient’s SUD recovery is stable, the 

likelihood of managing his or her pain increases.

The need for formal addiction treatment often 

necessitates a change in the plan for opioids,

by discontinuing them or by changing the 

treatment setting through which they are 

provided. 

Acute pain episodes 

When patients who have CNCP and an SUD 

require acute pain management, such as for 

postoperative pain, precautionary steps can 

minimize risk of relapse. 

Patients in recovery may benefit from nonpharmacological pain control. Some patients 

in recovery from SUDs may prefer to avoid 

the use of any medication. Evidence shows 

that stress management, CBT, manual therapies, and acupuncture offer effective relief for 

certain types of acute pain (Hurwitz et al.,

2008; Vernon, Humphreys, & Hagino, 2007). 

Patients in recovery may benefit from being 

switched from short- to long-acting medications as quickly as appropriate (to minimize 

reinforcing effects). They may also benefit 

from bolstered recovery support during postoperative periods (Covington, 2008). 

Patients on agonist therapy for addiction or

pain may be continued on their current opioid 

or on an equivalent dose of an alternative opioid; however, this should not be expected to 

control acute pain, which requires supplementation with (often greater-than-usual doses of ) 

additional opioids. In this situation, adjuvant 

NSAIDs may allow clinicians to provide 

pain relief with a reduction in opioid dosage 

(Mehta & Langford, 2006), and multimodal 

analgesia should be considered (Maheshwari,

Boutary, Yun, Sirianni, & Dorr, 2006). 

Patients on buprenorphine for opioid

addiction may have reduced benefit from full 

agonist opioids used for acute pain, because 

the full agonist will be somewhat blocked.

Non-opioid analgesics can be used, but in 

some cases buprenorphine will need to be discontinued so that full agonist opioids for pain 

can be used (Alford et al., 2006). 

Patient-controlled analgesia should have 

relatively high bolus doses and short lockout 

intervals (specified intervals during which 

pressing the administration button results 

in no drug delivery), and patients should be 

closely monitored by medical staff. Pulse 

oximetry or end-tidal CO monitoring may 2

provide an additional margin of safety when 

high doses of opioids are required. 

Patients who are dependent on opioids or

sedatives (including benzodiazepines) should 

not be withdrawn from these medications 

while undergoing acute medical interventions. 

Exhibit 3-7 provides a discussion of treating 

patients who have sickle cell disease (SCD),

which brings recurring acute pain, often 

against a backdrop of persistent pain and 

hyperalgesia. 

Other comorbidities that can complicate pain 

treatment result from other chronic illnesses. 

Exhibit 3-8 offers suggestions for providers 

for treating CNCP in patients who have HIV/

AIDS. 

Assessing Treatment outcomes 

Treatment of chronic pain is usually an evolving

process, with medication and adjunctive therapies attempted, monitored, and adjusted or 

abandoned as indicated by patient response.

Chapter 2 provides information about ongoing

assessments. 
47 

3—Chronic Pain Management

exhibit 3-7 Treating patients Who have sickle cell Disease 

SCD is characterized by crises of acute pain, attributed to vasoocclusion, that is typically nociceptive but can be neuropathic as well. Opioids are the mainstay of treatment, although parenteral 

ketorolac may suffice in some crises and have opioid-sparing effects in others. 

Acute pain management is critical but is often poorly conducted. At times, mutual mistrust 

between the patient and the clinician may lead to fears of being discounted on the part of the 

patient and suspicions of symptom exaggeration on the part of the clinician. 

The development of CNCP further complicates the situation. When there is a clear structural 

explanation for pain (e.g., leg ulcers, avascular necrosis, osteomyelitis), appropriate (typically opioid) therapy is usually provided. Many patients, however, report chronic pain in the absence of 

detectable peripheral pathology. This pain has been attributed to central sensitization as a result 

of multiple episodes of severe pain. It can also result from ischemic neuropathic conditions. A small 

percentage of patients who have SCD develop an SUD, which adversely impact their pain reports 

and treatment responses. 

It is generally accepted that appropriate treatment of an SCD crisis requires prompt and aggressive 

analgesia. Some hospitals and emergency departments keep a log of SCD patients that documents 

their degree of opioid tolerance, typically effective agents, and doses required so that near-immediate relief can be provided to patients presenting for care. Chronic pain with persistent tissue 

pathology likely requires continuation of substantial opioid doses for acceptable relief, although 

peripheral and adjuvant agents should be used as appropriate. 

The treatment of chronic idiopathic pain in SCD often requires a multidisciplinary approach with 

emphasis on adjuvant analgesics and nonpharmacological therapies, including psychological therapies (Ballas, 2007). 

exhibit 3-8 Treating patients Who have hIv/AIDs 

A vast range of pain syndromes are common in patients who have HIV/AIDS. Some are the result 

of HIV infection, others result from immunosuppression, and others are unrelated but comorbid 

with AIDS. Pain commonly results from painful neuropathy, Kaposi’s sarcoma, herpes zoster, candida esophagitis, drug-induced pancreatitis, headache (including those resulting from meningitis), 

and numerous types of joint and myofascial pains. 

Patients are often both indigent and negatively viewed by clinicians—conditions that lead to 

reduced access to pain care. The patients may be sick, frail, and cachectic, creating challenges in 

the use of pharmacotherapies. A large number of patients have a comorbid SUD, which complicates 

the use of opioid analgesics. 

Core principles of treating CNCP, such as meticulous diagnosis of the pain mechanism and etiology 

and monitoring for benefits and adverse effects of treatment, and use of the World Health 

Organization’s pain ladder (see http://www.who.int/cancer/palliative/painladder/en/index.html) 

for titrating analgesics are applicable in this population. However, addressing the psychological 

aspects of the illness, as well as functional restoration, is especially important. Nonpharmacological 

therapies, including PT modalities, acupuncture, biofeedback training, and hypnosis, may be 

helpful. 

Breitbart, 2003. 
48 

Key points 

•	 Pain treatment goals should include improved functioning and pain reduction. 

•	 Treatment for pain and comorbidities should be integrated. 

•	 Non-opioid pharmacological and nonpharmacological therapies, including CAM,

should be considered routine before opioid treatment is initiated. 

•	 Opioids may be necessary and should not be ruled out based on an individual’s having

an SUD history. 

•	 The decision to treat pain with opioids should be based on a careful consideration of 

benefits and risks. 

•	 Addiction specialists should be part of the treatment team and should be consulted in 

the development of the pain treatment plan, when possible. 

•	 A substantial percentage of patients with and without SUDs will fail to benefit from 

prolonged opioid therapy, in which case it should be discontinued, as with any other 

failed treatment. 
In This Chapter

4 managing Addiction risk 

in patients Treated With 

opioids 

In ThIs chApTer 

•	Promoting Adherence 

•	Urine Drug Testing 

•	Inclusion of Family, 

Friends, and Others 

•	Nonadherence 

•	Tools To Assess ADRBs 

•	Documenting Care 

•	Managing Difficult 

Conversations 

•	Workplace Safety 

•	Drug Diversion 

•	Discontinuation of 

Opioid Therapy 

•	Key Points 

promoting Adherence 

Clinicians should adopt a universal precautions approach toward 

their patients who have chronic noncancer pain (CNCP) (Exhibit 

4-1). The term universal precautions first emerged in the context of 

infectious disease treatment and referred to using infection control 

procedures with all patients. In the context of pain treatment, a 

universal precautions approach refers to a minimum standard of care 

applied to all patients who have CNCP, whatever their assessed 

risk (Gourlay, Heit, & Almahrezi, 2005). A universal precautions

approach improves care and shows due diligence in an era of 

increasing illegal use of prescription opioids. 

Clinicians can help patients adhere to treatment plans by: 

•	 Employing treatment agreements. 

•	 Regulating visit intervals. 

exhibit 4-1 Ten steps of Universal precautions 

1. Make a diagnosis with appropriate differential. 

2. Perform a psychological assessment, including risk of addictive disorders. 

3. Obtain informed consent. 

4. Use a treatment agreement. 

5. Conduct assessments of pain level and function before and 

after the intervention. 

6. Begin an appropriate trial of opioid therapy with or without 

adjunctive medications and therapies. 

7. Reassess pain score and level of function. 

8. Regularly assess the “4As” of pain medication (see 

Documenting Care, below). 

9. Periodically review pain diagnosis and co-occurring conditions, including addictive disorders. 

10. Document initial evaluation and followup visits. 

Adapted from Gourlay et al., 2005. 

49 
50 

•	 Controlling medication supply. 

•	 Conducting urine drug testing (UDT). 

•	 To the degree possible, including the 

patient’s support network in monitoring 

efforts. 

Treatment Agreements 

A treatment agreement can be used to gauge 

and reinforce adherence to medication routines 

and to nonpharmacological therapies that can 

be critical for the patient’s return to normal 

function. It is unlikely that a patient can follow every element of an agreement exactly at 

all times throughout chronic opioid therapy.

The clinician’s role is to note departures from 

the plan, to make a differential diagnosis, and 

to adjust the plan as needed. 

Significant departures from the agreement may

indicate that other members of the treatment 

team need to be consulted or that the patient’s 

care should be transferred to a specialist. Any 

actions the patient is expected to take to return

to adherence should be clearly explained.

Treatment agreements are discussed at length

in Chapter 5. 

Visit Intervals 

Patients on opioid therapy typically meet 

with a clinician monthly. However, patients 

who have histories of substance use disorders 

(SUDs) may require more frequent visits, such 

as weekly, whereas patients who are in stable 

recovery may be seen less often. Other factors 

that affect the frequency of visits include the 

complexity of the pain diagnosis, the status of 

the pain management, and the medications 

being prescribed. 

A schedule of routine visits has advantages 

over sporadic appointments arranged by the 

patient. It encourages the patient to consider 

the pain a manageable condition rather than 

an occasionally erupting crisis. Routine also 

allows for close monitoring of adherence. 

A patient who misses or reschedules appointments should be evaluated for relapse to an 

SUD. 

Medication Supply 

The Drug Enforcement Administration’s 

(DEA’s) “do not fill until” option allows clinicians to write a 3-month prescription that 

can be filled in spaced intervals (Exhibit 4-2).

However, only rarely should a patient with 

an SUD history be seen as infrequently as 

every 3 months. Patients who find it difficult 

to adhere to treatment plans may be better 

served by more frequent visits during which 

prescriptions for smaller amounts of medication are provided. In this case, clinicians can 

use the “do not fill until” strategy to divide a 

month’s supply into, for example, three 10-day 

prescriptions for patients who cannot handle a 

month’s worth of medication. 

Clinicians also can promote adherence 

through pill counts or by recruiting (with 

the patient’s consent) a pharmacist or trusted 

family member to dispense medication daily.

Patients who require tighter-than-weekly dispensing of medication also probably require a 

exhibit 4-2 Issuance of multiple 

prescriptions for schedule II 

controlled substances 

71 Federal Register 52724 allows clinicians 

to write multiple prescriptions—to be filled 

sequentially—for the same Schedule II controlled substance. The multiple prescriptions, 

in effect, allow a patient to receive, over 

time, up to a 90-day supply of that scheduled 

medication. But the law can also be used 

to write sequential prescriptions for a much 

shorter period, which may be appropriate 

for patients who benefit from tight structure. 

Information on other aspects of the regulation, as well as the conditions under which 

multiple prescriptions can be written, is at 

http://www.deadiversion.usdoj.gov/21cfr/ 

cfr/2106cfrt.htm. 
51 

4—Managing Addiction Risk In Patients Treated With Opioids

 

 

 

 

 

 

 

 

 

 

higher level of care and will often benefit from 

comanagement with an addiction specialist.

Exhibit 4-3 presents a scenario regarding 

medication supply. 

Urine Drug Testing 

UDT can detect the presence of some prescribed

and unprescribed substances and, therefore,

can be a useful tool for improving patient 

care (Cone & Caplan, 2009; Heit & Gourlay,

2004; McMillin & Urry, 2007). Couto,

Romney, Leider, Sharma, and Goldfarb (2009) 

studied data from the urine tests of more than 

900,000 patients on chronic opioid treatment.

The researchers found that 75 percent of the 

patients showed at least one sign of nonadherence to opioid regimens (e.g., having no 

detectable levels of the prescribed medication 

in their urine, having evidence of an illicit 

drug). As when using other tools, the clinician must understand the limitations of UDT 

and interpret results in light of other clinical 

findings. 

There are two common kinds of urine drug 

tests: 

•	 Immunoassay (IA) screens, which use 

antibodies to detect a drug or metabolite 

(e.g., opioids) in urine 

•	 Specific substance identification tests,

such as GC/MS (gas chromatography/

mass spectroscopy) or HPLC (highperformance liquid chromatography),

which use more sophisticated methods to 

detect the presence of specific substances 

exhibit 4-3 Talking With patients About medication supply 

Clinician “I see that you are here because you ran out of your pain medication before you were 

due to pick up the next prescription.” 

Patient “I took extra pills for a few days and now I’m out. I’m hurting more because I don’t have 

any pills.” 

Clinician “Can you tell me what happened?” 

Patient “I fell and hurt my knee, and it was really bothering me, so I took more than I usually 

do.” 

Clinician “We have a written agreement that you’ll take your medications only as prescribed.” 

Patient “Yeah, but it made sense because my knee hurt so bad.” 

Clinician “Knee pain is a different kind of pain, and increasing your opioid medication is not necessarily the best treatment for that. Next time, please call me first as we agreed.” 

Patient “Okay, I’m sorry.” 

Clinician “Whenever one of my patients breaks the agreement for any reason, I always ask for a 

urine sample. When did you last take your medicine?” 

Patient “I just ran out yesterday.” 

Clinician “So you did not take anything else when you ran out of your prescription?” 

Patient “No! I didn’t have anything else to take.” 

Clinician “Okay. I’ll write your prescription while you go see the nurse. If your urine sample is 

okay, I’ll give you the prescription.” 
52 

Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders

Immunoassays 

Heit and Gourlay (2004) recommend testing 

for the following substances during routine 

screening: cocaine, amphetamines/metham

phetamine, opioids, methadone, marijuana,

and benzodiazepines. 

Although IA screens are sensitive to natural 

opioids, they have limited ability to detect 

synthetic and semisynthetic opioids (e.g.,

hydrocodone, fentanyl, oxycodone, metha

done). If an IA screen fails to detect the 

presence of expected opioids, the results can 

be confirmed with a more specific substance 

identification test. 

IA screens can be conducted at the point of 

care (POC) or in a laboratory. Exhibit 4-4 lists 

the benefits and limitations of POC testing.

POC results that are positive for an illicit sub

stance or negative for the prescribed substance 

class can be verified with a confirmatory test. 

Specific Substance Identification 

Tests 

Because IA screens cannot reliably detect 

synthetic and semisynthetic opioids, they have 

limited utility for monitoring adherence to 

­

­

­

opioid treatment. However, they can detect 

whether the patient on chronic opioid therapy 

is using, for example, marijuana, amphet

amines, or cocaine. GC/MS or HPLC provide 

specific information about what compounds 

were consumed. Substance identification tests 

can also confirm the results of an IA screen. 

It is useful for clinicians prescribing chronic 

opioid therapy to maintain a relationship with 

the testing laboratory that they use so that 

they can communicate specific needs, such as 

a “no limits” test to identify small amounts of 

substances or specifically sought substances 

that may not routinely be assessed. 

Urine Drug Testing Results 

UDT is subject to false-positive and falsenegative results. The clinician must interpret 

results carefully and explore the possible 

causes of unexpected findings before taking 

action. For example, prescribed medication 

may not show up in a UDT result because 

(Gourlay et al., 2006): 

•	 The patient did not use medications 

or did not use them recently. 

­

exhibit 4-4 poc Testing Benefits and limitations 

category Description 

Benefit Convenient 

Fast 

Single-use kits available 

Requires little training 

Limitation Identifies only drug class or metabolite, so of limited use for adherence 

monitoring 

Clinicians must clearly understand cutoff scores and whether they are appropriate 

Subject to cross-reactivity (false-positive results) 

Testing instructions and cutoff scores vary 

Little quality control 

Little or no technical support 

Adapted from Gourlay, Heit, & Caplan, 2006. 
53 

4—Managing Addiction Risk In Patients Treated With Opioids

 

 

 

 

 

•	 The patient excretes medications or 


metabolites at a rate different from 


normal.
 

•	 The test was not sufficiently sensitive to 

detect the medications at the concentrations present. 

•	 There was a clerical error. 

If the results of UDT are unexpected, the 

clinician may want to take the following steps,

recommended by Gourlay and Heit (2009): 

•	 Contact the laboratory to confirm there 

was no clerical error. 

•	 Discuss with the laboratory what type of 

followup test or confirmatory test should 

be conducted. 

•	 Discuss the results with the patient and 

document the UDT results and discussion in the patient’s medical record. 

•	 Confirm disputed results with the recommended laboratory test. 

An unexpected result should be discussed 

face-to-face with the patient (Exhibit 4-5).

The presence of unprescribed or illicit substances does not render a patient’s pain complaints illegitimate, but it may suggest abuse or 

addiction. Repeated unexpected results suggest 

the need for evaluation by an addiction specialist. If a patient with CNCP is diagnosed 

with a comorbid SUD, the patient must be 

willing to accept treatment for both disorders.

It is reasonable for the clinician, without getting into a dispute about patients’ rights to use 

substances or the benefits of medical marijuana, to make access to opioid therapy contingent on the patient’s willingness to relinquish 

use of illicit substances. This can be presented 

simply as a way to ensure the patient’s access 

to treatment and the clinician’s continued ability to prescribe. If the person is unwilling to 

relinquish recreational use, the pain problem 

may not warrant chronic opioid therapy. If the 

patient is unable to relinquish the drugs, then 

addiction treatment is indicated (Covington,

2008). 

exhibit 4-5 Talking With patients About Aberrant Urine Drug Testing results 

Clinician “It seems you have not been taking your medications.” 

Patient A “Yes, I have.” 

Clinician “Some of it should be showing up in your urine, but it’s not.” 

Patient A “My husband twisted his ankle last week. I might have given him a couple of tablets.” 

Clinician “You must take your medications as prescribed. That’s the only way I can determine 

whether they are effective in treating your pain. And I need to explain to you again the 

harm that can result when someone else takes medication that has been prescribed to 

you based on your body’s needs.” 

_______________________________________________________________________________________ 

Clinician “It seems you have been taking medications that I haven’t prescribed.” 

Patient B “No, I haven’t.” 

Clinician “Your last urine test was positive for benzodiazepines. Can you think of any reasons why 

they might have appeared?” 

Patient B “Oh, that. I was stressed out because my pain was so bad. My buddy gave me a pill.” 

Clinician “There are several reasons why your pain may have gotten worse. It’s really important 

that I know what medications you are taking and that you don’t take medications that I 

have not prescribed for you.” 
54 

Intervals for UDT depend on the degree of 

oversight the patient requires. The tests can 

be scheduled or random, depending on the 

patient’s risk level; however, if patients are 

tested selectively, there is a risk of overtesting 

minorities and other marginalized groups and 

failing to detect substance abuse in patients

whose ethnicity and socioeconomic status

mirror those of the clinician. 

Clinicians should help patients understand

that UDT helps protect their recovery, their 

access to analgesia, and the clinician’s ability to 

prescribe and that urine drug tests are neither 

punitive nor discriminatory because they are 

expected of all patients who receive chronic 

opioid therapy. Exhibit 4-6 presents sample 

scenarios for addressing UDT with patients. 

Inclusion of Family, Friends, and 

others 

With support from others, the patient may be 

better able to comply with pain treatment. Just 

as important, the inclusion of others enables 

the clinician to obtain a clearer picture of the 

patient’s response to treatment, including his 

or her ability to adhere to an opioid medication regimen, any loss of function, or development of aberrant behaviors that may indicate 

relapse. When a patient has a history of an 

SUD, it is crucial that the prescribing clinician 

obtain collateral information from household 

members, physical therapists, pharmacists,

and other members of the patient’s healthcare 

team. Given that patients may not always 

realize or disclose their problems with drugs,

safety considerations require that prescriptions

for addictive substances be contingent on 

the clinician’s unrestricted access to collateral 

information. 

nonadherence 

At some point in the treatment of chronic pain,

patients are likely to fail to adhere to their 

treatment agreement. Behavior that suggests 

substance misuse, abuse, or addiction is known 

as aberrant drug-related behavior (ADRB).

ADRB includes: 

•	 Being more interested in opioids (especially immediate-release and nongeneric) 

than in other medications or in any other 

aspect of treatment. 

•	 Taking doses larger than those prescribed 

or increasing dosage without consulting 

the clinician. 

•	 Insisting that higher doses are needed. 

•	 Resisting UDT, referrals to specialists,


and other aspects of treatment.
 

•	 Resisting changes to opioid therapy. 

•	 Repeatedly losing medications or prescriptions or seeking early refills.
 

•	 Making multiple phone calls about 


prescriptions.
 

•	 Attempting unscheduled visits, typically 

after office hours or when the clinician is 

unavailable. 

•	 Appearing sedated. 

•	 Misusing alcohol or using illicit drugs. 

•	 Showing deteriorating functioning and 

beginning to experience adverse consequences from medications (e.g., problems 

at home or on the job). 

•	 Injecting (having track marks) or snorting 

oral formulations. 

•	 Obtaining medications illegally (e.g.,

from multiple clinicians, street dealers,

family members, the Internet, forged 

prescriptions). 
55 

4—Managing Addiction Risk In Patients Treated With Opioids

 

 

 

 

 

 

 

 

 

 

exhibit 4-6 Talking With patients Who Are resistant to Urine Drug Testing 

Patient A “I can’t give you a urine sample today. I just peed.” 

Clinician “Not a problem. There’s a water fountain in the hallway. Why don’t you take in some 

fluids and come back when you’re ready. I’ll leave your refill prescription with the receptionist, and you can pick it up after we’ve run your screen.” 

_______________________________________________________________________________________ 

Patient B “Why do I need to give you a urine sample? Don’t you trust me?” 

Clinician “The urine sample gives me a great deal of useful information about how you are using 

your medications and whether you are running into problems with other substances.” 

Patient B “It’s spying.” 

Clinician “It may seem like that to you, but it’s a standard part of care for all my patients. Any 

level of substance use can affect a patient’s life and the management of the pain. Is 

there something we need to talk about?” 

_______________________________________________________________________________________ 

Patient C “My problem was alcohol, doc. I was never a drug addict. You don’t have to treat me 

like one.” 

Clinician “I’m sorry if this gives you the impression that I am judging you. As your doctor, I have a 

job to identify and resolve any issues that may interfere with your pain treatment, sooner 

rather than later. The drug screen helps me do that.” 

_______________________________________________________________________________________ 

Patient D “I’m philosophically opposed to drug tests.” 

Clinician “I understand. I’ve had other reluctant patients. Can you tell me why you feel this way?” 

Patient D “It just seems like an invasion of privacy.” 

Clinician “Yes, it does. A lot of things that happen in the doctor’s office can seem like an invasion 

of privacy. But our treatment options are limited if we can’t run the test.” 

Patient D “That’s not fair.” 

Clinician “I will still work with you as your pain doctor, no matter what the test reveals. That’s fair, 

isn’t it?” 

Patient D “I still don’t want to do it.” 

Clinician “I’d like to have you talk with Joe [the addiction counselor on the patient’s treatment 

team]. He can help you sort this out.” 

_______________________________________________________________________________________ 

Patient E “I hate tests.” 

Clinician “There are no passing or failing grades here. I am not going to flunk or fire you based 

on what I learn. In fact, we go over the results together, and we decide together how to 

interpret them and what to do if anything shows up unusual. How does that sound?” 

_______________________________________________________________________________________ 

Patient F “But I gave you a urine sample last time I was here.” 

Clinician “Yes, you did. Let’s look at your treatment agreement. Here it is: Item 5. We agreed that 

you might be asked for a screen at every appointment.” 
56 

•	 Behaving in an intimidating or threatening manner. 

•	 Having urine drug tests that do not show 

the presence of prescribed opioids. 

•	 Not adhering to nonpharmacological 


components of treatment.
 

Patient behavior is highly variable and dependent on circumstances, and the evidence base 

does not decisively implicate any single behavior or set of drug-related behaviors as being 

indicative of addiction. ADRB can be driven 

by other causes, including: 

•	 Misunderstanding instructions. 

•	 Seeking euphoria. 

•	 Using medications to deal with fear,


anger, stress, sleep problems, or other 


issues.
 

•	 Diverting medications for profit. 

•	 Coping with untreated mental disorders. 

•	 Coping with undertreated pain, also 

known as pseudoaddiction (Exhibit 4-7). 

•	 General nonadherence. 

ADRBs that clinicians are most likely to 

observe (or that patients are most likely to 

report) are often the behaviors that are most 

ambiguous (e.g., not following a medication 

regimen precisely, running out of a prescription early). The extreme behaviors that are 

easier to interpret (e.g., selling prescriptions,

altering the medication’s delivery mode) are 

ones that may elude observation during an 

office visit. The development of a strong therapeutic relationship facilitates these often difficult conversations when and if ADRBs occur. 

Tools To Assess Aberrant Drugrelated Behaviors 

Tools exist to help clinicians assess ADRBs in 

patients on chronic opioid therapy. However,

evidence for their validity is limited (Chou,

Fanciullo, Fine, Miaskowski, et al., 2009). The 

Addiction Behaviors Checklist (Wu et al.,

2006) helps determine whether opioids have 

become a problem for the patient (Exhibit 

4-8). It is for ongoing evaluation and can flag 

addiction problems as they develop. The tool 

can be quickly administered at each office

visit; three or more “yes” responses should trigger more careful monitoring or intervention. 

The Current Opioid Misuse Measure 

(Butler et al., 2007) asks patients about their 

behavior in the 30 days before the appointment (Exhibit 4-9). Butler and colleagues 

recommend a conservative cutoff score of 9,

which yields some false-positive results, but 

misses fewer patients who may be misusing 

medications. 

exhibit 4-7 pseudoaddiction 

Patients sometimes display ADRB in response to undertreated pain. This phenomenon has been 

termed pseudoaddiction (Weissman & Haddox, 1989). It is often unclear how to determine the 

presence of pseudoaddiction in a patient, and the explanation of pseudoaddiction must be applied 

cautiously in patients who have a known SUD. Clinicians may never know with certainty what motivates ADRB in patients. 
57 

4—Managing Addiction Risk In Patients Treated With Opioids

 

 

 

 

 

 

 

 

 

 

 

exhibit 4-8 Addiction Behaviors checklist 

Item Yes no not Assessed 

Addiction Behaviors Since Last Visit 

1. Patient used illicit drugs or evidences problem drinking 

2. Patient has hoarded medication 

3. Patient used more opioids than prescribed 

4. Patient ran out of medications early 

5. Patient has increased use of opioids 

6. Patient used analgesics PRN when prescription is for 

time-contingent use 

7. Patient received opioids from more than one provider 

8. Patient bought medications on the streets 

Addiction Behaviors Within Current Visit 

1. Patient appears sedated or confused (e.g., slurred 

speech, unresponsive) 

2. Patient expresses worries about addiction 

3. Patient expresses a strong preference for a specific type 

of analgesic or a specific route of administration 

4. Patient expresses concern about future availability of 

opioid 

5. Patient reports worsened relationships with family 

6. Patient misrepresents analgesic prescription or use 

7. Patient indicates she or he “needs” or “must have” 

analgesic medications 

8. Discussion of analgesic medications is the predominant 

issue of visit 

9. Patient exhibits lack of interest in rehabilitation or 

self-management 

10. Patient reports minimal/inadequate relief from opioid 

analgesic 

11. Patient indicates difficulty with using medication 

agreement 

Other 

1. Significant others express concern over patient’s use of 

analgesics 

Reprinted from Wu et al., 2008. The Addiction Behaviors Checklist: Validation of a new clinician-based measure of inappropriate opioid use in chronic pain. Journal of Pain and Symptom Management, 32(4), 342–351. Adapted with permission 

from Elsevier. 
58 

Documenting care 

Meticulous documentation of chronic opioid 

therapy is essential. It is both a Federal and 

State requirement, and the quality of documentation can determine whether a clinician 

is judged to be practicing medicine or trafficking in drugs. In addition, longitudinal documentation is essential to permit a determination over time of the extent to which treatment is an asset or a liability to the patient.

Documentation also provides protection for 

the clinician if drug enforcement authorities 

conduct an investigation. 

The practitioner must be familiar with the 

requirements of the State in which he or 

she practices; however, generally there must 

be documentation of an adequate medical 

workup of the condition being treated, an 

evaluation for psychiatric comorbidity including SUD, a plan of care, amounts of scheduled 

medications prescribed, and instructions for 

use of medications. Some States require that 

chronic opioid therapy be used only if other 

treatments are ineffective or ill-advised. The 

University of Wisconsin’s Pain and Policy 

Studies Group maintains a Web site that 

describes the regulations of different States 

regarding opioid prescribing (http://www.

painpolicy.wisc.edu/). 

exhibit 4-9 current opioid misuse measure 

(Measured on a Scale of 0=Never to 4=Very Often) 

1. How often have you had trouble with thinking clearly or had memory problems? 

2. How often do people complain that you are not completing necessary tasks (i.e., doing 

things that need to be done, such as going to class, work, or appointments)? 

3. How often have you had to go to someone other than your prescribing physician to get sufficient pain relief from your medications (i.e., another doctor, the emergency room)? 

4. How often have you taken your medications differently from how they are prescribed? 

5. How often have you seriously thought about hurting yourself? 

6. How much of your time was spent thinking about opioid medications (having enough, taking 

them, dosing schedule, etc.)? 

7. How often have you been in an argument? 

8. How often have you had trouble controlling your anger (road rage, screaming, etc.)? 

9. How often have you needed to take pain medications belonging to someone else? 

10. How often have you been worried about how you’re handling your medications? 

11. How often have others been worried about how you’re handling your medications? 

12. How often have you had to make an emergency phone call or show up at the clinic without 

an appointment? 

13. How often have you gotten angry with people? 

14. How often have you had to take more of your medication than prescribed? 

15. How often have you borrowed pain medication from someone else? 

16. How often have you used your pain medicine for symptoms other than for pain (to help you 

sleep, improve your mood, relieve stress, etc.)? 

17. How often have you had to visit the emergency room? 

Reprinted from Butler, et al., 2007. Development and validation of the Current Opioid Misuse Measure. Pain, 130, 144– 

156. Used with permission from Elsevier. 
59 

4—Managing Addiction Risk In Patients Treated With Opioids

Like other treatments, opioid therapy should 

be continued only so long as it is effective.

Many clinicians have found it useful to monitor and document opioid response using the 

“4As” of Passik and colleagues (2004): analgesia, activities of daily living, adverse events, and 

ADRBs. 

managing Difficult conversations 

Patients who have CNCP can be especially 

difficult to treat because their condition often 

eludes diagnosis and because unremitting pain 

itself can affect their ability to be civil. When 

an SUD or other co-occurring disorder is 

overlaid onto the pain, the likelihood of difficult behavior from the patient increases. Such 

a patient has complex and intense needs that 

are best served by a treatment team approach 

that allows for frequent assessment and care 

of the patient without overburdening any one 

member of the team (see Chapter 3). 

The following activities can help build a 

therapeutic relationship between the treatment 

team and the patient: 

•	 Listening actively 

•	 Asking open-ended, nonjudgmental 


questions 


•	 Restating a patient’s report to make sure 

it has been understood 

•	 Using clarification statements (“It sounds 

as if the pain is worse than usual for you”) 

•	 Demonstrating empathy 

•	 Using feeling statements (“This must be 

very difficult for you”) 

One strategy for demonstrating empathy is to 

specifically acknowledge the effort required 

simply to cope with pain daily. The clinician

should not promise overly optimistic results

and should educate patients so that they form 

reasonable expectations about outcomes. It

may also help to suggest that patients focus 

on improvements in functioning and avoid 

defining their lives by their pain. 

Patients who have chronic pain, as well as those

with SUDs, and perhaps especially those with 

both, can elicit strong negative responses from 

treatment providers. These negative reactions 

impede efforts to experience and communicate

empathy. It is useful, first of all, for the clinician to recognize these reactions and to seek 

to understand them. Frequently, they are simply

a result of the frustration attendant on treating difficult or intractable problems. They may 

result from feelings that the clinician is working harder for the patient’s wellness than is the 

patient. It may help for the clinician to remind 

himself or herself that, no matter how lacking 

in motivation the patient seems, no one would 

ever wish for a typical life of a person with 

comorbid pain and addiction. 

Workplace safety 

Clinicians and their patients must be protected

from violence in the workplace. Clinic staff 

members should be encouraged to be proactive and aware of their surroundings, report 

suspicious activity, and use common sense to 

make good decisions about aggressive patients 

or family members. Clinicians should plan for 

occasional disruptive or aggressive behavior 

and position themselves in the examination 

room between the patient and the door. If a 

patient becomes threatening, security personnel or law enforcement may be needed. The 

consensus panel recommends that clinicians 

develop crisis management policies and plans 

and ensure that staff members are trained and 

drilled on their implementation. A plan should 

be developed for contacting public safety

officials (discreetly, if necessary) in urgent or 

emergent situations. The plan should include 

a distress signal to alert all staff members.

Contact information for public safety officials 

should be readily available. 
60 

Drug Diversion 

Some patients sell or trade their medications,

and sometimes patients give their medica

tions to family or friends for various reasons.

Medications taken by people other than for 

whom they are prescribed are said to be 

“diverted.” 

Unequivocal evidence of diversion is rare,

although patients often acknowledge it when 

confronted. All members of the treatment 

team should be alert to the patient who: 

•	 Is known to have contact with people 

with active SUDs. 

•	 Cannot produce the remainder of a par

tially used prescription when asked for a 

pill or patch count. 

•	 Has attempted to alter or forge 

prescriptions. 

•	 Has been “doctor shopping” to obtain 

additional medications. 

•	 Does not comply with the nonpharma

cological components of recommended 

treatment. 

•	 Strongly prefers brand name drugs or 

drugs with high street value. 

•	 Fails to demonstrate the presence of 

prescribed opioids in appropriate UDT 

results. 

­

­

­

Clinicians should know which drugs are popular

in their communities and be vigilant when 

prescribing medications that have high street 

value (Exhibit 4-10). Many clinicians scrupu

lously avoid prescribing medications with high 

­

marketability to patients who have an addiction

disorder or histories of diversion. 

Clinicians should remind patients of their 

responsibility to protect their medications 

against theft and diversion (see Chapter 

5). Clinicians must understand and comply 

with State laws regarding prescribing prac

tices. State laws on the amount of opioids 

prescribed and prescription expiration may 

be more restrictive than Federal laws. State 

laws can be found at the Federation of State 

Medical Boards Web site (http://www.fsmb.

org). 

Some clinicians have inordinately restricted 

their prescribing because of a false belief that 

there has been a “crackdown” on clinicians 

prescribing opioids for pain. DEA’s policy 

statement on dispensing scheduled medica

tions for the treatment of pain, which includes 

a response to concerns of a crackdown, is 

found at http://www.deadiversion.usdoj.gov/

fed_regs/notices/2006/fr09062.htm. 

Strict boundaries should be placed around 

a patient who pushes for medications that 

the clinician believes are unwise choices. In 

this situation, the clinician’s responsibility is 

to prescribe what is indicated and not what 

the patient desires. Although all diversion is 

unlawful, there are degrees of seriousness; for 

example, a patient who gives a hydrocodone 

tablet to a spouse who sustained a back sprain

should not be treated in the same way as a 

“pseudo-patient” who seeks medications to 

resell. If diversion is suspected, treatment 

monitoring must be tightened. Clinicians 

­

­

exhibit 4-10 resources for Information on Drug Use Trends 

resource Web site 

National Institute on Drug Abuse’s 

Community Epidemiology Work Group 

http://www.drugabuse.gov/about/organization/ 

CEWG/CEWGHome.html 

Drug Abuse Warning Network http://dawninfo.samhsa.gov 

Centers for Disease Control and Prevention 

National Center for Health Statistics 

http://www.cdc.gov/nchs 
61 

4—Managing Addiction Risk In Patients Treated With Opioids

should not tolerate any serious diversion,

which is a breach of trust that usually calls 

for cessation of opioid therapy or even ending 

the clinician–patient relationship. Evidence of 

diversion should be documented. 

State prescription monitoring programs, which 

currently operate in 38 States, may be useful 

to clinicians who suspect a patient of “doctor shopping,” that is, obtaining scheduled 

medications from multiple clinicians (Wang 

& Christo, 2009). Information regarding programs and a list of States that have active programs are at http://www.namsdl.org/presdrug.

htm. 

Discontinuation of opioid 

Therapy 

The best reason to discontinue opioid therapy 

is that the pain has resolved, but that is often 

not the case. Other likely reasons for discontinuation include the following: 

•	 Opioids are no longer effective. 

•	 Opioids no longer stabilize the patient 

or improve function. 

•	 The patient loses control over the 


medication.
 

•	 The patient is diverting the medication. 

•	 The patient is using alcohol, benzodiazepines, or illicit drugs. 

•	 Adverse effects are unmanageable. 

When the benefits of opioid therapy are 

outweighed by its harms, therapy should be 

discontinued. Of course, this statement applies

to all medications, of whatever category. Exhibit

4-11 presents an algorithm for discontinuing 

chronic opioid therapy. 

Patients tapering off opioids may experience 

both short-term withdrawal (which occurs 

immediately) and protracted withdrawal.

Short-term withdrawal begins when the 

level of opioid in the blood falls below the 

accustomed level for the patient. It usually 

abates after a few days or a week (depending 

on the half-life of the medication). Patients 

may experience increased pain and withdrawal 

hyperalgesia. Symptoms and signs of opioid 

withdrawal are as follows. 

Symptoms include: 

•	 Abdominal cramps, nausea, vomiting,


diarrhea
 

•	 Bone and muscle pain 

•	 Anxiety 

•	 Insomnia 

•	 Increased pain sensitivity in the original 

painful site 

Signs include: 

•	 Tachycardia 

•	 Hypertension 

•	 Fever 

•	 Mydriasis 

•	 Hyperreflexia 

•	 Diaphoresis 

•	 Piloerection 

•	 Lacrimation, yawning 

•	 Rhinorrhea 

•	 Myoclonus 

Protracted withdrawal from opioids includes 

anxiety, depression, sleep disturbances, fatigue,

dysphoria, and irritability, which can last 

for weeks or months following withdrawal 

from short- and long-acting opioids (Collins 

& Kleber, 2004; Satel, Kosten, Schuckit, & 

Fischman, 1993). These symptoms can be 

attenuated with tricyclic antidepressants,

gabapentin, and other nonaddicting agents.

Discomfort may develop at any time during 

the weaning process, so patients should be 

monitored until the process is complete and 

any symptoms addressed. Cognitive–behavioral

therapy may help with cravings. Not all 

patients experience protracted withdrawal. 
62 

exhibit 4-11 exit strategy 

Note: This algorithm does not indicate a maximum trial dose, as none has been established by research. However, it can 

be said that doses above 200 mg morphine equivalents per day have not been studied systematically, and higher doses 

are more likely to be associated with active addiction than are lower doses (Ballantyne, 2006). Some clinicians have recommended doses up to 300 mg morphine equivalents per day. Analgesic Research, personal communication, October 30, 

2009; Covington, personal communication, October 30, 2009. 
63 

4—Managing Addiction Risk In Patients Treated With Opioids

For patients whose active addiction necessitates

discontinuation of opioid therapy, referral for 

specialized addiction treatment is crucial. 

There are many reasons for discontinuing 

scheduled medications but very few for 

discontinuing care of the patient. When 

opioids are a liability, whether because of 

poor analgesic efficacy or patient ADRB, the 

clinician should usually offer to continue to 

provide non-opioid therapies and treatment;

that is, stopping opioids does not mean 

stopping treatment. 

The clinician who elects to discharge a patient 

from his or her practice should inform the 

patient in writing. To avoid charges of abandonment, the clinician should provide the 

patient with contact information for other clinicians, along with a written tapering schedule 

and prescriptions for the medications that 

require a taper. In cases in which the clinician–

patient relationship is hostile or dangerous or 

in which the patient presents a danger to the 

clinician, a letter alone can suffice. 

Key points 

•	 Patients on chronic opioid therapy should be monitored closely for signs of benefit,

harm, and ADRBs. 

•	 All ADRBs should be documented, investigated, and acted on. 

•	 Difficult conversations should be managed with compassion and empathy. 

•	 Clinicians should establish and respectfully maintain strict limits with patients who 

insist on opioids. 

•	 Clinicians should establish relationships with drug-testing laboratory staff and addiction specialists. 

•	 When it is necessary to discontinue chronic opioid therapy, a conscientious tapering 

plan should be provided. 

65 

5 patient education and 


Treatment Agreements
 

In ThIs chApTer 

•	The Value of Patient 

Education 

•	Providing Effective 

Education 

•	The Internet as a Source 

of Patient Education 

•	Education Content 

•	Opioid Information 

•	Methadone Maintenance 

Therapy Information 

•	Treatment Agreements 

•	Key Points 

The value of patient education 

No randomized controlled trials have specifically evaluated the

effect of patient education on treatment outcomes; however, Brox 

and colleagues (2006) studied 60 patients who had persistent low 

back pain at least a year after surgery for disc herniation. Patients 

were randomized to receive either lumbar fusion with transpedicular 

screws or cognitive intervention, which consisted largely of education on back hygiene and exercises. Outcomes were essentially the 

same for the two groups. 

The potential value of patient education is also supported by ad 

hoc reviews in the medical literature. For instance, VA/DoD Clinical 

Practice Guideline for the Management of Opioid Therapy for Chronic 

Pain (Department of Veterans Affairs & Department of Defense 

[VA/DoD], 2010) recommends both patient and family education, as do other pain treatment guidelines (Chou, Fanciullo, Fine,

Adler, et al., 2009; Institute for Clinical Systems Improvement,

2007). Patient education is also necessary for truly informed consent. Geppert (2004, p. 163) defines informed consent as follows:

“Informed consent encompasses the capacity to understand the risks,

benefits, and alternatives of a treatment, to communicate a choice 

regarding therapy, to deliberate and reason about the consequences 

of the proposed medication, and to appreciate how the treatment 

will affect life and values.” Informed consent is particularly important when clinicians are prescribing potentially addictive medications to patients who have histories of substance use disorders 

(SUDs) and other behavioral health disorders. 

Providing culturally sensitive and linguistically appropriate education 

can: 

•	 Improve adherence. 

•	 Help the patient understand medication responses that are 

expected and normal and those that are of concern and warrant 

a phone call. 

•	 Allay fears about particular treatments or medications. 
66 

•	 Increase satisfaction with treatment by 

promoting realistic expectations. 

•	 Provide an opportunity to discuss any 


concerns.
 

•	 Strengthen the clinician–patient relationship by demonstrating respect and 

enhancing patient feelings of self-efficacy. 

•	 Improve health, well-being, and 


outcomes.
 

In addition, patient education provides a 

forum in which clinicians can ask patients 

about their perceptions of their condition and 

explore patients’ conceptions and misconceptions about their condition and its treatment. 

Clinicians should encourage patients to

talk about their use of complementary and 

alternative medicine (CAM) and other nonpharmacological approaches to pain. 

Providing education and soliciting questions 

require an initial time commitment; however,

these efforts ultimately save time. A patient 

is less likely to make unnecessary emergency 

appointments when he or she clearly understands what to expect from a medication or 

treatment and has a specific plan for what 

actions to take when pain flares. 

providing effective education 

Effective education is a process that begins at 

treatment initiation and continues throughout 

treatment. The treatment needs of patients 

who have chronic noncancer pain (CNCP) 

and SUD change over time, necessitating 

ongoing education. Family members, especially 

caregivers, frequently play important roles in 

pain treatment (Glajchen, 2001) and ought to 

be involved in educational efforts. 

Educational approaches must be tailored to 

each patient’s needs. The clinician or other 

members of the treatment team should 

develop a repertoire of educational materials

and approaches to meet the differing needs 

of patients. Approaches should consider: 

•	 Primary languages spoken by patients. 

•	 Culture, gender, race/ethnicity, and age of 

patients.

•	 Resources in the local community (e.g.,

availability of hospitals, pharmacies). 

•	 Educational, general literacy, and health 

literacy levels of patients. 

•	 Cognitive function of patients. 

Health literacy has been defined as “the 

capacity to obtain, process, and understand 

basic health information and services needed 

to make appropriate health decisions” (U.S.

Department of Health and Human Services,

2000, p. vi). Online sources for more information and training on health literacy are in 

Exhibit 5-1. 

exhibit 5-1 selected online sources of Information on health literacy 

organization Web site 

American Medical Association Health Literacy Kit 

(continuing medical education credits available) 

http://www.ama-assn.org/ama/pub/ 

physician-resources.shtml 

Health Resources and Services Administration 

(HRSA) Unified Health Communication 

101: Addressing Health Literacy, Cultural 

Competency, and Limited English Proficiency 

http://www.hrsa.gov/healthliteracy/default.htm 

Center for Health Care Strategies, Inc., Health 

Literacy Fact Sheets 

http://www.chcs.org/usr_doc/ 

Health_Literacy_Fact_Sheets.pdf 

Institute of Medicine Health Literacy: A 

Prescription to End Confusion 

http://www.iom.edu/Reports/2004/ 

Health-Literacy-A-Prescription-to-End-Confusion. 

aspx 
67 

 

 

 

 

 

To enhance communication with a diverse 

patient population, HRSA recommends that 

the treatment team (http://www.hrsa.gov/

healthliteracy): 

•	 Use simple language and short sentences 

and define technical terms. 

•	 Supplement instruction with appropriate 

materials (e.g., videos, models, pictures). 

•	 Ask patients to explain or demonstrate 

the clinician’s instructions (teach-back 

method; see Exhibit 5-2). 

•	 Ask open-ended questions that begin 

with “how” and “what,” rather than 

closed-ended, yes/no questions. 

•	 Organize information so that the most 

important points stand out and repeat 

this information. 

•	 Consider gender; age; and the cultural,

ethnic, and racial diversity of patients 

when selecting or designing educational 

materials. 

•	 Offer assistance with completing forms. 

Oral communication can be supplemented 

with charts, diagrams, and other visual aids.

These can help patients with limited English 

proficiency or low-literacy skills as well as 

those who learn more efficiently from graphic 

representations. Patient education materials 

are available in several languages at

http://www.healthinfotranslations.org.

In some cases, a translator may be necessary. 

Communication also can be enhanced by 

using the teach-back method (or “interactive 

communication loop”) (Schillinger et al.,

2003). This method can be effectively used 

with any patient but may be particularly helpful with those who have low general knowledge or health literacy or who are in early 

recovery from an SUD. 

The method involves the clinician’s explaining

or demonstrating an instruction or concept to 

the patient, then asking the patient to repeat 

the instruction or information back in his or 

her own words (not verbatim) or to repeat the 

demonstration. When asking, the clinician 

takes responsibility for any misunderstanding 

(e.g., “I want to be sure I explained this well 

enough”). If the patient cannot demonstrate 

or does not appear to understand the instruction, the clinician tries again. This is repeated 

until the patient clearly understands what he 

or she is expected to do. Exhibit 5-2 offers a 

sample teach-back dialog. 

exhibit 5-2 Talking With patients Following a Teach-Back Approach 

Clinician “You’re going to take this medicine, the green pill, two times each day: once in the 

morning, once at bedtime. Now, to be sure I explained this well enough, please tell me 

in your own words how you’ll take this medicine.” 

Patient “Uh ... I’m going to take two green pills in the morning and two green pills when I go to 

bed.” 

Clinician “Well, no. I’m sorry I wasn’t clear. You will take one pill in the morning and one pill 

before you go to bed. Now, tell me again how you’ll take this medication.” 

Patient “Okay, I think I’ve got it now. I’m going to take one pill in the morning and one pill 

before bed.” 

Clinician “That’s it. I am also going to write the instructions out for you. I also want to go over 

some information on when to call me. I am going to attach this information to your prescription. Please call me with any questions or concerns.” 
68 

Take-home handouts and pamphlets may 

aid recall and provide additional information.

Clinicians can prepare their own handouts, but 

many can be found online. University medical 

centers and government Web sites are a good 

source of reliable patient education resources,

and pharmaceutical companies almost always 

offer patient education sheets on specific medications. Professional associations also often 

have useful materials, such as patient communication aids (e.g., Pain Log, Quality of Life 

Scale). Clinicians should review these documents for appropriateness, print them out, go 

over them with patients, and allow patients to 

take them home. 

The Internet as a source of 

patient education 

Many patients use the Internet as a source of 

health information. Although the Internet can 

be a useful adjunct to in-office education, it 

is also a source of much misinformation and 

marketing disguised as education. 

Clinicians can offer guidance and recommend 

Web sites with reliable content on chronic pain

management and SUDs. Exhibit 5-3 lists a few

such Web sites with information on chronic 

pain, and Exhibit 5-4 lists Web sites with 

information on SUDs. 

exhibit 5-3 reliable Web sites With Information on chronic pain and pain 

Treatment 

organization Web site 

Aetna Intellihealth http://www.intellihealth.com 

Agency for Healthcare Research and Quality http://www.ahrq.gov 

American Academy of Family Physicians http://www.familydoctor.org 

American Academy of Pain Medicine http://www.painmed.org 

American Cancer Society http://www.cancer.org 

American Chronic Pain Association http://www.theacpa.org 

American Pain Foundation http://www.painfoundation.org 

American Pain Society http://www.ampainsoc.org 

American Society of Anesthesiologists http://www.asahq.org 

Arthritis Foundation http://www.arthritis.org 

Breastcancer.org http://www.breastcancer.org 

Emerging Solutions in Pain http://www.emergingsolutionsinpain.com 

Komen Foundation http://ww5.komen.org 

MedicineNet, Inc. http://www.medicinenet.com 

National Cancer Institute http://www.cancer.gov (click PDQ, physician data 

query) 

National Institutes of Health http://www.nih.gov 

National Pain Foundation http://www.nationalpainfoundation.org 

Veterans Affairs http://www.va.gov/painmanagement 

WebMd http://www.webmd.com 
69 

5—Patient Education And Treatment Agreements

­

­

­

exhibit 5-4 reliable Web sites With Information on substance Use Disorders 

organization Web site 

National Institute on Alcohol Abuse and 

Alcoholism 

http://www.niaaa.nih.gov 

National Institute on Drug Abuse http://www.drugabuse.gov 

National Library of Medicine http://www.nlm.nih.gov 

Parents. TheAntiDrug.com http://www.theantidrug.com 

Partnership for a Drug-Free America http://www.drugfree.org 

Substance Abuse and Mental Health Services 

Administration 

http://www.samhsa.gov 

education content 

General Information 

The specifics of patient education vary from 

patient to patient and over time. However,

general content areas for patient education 

include information about: 

•	 The patient’s condition and the nature of 

the patient’s chronic pain. 

•	 Treatments available, including nonphar

macological options. 

•	 The risks and benefits of treatment 

options. 

•	 How and when to take medications. 

•	 How to keep medications safely away 

from children (out of reach or locked up). 

•	 The patient’s responsibility for keeping 

track of medications and not losing them 

or giving them to others.

•	 Any medication interactions. 

•	 Common side effects of medication, their 

expected duration, and ways to manage 

them (e.g., a high-fiber diet to manage 

constipation common to opioid use). 

•	 Warnings and potential adverse events 

associated with medications and other 

treatments. 

•	 Pros and cons of CAM. 

•	 Risks to pregnant and lactating women. 

­

•	 The degree of pain relief the patient can 

realistically expect from a treatment. 

•	 How to use treatment apparatus (e.g.,

transcutaneous electrical nerve stimula

tion machine). 

•	 How best to use the Internet to find 

information and sources of support. 

•	 Under what conditions the patient should 

immediately call the clinician or go to the 

emergency department. 

•	 How to deal with episodes of acute pain 

(e.g., from surgery or trauma), as well as 

flareup pain. 

Patients may benefit from referrals to psychol

ogists for assistance in basic coping skills and 

to physical therapists and other professionals 

(Naliboff, Wu, & Pham, 2006) for therapies 

that can be used in place of or in addition 

to medication (e.g., meditation, relaxation,

stretching, distraction). 

opioid Information 

Use of opioids requires additional educational 

efforts. To give informed consent, patients 

must understand the expected benefits as well 

as the uncertainties of chronic opioid therapy.

Specifically, they must understand that excel

lent analgesia can almost always be provided 

by starting opioids; however, long-term studies 

are limited and often of poor quality. They 
70 

 

 

 

 

 

suggest that benefit diminishes with time;

after 11⁄2 years, about one-half of patients 

dropped out of opioid therapy because of side 

effects or the therapy’s loss of efficacy. Those 

continuing to take opioids had about 30­

percent pain reduction (Kalso, Edwards,

Moore, & McQuay, 2004). 

Patients must also understand the risks of 

therapy, which include overdose (by patient,

others, pets), constipation, sedation, and hormone changes, and the hazards of combining opioids with sedating drugs or alcohol.

Finally, they should understand that tolerance 

and physical dependence are expected consequences of extended therapy, that these conditions do not necessarily indicate the presence 

of an addictive disorder, but that they do 

require that arrangements be made to prevent 

abrupt withdrawal when either the patient 

or clinician is out of town or the clinician is 

otherwise unavailable. Policies of the clinician 

or program (e.g., requirements for urine drug 

testing, responses to lost or stolen prescription 

reports, early refill requests) should be

communicated in advance. 

In addition, patients need to understand (VA/

DoD, 2010): 

•	 The titration process, how soon the 

patient can expect maximum effectiveness, and why taking medications exactly 

as prescribed is important to the titration 

process. 

•	 The risks of discontinuing the medication 

abruptly (e.g., withdrawal symptoms). 

•	 How medication will be safely discontinued

(e.g., tapering, managing withdrawal 

symptoms). 

•	 That drowsiness is a common side effect 

during titration and that patients should 

not try to drive or operate heavy machinery until drowsiness is cleared. 

•	 How to discuss pain therapy, analgesic 

needs, and recovery status with other 

health professionals (e.g., dentists, anesthesiologists). (See Exhibit 5-5.) 

exhibit 5-5 Talking With patients Before surgery 

Anesthesiologist: “I understand you are scheduled for knee-replacement surgery. Is there 

anything else you would like me to know about your health?” 

Patient: “Yes, I was addicted to Vicodin many years ago. I still have chronic low 

back pain even though I had a laminectomy and fusion about 5 years ago. 

The pain following surgery was terrible. I do not want to go through that 

again. Doctor, I do not want to suffer. ” 

Anesthesiologist: “I see. Please tell me more. I want to make sure that I have all the information so that your surgeon and I can develop a pain management plan to 

address your concerns.” 

Patient: “I take buprenorphine. It works very well for me.” 

Anesthesiologist: “Thank you for sharing this information. Knee surgery patients can feel a 

lot of pain afterward. Since we have 2 days before your surgery, we should 

be sure the doctor prescribing your buprenorphine knows that you are 

scheduled for surgery. She may want to change your buprenorphine dose. 

Also, we will consider using other pain medications or techniques to manage your pain. We’ll need to closely monitor you and assess your pain. We 

will also want to be sure that your support people are aware of the plan 

and are available to help you. May I contact your doctor and nurses?” 
71 

Patients also need to know about legal and 

regulatory issues (VA/DoD, 2010), including: 

•	 The legal responsibilities of the clinician. 

•	 That it is illegal to give away, trade, share,

or sell prescription opioids. 

•	 The potential effect of regulatory 


issues on occupation, lifestyle, and use 


(e.g., pilots, commercial drivers; Chou 


and colleagues [2009] provide more 


information).
 

•	 The responsibility of the patient to report 

stolen medications both to the police and 

to the clinician. 

methadone maintenance Therapy 

Information 

Patients on methadone maintenance therapy 

(MMT) for opioid dependence need to understand how pain treatment will affect their 

MMT and vice versa. Patients also need to 

understand that long-term use of opioids can 

bring tolerance, may cause them to become 

more sensitive to pain (to have opioid-induced

hyperalgesia), and can cause the opioids to 

become ineffective over time. (Chapter 3 

provides more information on opioid-induced

hyperalgesia.) 

In general, when patients receiving MMT 

have inadequate pain control, options include 

non-opioid therapies and dividing the daily 

methadone dose into three-times-a-day 

dosing. If a decision is made to increase the

dose of methadone by the pain-treating 

clinician, it should be done only in concert 

with the MMT program. The patient must 

be monitored for continued participation in 

an aggressive recovery program and for evidence that the increased dose of methadone 

leads to demonstrable reductions in pain or 

improvements in function. 

Treatment Agreements 

As with patient education, opioid treatment 

agreements (contracts) have had no randomized controlled trials that have specifically 

evaluated their effect on treatment outcomes. 

Such agreements are, however, recommended 

in clinical guidelines and are frequently used 

in practice. Although written agreements specific to prescribed opioids are most frequently 

discussed, agreements can be used for other 

treatment modalities (e.g., exercise regimens). 

Disagreement exists about the use of agreements

when prescribing opioids (Heit, 2003). Some 

guidelines recommend opioid agreements only 

when the patient has or is at risk for an SUD.

Others are concerned that “opioid contracts 

may diminish patient autonomy; autonomy and

adherence may sometimes represent conflicting values in chronic opioid therapy” (Arnold,

Han, & Seltzer, 2006, p. 294). 

These concerns can be mitigated somewhat 

by the way in which treatment agreements 

are established. Patients can be informed that 

treatment agreements are mutually agreed-on 

plans and courses of action. Providing education on options and involving the patient in 

planning and writing treatment agreements can

preserve patient autonomy while establishing 

necessary guidelines. Arnold and colleagues 

(2006) suggest that, if a clinician chooses to 

use an opioid agreement, it should: 

•	 Use neutral, nonconfrontational language. 

•	 Be written so that the patient can understand it. 

•	 Emphasize opioids as a part of a comprehensive pain management plan that 

also includes physical therapy, counseling,

and other medications for co-occurring 

disorders, as needed. 

•	 Emphasize the clinician’s responsibility to 

work with the patient to alleviate his or 

her symptoms. 
72 

•	 Explain that the agreement protects the 

patient’s access to scheduled medications 

and protects the clinician’s license to 

prescribe them. 

•	 Describe behaviors that are incompatible 

with chronic opioid therapy (e.g., getting 

prescriptions from other clinicians, losing 

medications). 

•	 Describe the actions the clinician may 


take in response to these behaviors up 


to and including cessation of opioid 


prescribing.
 

As when treating all patients, the clinician 

can assess the ability of the patient with or in 

recovery from an SUD to make an informed 

decision (Longo, Parren, Johnson, & Kinsey,

2000). If the clinician becomes aware of limitations, he or she can (in addition to or instead 

of having a written agreement) involve the 

patient’s family in treatment, with the patient’s 

permission (Geppert, 2004). 

Treatment agreements vary considerably 

from practice to practice and from patient to 

patient. However, some common elements of 

agreements include the following (Fishman,

2007; Heit, 2003; Jacobson & Mann, 2004;

VA/DoD, 2010; Ziegler, 2007): 

•	 Timeframe of the agreement 

•	 Goals of therapy 

•	 Risks and benefits of chronic opioid 


therapy
 

•	 Requirement for obtaining prescriptions 

from a single clinician and a named 

pharmacy 

•	 Activities for pain management (e.g.,


exercise, CAM)
 

•	 Risk and benefit statement, including lists 

of possible side effects 

•	 Proscription against changing medication 

dosage without permission 

•	 Schedule for regular medical visits for 


evaluation of the agreed-on treatment
 

•	 Requirement of complete, honest selfreport of pain relief, side effects, and 

function at each medical visit 

•	 Limits on medication refills 

•	 Limits on replacing lost medications or 

prescriptions 

•	 Consent for random urine drug testing 

and other specified testing 

•	 Required pill counts 

•	 Consent for appropriate release of information (e.g., from family members, other 

clinicians, counselors, substance abuse 

treatment programs) 

•	 Participation in agreed-on SUD recovery 

activities (e.g., treatment, continuing care,

mutual-help groups) 

•	 Requirements of the clinician 

•	 Participation in agreed-on psychiatric 


treatment activities
 

•	 Possible consequences of not following 

the treatment agreement 

A useful treatment agreement should be revised

as the patient’s needs and circumstances change.

An opioid agreement by American Academy 

of Pain Management is online at http://

www.aapainmanage.org. Exhibit 5-6 presents 

another sample pain treatment agreement for 

a woman in recovery from an SUD. 
73 

 

exhibit 5-6 sample pain Treatment Agreement 

Patient: Irene Simpson Doctor: Dr. Miller Date: 1-19-10 

This treatment plan has been developed to manage neck pain and tension headaches. It is open to 

changes when both the doctor and I agree that the changes are in my best interest and are likely 

to improve my pain management or overall health. A primary goal of the plan is to protect my 

recovery from addiction. 

1. My daily medications: 

gabapentin, 1,200 mg three times daily. 

duloxetine, 90 mg every morning. 

topiramate, 100 mg at bedtime. 

2. At the first indication of a headache, I will take ibuprofen (600 mg). 

3. If possible, I will lie down in a darkened room with an ice pack to my neck and shoulders for 

15 to 20 minutes to give the medication time to work; if the headache is still present in 30 

minutes, I will take acetaminophen (500 mg). Use of opioid medications can be considered if 

this plan is unsuccessful. However, under no circumstances will I seek these medications from 

other doctors, friends, or the Internet. Instead, I will discuss my cravings and sense that the 

plan is not working with Dr. Miller, Joan Small, and my sponsor. 

4. I will see Dr. Wong weekly or as recommended for acupuncture treatments. 

5. I will walk 15 to 30 minutes daily. 

6. I will attend the pain management group with Joan weekly and see Joan for individual 

sessions as indicated. 

7. I will obtain all prescriptions for headache or other pain and for addiction recovery from 

Dr. Miller, and I will fill all prescriptions at the Main Street Pharmacy. 

8. I will not visit other physicians or the emergency department without first talking to Dr. Miller 

or to the doctor who is covering for him. 

9. I will attend my home group (Tuesday Night Women’s Group) weekly, plus two other weekly 

Narcotics Anonymous (NA) meetings of my choice; I will talk with my sponsor at least weekly 

and will call her when I feel despondent or have cravings to drink or take opioid pills. 

10. My daily meditation will focus on removing myself from conflicts where I do not have a direct 

role to play. I will try to remind myself when “I don’t have a horse in this race” at work or at 

home. 

Important Phone Numbers: 

Dr. Miller’s Office ................................... 222-3800 

Dr. Miller’s Answering Service ............... 222-9000 

Main Street Pharmacy ............................380-2000 

Joan Small’s Office ................................ 380-2132 

NA Hotline ............................................. 234-0081 

Abby (sponsor) .......................................382-9970 

Patient: _______________________________ Doctor:___________________________ Date:_________ 

Sample Pain Treatment Agreement ©MediCom Worldwide, Inc., 101 Washington St., Morrisville, PA 19067. 

Ziegler, P. Treating Chronic Pain in the Shadow of Addiction. Monograph 2007. Available at: 

http://www.emergingsolutionsinpain.com/index.php?option=com_continued&view=dispfm&Itemid=280&course=42 
74 

Key points 

•	 Patient education is necessary for informed consent, and it equips patients to take an 

active role in their pain management. 

•	 Education must be tailored to the individual patient. More research is needed on tailoring education to patients who have CNCP. 

•	 Clinicians should take time to educate their patients and make sure patients understand 

how to help themselves. 

•	 People learn in different ways; clinicians should have a variety of learning materials at 

their disposal.

•	 Treatment agreements document the treatment plan and the responsibilities of the 

patient and the clinician. 
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87 

Appendix B—Assessment 

Tools and resources 

exhibit B-1 Tools To Assess pain level 

Tool resource 

Faces Pain Scale http://painsourcebook.ca/docs/pps92.html 

Numeric Rating Scale http://www.rnao.org/pda/pain/page4.html 

Verbal Rating Scale/Graphic http://www.rnao.org/pda/pain/page4.html 

Rating Scale 

Visual Analog Scale http://www.rnao.org/pda/pain/page4.html 

exhibit B-2 Tools To Assess several Dimensions of pain 

Tool resource 

Brief Pain Inventory http://www.mdanderson.org (long and short 

forms) 

McGill Pain Questionnaire Centre for Evidence Based Physiotherapy 

http://www.cebp.nl/vault_public/ 

filesystem/?ID=1400 (long form) 

Center for Gerontology & Health Care Research 

at Brown University 

http://www.chcr.brown.edu/pcoc/ 

SHORTMCGILLQUEST.PDF (short form) 

exhibit B-3 Tools To Assess pain Interference and Functional 

capacities 

Tool resource 

Katz Basic Activities of Daily University of Texas School of Nursing at 

Living Scale Houston 

http://son.uth.tmc.edu/coa/FDGN_1/ 

RESOURCES/ADLandIADL.pdf 

Pain Disability Index Pain Balance 

http://www.painbalance.org/pages/search. 

aspx?q=pain+disability+index 

Roland-Morris Disability National Primary Care Research and 

Questionnaire Development Centre, University of Manchester, 

UK 

http://www.rmdq.org 

WOMAC index http://www.womac.org 
88 

exhibit B-4 Tools To screen for substance Use Disorder 

Tool resource 

Alcohol, Smoking, and Substance 

Involvement Screening Test 

World Health Organization 

http://www.who.int/substance_abuse/activities/assist/en/ 

index.html 

Alcohol Use Disorders 

Identification Test (AUDIT) 

World Health Organization, Department of Mental Health and 

Substance Dependence 

http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6a.pdf 

AUDIT-C Department of Veterans Affairs 

http://www.hepatitis.va.gov/vahep?page=prtop03-audit_c 

CAGE Adapted to Include Drugs 

(CAGE-AID) 

Michigan Quality Improvement Consortium 

http://www.mqic.org/pdf/CAGE_CAGE_AID_ 

QUESTIONNAIRES.pdf 

Drug Abuse Screening Test Project Cork 

http://www.projectcork.org/clinical_tools/html/DAST.html 

Michigan Alcoholism Screening 

Test (MAST) (MAST-G for older 

patients) 

National Institute on Alcohol Abuse and Alcoholism 

http://pubs.niaaa.nih.gov/publications/assesing%20alcohol/ 

instrumentpdfs/42_mast.pdf 

exhibit B-5 Tools To Assess emotional Distress, Anxiety, pain-related Fear, and 

Depression 

Tool resource 

Beck Depression Inventory (BDI) It is possible to download the 1961 BDI version, the copyright 

for which is held by the American Psychological Association 

rather than Pearson Education. The original BDI is widely 

available to academic researchers via interlibrary loan, under 

fair use provisions of international copyright law: Beck, Ward, 

Mendelson, Mock, & Erbaugh, 1961. 

Order BDI-II through Pearson at http://pearsonassess.com/ 

HAIWEB/Cultures/en-us/default 

Brief Patient Health Questionnaire Department of Defense/Veterans Health Administration 

http://www.pdhealth.mil/guidelines/downloads/appendix1.pdf 

Center for Epidemiologic Studies 

Depression Scale 

Counselling Resource 

http://counsellingresource.com/quizzes/cesd/index.html 

Geriatric Depression Scale Stanford University 

http://www.stanford.edu/~yesavage/GDS.html (long form) 

http://www.stanford.edu/~yesavage/GDS.english.short.html 

(short form) 

Profile of Chronic Pain: Screen http://shop.goalistics.com/products/profile-of-chronic-pain 

Clinician Administered PTSD Scale U.S. Department of Commerce National Technical Information 

Service 

http://www.ntis.gov/search/product. 

aspx?ABBR=AVA21105CDRM 
89 

Appendix B—Glossary 

exhibit B-5 Tools To Assess emotional Distress, Anxiety, pain-related Fear, and 

Depression (continued) 

Tool resource 

Davidson Trauma Scale Multi-Health systems, Inc. 

http://www.mhs.com/product. 

aspx?gr=cli&prod=dts&id=overview 

Posttraumatic Diagnostic Scale Pearson Assessments 

http://www.pearsonassessments.com 

State-Trait Anxiety Inventory Mind Garden 

http://www.mindgarden.com/products/staisad.htm 

Tampa Scale for Kinesiophobia http://www.medicalpanels.vic.gov.au/wps/wcm/connect/ 

wsinternet/worksafe/home/forms+and+publications/ 

educational+material/tampa+scale+for+kinesiophobia 

exhibit B-6 Tools To Assess coping 

Tool resource 

Chronic Pain Acceptance 

Questionnaire 

http://www.somasimple.com/pdf_files/acceptance_pain.pdf 

(appendix to McCracken, Vowles, & Eccleston, 2004) 

Fear-Avoidance Beliefs 

Questionnaire 

WorkSafe Victoria 

http://www.workcover.vic.gov.au 

 

 

 

 

 

 

_______________________________________________ ______________ 

 

_______________________________________________ ______________ 

 

Appendix c—cFr sample 

consent Form and list of 

personal Identifiers 

sample consent Form 

I, __________________, authorize XYZ Clinic to receive from/disclose to ___________________

(Name of patient/participant) (Name of person/organization) 

for the purpose of ________________________________________ the following information

(Need for disclosure) 

______________________________________________________________________________. (Nature of the disclosure) 

I understand that my records are protected under the Federal and State Confidentiality 

Regulations and cannot be disclosed without my written consent unless otherwise provided 

for in the regulations. I also understand that I may revoke this consent at any time except to 

the extent that action has been taken in reliance on it and that in any event this consent expires 

automatically on ________________________________ unless otherwise specified below.

(Date, condition, or event) 

Other expiration specifications:_____________________________________________________ 

Signature of patient/participant Date 

Signature of parent/guardian, where required Date 

91 
92 

Individual Identifiers Under the 

privacy rule 

The following 18 identifiers of a person or of 

relatives, employers, or household members 

of a person must be removed, and the covered entity must not have actual knowledge 

that the information could be used alone or 

in combination with other information to 

identify the individual, for the information to 

be considered de-identified and not protected 

health information (PHI): 

•	 Names 

•	 All geographic subdivisions smaller than 

a State, including county, city, street 

address, precinct, ZIP Code,* and their 

equivalent geocodes 

•	 All elements of dates (except year) 

directly related to an individual: all 

ages >89 and all elements of dates 

(including year) indicative of such age 

(except for an aggregate into a single 

category of age >90) 

•	 Telephone numbers 

•	 Fax numbers 

•	 Email addresses 

•	 Social Security numbers 

•	 Medical record numbers 

•	 Health-plan beneficiary numbers 

•	 Account numbers 

•	 Certificate and license numbers 

•	 Vehicle identifiers and serial numbers,

including license plate numbers 

•	 Medical device identifiers and serial 

numbers 

•	 Internet universal resource locators 

(URLs) 

•	 Internet protocol (IP) addresses 

•	 Biometric identifiers including fingerprints and voice prints 

•	 Full-face photographic images and any 

comparable images 

•	 Any other unique identifying number,

characteristic, or code, except that covered 

identities may, under certain circumstances, assign a code or other means of record 

identification that allows de-identified 

information to be re-identified 

Source: 45 CFR § 164.514 [b][2][i]. 

* The first three digits of a ZIP Code are excluded from the PHI list if the geographic unit 

formed by combining all ZIP Codes with the same first three digits contains >20,000 people. 
Appendix D—resources 

for Finding complementary 

and Alternative Therapy 

practitioners 

Type of Therapy resource 

Acupuncture American Association of Acupuncture and Oriental 

Medicine (AAAOM) 

http://www.aaaomonline.org 

National Certification Commission for Acupuncture 

and Oriental Medicine (NCCAOM) 

http://www.nccaom.org 

Biofeedback Association for Applied Psychophysiology and 

Biofeedback 

http://www.resourcenter.net/Scripts/4Disapi9.dll/ 

4DCGI/resctr/search.html 

Chiropractic American Chiropractic Association 

http://www.acatoday.org 

Massage American Massage Therapy Association 

http://www.amtamassage.org/findamassage/ 

locator.aspx 

93 

Appendix e—Field reviewers
 

Jane C. Ballantyne, M.D., FRCA

Professor, Anesthesiology and Critical 

Care 

Penn Pain Medicine Center 

Philadelphia, Pennsylvania 

Declan T. Barry, Ph.D.

Associate Research Scientist 

Yale University School of Medicine

New Haven, Connecticut 

Sharon M. Freeman, Ph.D., M.S.N.,

PMHCNS-BC, CARN-AP

CEO 

Center for Brief Therapy, P.C.

Fort Wayne, Indiana 

Cynthia M. A. Geppert, M.D.,

Ph.D., M.P.H., FAPM, DAAPM

Chief 

Consultation Psychiatry & Ethics 

New Mexico Veterans Affairs Health 

Care System 

Associate Professor of Psychiatry

Director of Ethics Education 

University of New Mexico School of 

Medicine 

Albuquerque, New Mexico 

Patricia M. Good 

Chief (retired)

Liaison and Policy Section

Office of Diversion Control 

Drug Enforcement Administration

Arlington, Virginia 

Douglas Gourlay, M.D., M.Sc.,

FRCP(C), FASAM

Director 

Pain and Chemical Dependency 

Division 

Wasser Pain Centre 

Mount Sinai Hospital 

Centre for Addiction and Mental 

Health 

Toronto, Canada 

Howard A. Heit, M.D., FACP,

FASAM 

Assistant Clinical Professor of 

Medicine 

Georgetown School of Medicine

Fairfax, Virginia 

Nathaniel Katz, M.D., M.S.

Adjunct Assistant Professor of 

Anesthesia 

Tufts University School of Medicine 

President & CEO 

Analgesic Research

Needham, Massachusetts 

Kenneth L. Kirsh, Ph.D.

Assistant Professor 

Pharmacy Practice and Science

University of Kentucky

Lexington, Kentucky 

95 
96 

Paul Kreis, M.D.

Professor, Medical Director

Division of Pain Medicine 

University of California, Davis

Sacramento, California 

Pamela A. Pavilonis, M.B.A., M.S., N.D.

Naturopathic Physician

West Linn, Oregon 

Seddon R. Savage, M.D., M.S.

Director 

Dartmouth Center on Addiction Recovery 

and Education 

Hanover, New Hampshire 

Pain Consultant 

Manchester VA Medical Center 

Manchester, New Hampshire 

Randy Seewald, M.D.

Medical Director 

Methadone Maintenance Treatment Program

Beth Israel Medical Center 

New York, New York 

Barbara St. Marie, ANP, GNP

Nurse Practitioner 

Burnsville, Minnesota 

Mark D. Sullivan, M.D., Ph.D.

Professor of Psychiatry and Behavioral 

Sciences 

University of Washington

Seattle, Washington 

Andrea Trescot, M.D.

Professor 

Department of Anesthesia and Pain Medicine

Director 

Pain Fellowship Program

University of Washington

Seattle, Washington 

Norman Wetterau, M.D., FAAFM,

FASAM 

New York, New York 

Penelope P. Ziegler, M.D., FASAM

Medical Director 

Virginia Health Practitioners’ Monitoring 

Program

Richmond, Virginia 
Appendix F— 

Acknowledgments 

Numerous people contributed to the development of this TIP, including the TIP 

Consensus Panel (see p. ix) and TIP field reviewers (see Appendix E). 

This publication was produced under the Knowledge Application Program 

(KAP), a Joint Venture of JBS International, Inc. ( JBS), and The CDM Group,

Inc., and for the Substance Abuse and Mental Health Services Administration,

Center for Substance Abuse Treatment. 

Lynne MacArthur, M.A., A.M.L.S., served as the JBS KAP Executive Project 

Co-Director, and Barbara Fink, RN, M.P.H., served as the JBS KAP Managing 

Project Co-Director. Other JBS KAP personnel included Candace Baker,

M.S.W., MAC, Deputy Director for Product Development; Kris Rusch, M.A.,

Senior Writer; Cathy Baker, M.Ed., Senior Writer; Martha Horn, Ph.D., Senior 

Writer; Frances Nebesky, M.A., Quality Assurance Editor; Wendy Caron,

Quality Assurance Manager; Erin P. Doherty, Copy Editor; and Erin Sandor,

Graphic Designer. 

97 

Index 

A 

Aberrant drug-related behavior

assessment tools, 56–57, 58

behaviors included, 54, 56

description, 54

Addiction. See also specific drugs; Substance use disorders

assessing substance use and addiction, 18–20

chronic nature of, 7

commonalities with chronic noncancer pain, 4

comorbidity with depression and anxiety, 9, 24–27

cross-addiction, 9, 22

cycle of chronic pain and, 9–10

definition, 2, 7, 20

dopamine and, 7, 8

environmental factors, 8–9

managing addiction risk in patients treated with opioids, 49–63

neurobiology of, 7–8

reward response and, 7–8

risk factors for, 8–9

screening for, 20–23

stress response and, 8

Addiction Behaviors Checklist 

description, 56

exhibit, 57

Addiction specialists

laws, regulations, and policies regarding, 35

medication supply issues and, 50–51

pain management and, 34–35

treatment agreements and, 50

withdrawal from opioids and, 61, 63

Addictive substances. See also specific substances 

definition, 2–3

Adjuvant medications

pain management issues, 35 

99 
100 

ADRB. See Aberrant drug-related behavior

Alcohol use disorders
 

“drink” definitions, 19


assessing pain and function in patients 


with, 16–20


cross-addiction and, 9


American Academy of Pain Management


treatment agreement sample, 73


American Academy of Pain Medicine


standardized terminology for addiction,
 

physical dependence, and tolerance, 2


American Pain Society


standardized terminology for addiction,
 

physical dependence, and tolerance, 2


American Psychiatric Association


benzodiazepine treatment guidelines, 36


American Society of Addiction Medicine


standardized terminology for addiction,
 

physical dependence, and tolerance, 2


Amphetamines


dopamine and, 8


Anticonvulsants. See also specific drugs


pain management issues, 35, 39


Antidepressants. See also specific drugs


pain management issues, 35, 39


serotonin syndrome and, 40


Anxiety


addiction risk factor, 9


association with chronic noncancer pain,


substance use disorders, and depression, 25


benzodiazepine treatment, 36, 39


coping and, 27


development of tolerance to anxiolytics 


and, 9–10

tools to assess emotional distress, anxiety,

pain-related fear, and depression 

(exhibit), 26, 88–89

withdrawal and, 10


Arnold, R. M.


treatment agreements, 71


Asmundson, G. J.


chronic noncancer pain and PTSD 


comorbidity, 25
 

Assessing pain and function. See also Patient 

assessment
 

assessing substance use and addiction, 18–20


complicating factors for, 16


corroboration by sources of information 


other than the patient, 18


documentation requirements, 15–16


functional impairment and, 16


mental status evaluations, 17


patients with histories of substance use 


disorders, 16–18

strengths and weaknesses of assessment 

tools, 17–18


tips for clinicians, 19


tools to assess pain interference with life 


activities and functional capacities 

(exhibit), 19


tools to assess pain level (exhibit), 17–18


tools to assess several dimensions of pain 


(exhibit), 18


work-related functional impairment and, 16
 

B 

Behavioral health
 

definition, 3


Benzodiazepines


addiction risk, 36


alternatives to, 39


pain management issues, 35–36, 39


side effects, 36


weaning from, 36


Brox, J. I.


patient education, 65


Buprenorphine


acute opioid withdrawal and, 43


mechanism of action, 43


pain management issues, 43–44, 46


replacement of opioids with, 43


Butler, S. F.


Current Opioid Misuse Measure, 56
 

C 

CAM. See Complementary and alternative 

medicine 
101 

Index

Cannabinoids
 

abuse potential, 37


mechanism of action, 37


pain management issues, 37


CBT. See Cognitive-behavioral therapy

Center for Substance Abuse Treatment
 

detoxification information, 45


general, ii, ix, xi, 23, 97


list of publications based on TIPs, 99–102


motivational interviewing information, 45


opioid treatment programs, 42


treatment strategies and models for working


with individuals with psychiatric 


comorbidities, 39


Chiropractic


pain management issues, 39


Chronic noncancer pain. See also Pain
 

anxiety and, 25


assessing pain and function, 15–20


basics of, 4


causes, 6


commonalities with addiction, 4


cross-addiction and, 9


cycle of chronic pain and addiction, 9–10


definition, 2–4, 3


depression and, 25


feedback cycles, 7


identification of the source of, 6


impact of, 1


mixed nociceptive and neuropathic type, 6


multidimensional nature of, 1, 13


negative reinforcement of substance use 


and, 9


neuropathic type, 6


nociceptive type, 6


pain management, 33–48


paradoxical reactions to substances used to 


treat, 10


physiological and psychological effects, 7


positive reinforcement of substance use 


and, 9


post-traumatic stress disorder and, 25–26


prevalence of, 1, 2


psychiatric comorbidities, 24–27
 

rebound symptoms, 10


statistics on substance use and chronic 


pain in the United States (exhibit), 1


suicide and, 27


tolerance to analgesic and anxiolytic 


substances and, 9–10


types of (exhibit), 6


Chronic pain syndrome


definition, 3


CNCP. See Chronic noncancer pain
 

Cocaine
 

dopamine and, 8


Cochrane Collaborations
 

physical therapy reviews, 38


review of opioid rotation, 45


Cognitive-behavioral therapy


discontinuation of opioid therapy and, 61


pain management issues, 38


Collateral information
 

managing addiction risk in patients treated 


with opioids and, 54


patient assessment and, 13


Complementary and alternative medicine


benefits of, 38–39


description, 38


resources for finding practitioners, 93


talking with patients about CAM


(exhibit), 38


Coping with pain


acceptance concept and, 27


cognitive-behavioral therapy and, 38


referral to psychologists for assistance 


with, 69


tools to assess coping (exhibit), 27


Crane, C.


suicide risk in patients with chronic 


noncancer pain, 27


Cross-addiction
 

description, 9


SUD involving any drug and susceptibility


to developing a cross-addiction with


opioids, 22


CSAT. See Center for Substance Abuse 


Treatment
 
102 

Cuoto, J. E.


urine drug testing data, 51


Current Opioid Misuse Measure


description, 56


elements of (exhibit), 58
 

D 

DEA. See Drug Enforcement Administration

Depression


addiction risk factor, 9


anxiety and, 25


chronic noncancer pain and, 25


tools to assess emotional distress, anxiety,


pain-related fear, and depression 


(exhibit), 26, 88–89


withdrawal and, 10


Diagnostic and Statistical Manual of Mental 

Disorders, Fourth Edition, Text Revision

substance dependence criteria, 20–21

Documentation requirements

assessing pain and function, 15–16

chronic opioid therapy, 58–59

elements to document during patient visits 

(exhibit), 31


Drug diversion


description, 60


legal and regulatory issues, 71


patient responsibility for protecting their 


medication supply, 60


resources for information on drug use 


trends (exhibit), 60


treatment monitoring and, 60–61


Drug Enforcement Administration


“do not fill until” option for prescriptions, 50


buprenorphine treatment and, 43–44


policy statement on dispensing scheduled 


medications, 60


DSM-IV-TR. See Diagnostic and Statistical 

Manual of Mental Disorders, Fourth 

Edition, Text Revision

Duloxetine
 

anxiety treatment, 39


depression treatment, 39
 

E 

Environmental factors
 

addiction, 9, 10
 

F 

Food and Drug Administration


anxiety treatments, 39
 

G 

Gabapentin


anxiety treatment, 39


withdrawal from opioids and, 61


Gender factors
 

“drink” definitions, 19


Genetic factors
 

addiction, 8–9, 10


Geppert, C. M.


informed consent, 65


Gourlay, D. L.


urine drug testing, 52, 53
 

H 

Health Insurance Portability and 


Accountability Act


patient privacy and, 24


Health Resources and Services Administration
 

patient education recommendations, 67


Heit, H. A.


urine drug testing, 52, 53


HIPAA. See Health Insurance Portability and 


Accountability Act


HIV/AIDS


pain management issues, 46


serotonin syndrome and, 40


treating patients who have HIV/AIDS 


(exhibit), 47


HRSA. See Health Resources and Services 


Administration
 

Hyperalgesia. See also Opioid-induced


hyperalgesia


definition, 3


methadone maintenance therapy and, 45


pain management issues, 45
 
103 

Index

I 

IAs. See Immunoassays

Immunoassays


benefits and limitations of, 52


POC testing benefits and limitations 


(exhibit), 52


Informed consent
 

CFR sample consent form, 91


individual identifiers under the privacy 


rule, 92


opioid therapy and, 69–70


patient education and, 65, 69–70


Insomnia
 

anticonvulsant treatment, 36


antidepressant treatment, 36
 

L 

Lamotrigine


post-traumatic stress disorder treatment, 39
 

M 

Managing addiction risk in patients treated 

with opioids


“do not fill until” option for prescriptions, 50


aberrant drug-related behavior, 54, 56


addiction behaviors checklist (exhibit), 57


collateral information and, 54


Current Opioid Misuse Measure (exhibit),


56, 58


discontinuation of opioid therapy, 61–63


documentation requirements, 58–59


drug diversion, 60–61, 71


exit strategy (exhibit), 62


issuance of multiple prescriptions for 


Schedule II controlled substances 

(exhibit), 50


key points, 63


managing difficult conversations, 59


medication supply issues, 50–51


nonadherence, 54, 56


patient’s support network and, 50, 54


promoting adherence, 49–51


pseudoaddiction (exhibit), 56


resources for information on drug use 


trends (exhibit), 60
 

talking with patients about medication 

supply (exhibit), 51


ten steps of universal precautions (exhibit), 49


therapeutic relationship and, 59, 63


tips for clinicians, 49–50, 53, 59


treatment agreements, 50


universal precautions approach, 49


urine drug testing, 51–54, 55


visit intervals, 50


workplace safety issues, 59


Massage therapy


pain management issues, 39


Medication supply issues


“do not fill until” option for prescriptions, 50


“doctor shopping,” 61


addiction specialists and, 51


drug diversion and, 60


issuance of multiple prescriptions for 


Schedule II controlled substances 

(exhibit), 50


pill counts and, 50


talking with patients about medication 


supply (exhibit), 51


using a trusted family member to dispense 


medications, 50


Medication-assisted recovery


buprenorphine and, 43–44


methadone and, 44


naltrexone and, 44


Mental illness. See Psychiatric disorders; specific 

disorders 

Methadone
 

analgesic effects, 44


methadone titration (exhibit), 42


pain management issues, 44


patient education and, 44


referral to treatment programs, 42


Methadone maintenance therapy


hyperalgesia and, 45


opioid treatment programs and, 42


patient education regarding, 71


Mixed nociceptive/neuropathic pain


description, 6


MMT. See Methadone maintenance therapy
 
104 

N 

Naltrexone
 

mechanism of action, 44


pain management issues, 44


Narcotic
 

definition, 3


National Association of State Alcohol and Drug


Abuse Directors
 

research findings on Screening, Brief


Intervention, and Referral to Treatment, 23


National Institute for Health and Clinical 


Excellence
 

benzodiazepine treatment guidelines, 36


National Institute on Alcohol Abuse and 


Alcoholism
 

“drink” definitions, 19


National Institute on Drug Abuse


genetic vulnerability to addiction, 8


Neuropathic pain


description, 6


NIAAA. See National Institute on Alcohol 


Abuse and Alcoholism
 

Nicholson, B.


ongoing patient assessment needs, 31


NIDA. See National Institute on Drug Abuse


Nociceptive pain


description, 6


Non-opioid analgesics


pain management issues, 35


summary of (exhibit), 35–36


Nonpharmacological pain management


benefits of, 37


cognitive-behavioral therapy, 38


complementary and alternative medicine,


38–39
 

physical therapy, 38


therapeutic exercise, 37


Nonsteroidal antiinflammatory drugs


pain management issues, 35, 46


NSAIDS. See Nonsteroidal antiinflammatory 


drugs
 

O 

OIH. See Opioid-induced hyperalgesia 

Opioid Risk Tool


description, 28


elements of (exhibit), 30


Opioid treatment programs


patient management and, 42


referral to methadone therapy and, 42


Opioid-induced hyperalgesia


compared with tolerance, 44–45


definition, 3


Opioids


adverse effects of, 40


as part of a multidimensional treatment 


approach, 40


considerations before using for pain 


management, 40


discontinuation of opioid therapy, 43,


61–63
 

documentation of chronic opioid therapy,


58–59 

dose finding, 41–42

evaluating risk of developing problematic 

opioid use, 28–30


exit strategy (exhibit), 62


informed consent and, 69–70


legal and regulatory issues of therapy, 71


limitations of treatment with, 40


managing addiction risk in patients treated 


with, 49–63


methadone titration (exhibit), 42


monitoring use of, 42


opioid rotation (exhibit), 45


patient education issues, 69–71


reasons for discontinuing, 61, 63


referral to opioid treatment programs, 42


relapse issues, 40, 42–43


replacement of with buprenorphine, 43–44


risk of patient’s developing problematic 


opioid use (exhibit), 28


risk of therapy, 70


route of administration, 41


selection criteria, 41


serotonin syndrome and, 40


short-acting medications, 41


side effects, 70


signs and symptoms of withdrawal, 61
 
105 

Index

steps to take if opioid therapy is indicated 

(exhibit), 41

SUD involving any drug and susceptibility


to developing a cross-addiction with 


opioids, 22


titration schedules, 41–42


tolerance issues, 44–45


withdrawal and, 8, 43, 61


ORT. See Opioid Risk Tool


Otis, J. D.


chronic noncancer pain and PTSD 


comorbidity, 25
 

P 

Pain. See also Chronic noncancer pain


basics of, 4


categories of, 5


definition, 3


neurobiology of, 4–5


nociceptors and, 4–5


pain pathways (exhibit), 5


subjective nature of, 4


Pain management


acute pain episodes and, 46


addiction specialist role, 34–35


algorithm for managing chronic pain in 


patients with SUDs (exhibit), 34


benzodiazepines, 35–36


buprenorphine issues, 43–44, 46


cannabinoids, 37


cognitive-behavioral therapy, 38


complementary and alternative medicine,


38–39
 

key points, 48


managing addiction risk in patients treated 


with opioids, 49–63


methadone issues, 44


multidisciplinary team approach, 33–35


naltrexone issues, 44


non-opioid analgesics, 35


nonpharmacological treatments, 37–39


opioid therapy, 40–43


overview, 33


patient-controlled analgesia, 46
 

patients in medication-assisted recovery 

and, 43–44


patients in recovery and, 35–37, 46


patients on agonist therapy for addiction 


or pain and, 46


patients who have HIV/AIDS (exhibit), 47


patients who have sickle cell disease 


(exhibit), 47


patients with active addiction and, 45–46


physical therapy, 38


psychiatric comorbidities and, 39–40


summary of non-opioid analgesics 


(exhibit), 35


therapeutic exercise, 37


tolerance and hyperalgesia, 44–45


treatment outcomes and, 46


treatment team components, 33–34


Passik, S. D.


“4 As” of monitoring and documenting 


opioid response, 59


ongoing patient assessment needs, 31


Patient assessment
 

assessing ability to cope with chronic pain, 27


assessing pain and function, 15–20


assessing substance use and addiction, 18–20


collateral information and, 13


elements of, 13, 14–15, 23


elements of a comprehensive patient 


assessment (exhibit), 14–15


elements of screening, brief intervention,


and referral to treatment (exhibit), 23


elements to document during patient visits 


(exhibit), 31


evaluating risk of developing problematic 


opioid use, 28


false-positive or false-negative results and, 13


Federal protection of patient health 


information (exhibit), 24


key points, 32


limitations of standardized tools, 13


ongoing assessment needs, 30–31


Opioid Risk Tool, 28, 30


psychiatric comorbidities, 24–27


referrals for further assessment, 23–24
 
106 

Screener and Opioid Assessment for 

Patients with Pain—Revised, 28, 29


substance use disorder screening, 20–23


tips for clinicians, 15, 16–17, 19, 23–24,


30–31
 

tools for, 13, 15–23, 87–89


tools to assess coping (exhibit), 27


tools to assess emotional distress, anxiety,


pain-related fear, and depression (exhibit),


26, 88–89


tools to assess pain interference and 


functional capacities (exhibit), 87


tools to assess pain interference with 


life activities and functional capacities 


(exhibit), 19


tools to assess pain level (exhibit), 17–18, 87


tools to assess several dimensions of pain 


(exhibit), 18, 87


tools to screen for substance use disorders 


(exhibit), 22, 88


treatment setting options, 31–32


Patient education
 

content areas, 69


cultural sensitivity and, 65–66


effective education strategies, 66–68


family members and caregivers and, 66


health literacy and, 66


Health Resources and Services 


Administration recommendations, 67


informed consent and, 65, 69–70


Internet as a source of, 66, 68


key points, 74


linguistically appropriate materials, 65–66


methadone maintenance therapy, 71


methadone treatment, 44


online sources, 66, 68


opioid information, 69–71


reliable Web sites with information on 


chronic pain and pain treatment 


(exhibit), 68


reliable Web sites with information on 


substance use disorders (exhibit), 69


selected online sources of information on 


health literacy (exhibit), 66


take-home handouts and pamphlets, 68
 

talking with patients before surgery 


(exhibit), 70


talking with patients following a teach-


back approach (exhibit), 67


teach-back method, 67


time commitment and, 66


urine drug testing, 54


value of, 65


Patient-controlled analgesia


monitoring of, 46


Physical dependence


definition, 2, 3


Physical inactivity


chronic noncancer pain and, 7


Physical therapy


for patients with HIV/AIDS, 47


pain management issues, 38


Post-traumatic stress disorder
 

chronic noncancer pain and, 25–26


lamotrigine treatment, 39


symptoms, 26


tools to assess emotional distress, anxiety,


pain-related fear, and depression 


(exhibit), 26


Pregabalin


anxiety treatment, 39


Pseudoaddiction
 

definition, 3


exhibit describing, 56


Psychiatric disorders. See also specific disorders


addiction risk factor, 9


comorbidity with addiction, 9, 24–27,


39–40 

difficulty of differentiating a substance-


induced condition from a primary 


psychiatric disorder, 25


pain management issues, 39–40 

PT. See Physical therapy 

PTSD. See Post-traumatic stress disorder 

R 

Recovery


definition, 3


Referring patients for further assessment


clinician-patient relationship and, 24
 
107 

Index

confidentiality and, 24


Federal protection of patient health 


information (exhibit), 24


need for pain treatment and, 23


SUD specialists, 23


tips for clinicians, 23–24


Relapse


definition, 4


opioid use and, 40, 42–43


Reward response


cravings and, 8, 61


mechanism of, 7–8


withdrawal and, 8
 

S 

SAMHSA, See Substance Abuse and Mental 

Health Services Administration 

SBIRT. See Screening, Brief Intervention, and 

Referral to Treatment 

SCD. See Sickle-cell disease 

Screener and Opioid Assessment for Patients 

with Pain—Revised
 

description, 28


questions (exhibit), 29


Screening, Brief Intervention, and Referral to 

Treatment
 

description, 23


elements of (exhibit), 23


Selective serotonin reuptake inhibitors


anxiety treatment, 39


Serotonin syndrome


description, 40


Sickle-cell disease
 

description, 46, 47


treating patients who have SCD (exhibit),


47
 

SOAPP-R. See Screener and Opioid 

Assessment for Patients with 

Pain—Revised 

Somatization
 

categories of, 27


description, 27


SSRIs. See Selective serotonin reuptake 

inhibitors 

States
 

documentation of chronic opioid therapy, 58


laws, regulations, and policies regarding 


addiction specialists, 35


prescription monitoring programs, 61


Stress response


mechanism of, 8


Substance Abuse and Mental Health Services 


Administration
 

general, ii, ix, xi, 1, 4, 23, 69, 97, 99 


Screening, Brief Intervention, and Referral to 


Treatment, 23


Substance use disorders. See also Addiction;
 

specific substances


algorithm for managing chronic pain in 

patients with SUDs (exhibit), 34


anxiety and, 25


assessing pain and function in patients 


with SUDs, 16–20


basics of, 4


cognitive-behavioral therapy and, 38


cross-addiction and, 9, 22


definition, 4


DSM-IV-TR criteria for substance abuse 


and substance dependence (exhibit), 21


items to include in substance use 


assessment (exhibit), 20


pain management issues, 33–48


patients in recovery, 35–37, 46


patients with active addiction, 45


positive and negative reinforcement link 


with chronic noncancer pain, 9


prevalence of chronic noncancer pain and, 1


psychiatric comorbidities, 24–27


referral for addiction treatment, 45


reliable Web sites with information on 


substance use disorders (exhibit), 69


screening for, 20–23


steps following substance abuse assessment 


(exhibit), 22


suicide and, 27


tolerance and, 9–10


tools to screen for (exhibit), 22, 88


SUDs. See Substance use disorders 
108 

Suicide
 

chronic noncancer pain and, 27


substance use disorders and, 27


withdrawal and, 10
 

T 

Tang, N. K.


suicide risk in patients with chronic 


noncancer pain, 27


Teach-back approach to patient education


description, 67


talking with patients following a teach-


back approach (exhibit), 67


TIPs. See Treatment Improvement Protocols


Therapeutic exercise


pain management issues, 37


Tolerance
 

analgesic and anxiolytic substances used to 


treat chronic noncancer pain and, 9–10


compared with opioid-induced 


hyperalgesia, 44–45


definition, 2, 4


Transcutaneous electrical nerve stimulation
 

pain management issues, 38


Trazodone
 

anxiety treatment, 39


Treatment agreements


addiction specialists and, 50


common elements of, 72


informed decisions about, 72


key points, 74


revising, 72


sample pain treatment agreement 


(exhibit), 73


tips for clinicians, 71–72


uses for, 50, 71


Treatment Improvement Protocols


audience for, 2


definitions, 2–4


purpose of, 2


Treatment settings


local resources, 31–32


pain clinics, 31


primary care physicians and, 32


specialty consultations, 32
 

Tricyclic antidepressants. See also specific drugs
 

anxiety treatment, 39


withdrawal from opioids and, 61
 

U 

U.S. Department of Defense

VA/DoD Clinical Practice Guideline for the


Management of Opioid Therapy for Chronic


Pain, 65


U.S. Department of Veterans Affairs

VA/DoD Clinical Practice Guideline for 


the Management of Opioid Therapy for 


Chronic Pain, 65
 

UDT. See Urine drug testing

Universal precautions


description, 49


ten steps of universal precautions (exhibit), 49


University of Wisconsin

Pain and Policy Studies Group Web site 


of State regulations regarding opioid 


therapy, 58


Urine drug testing


“no limits” tests, 52


efficacy of, 51


false-positive and false-negative results, 52–53


immunoassays, 52


intervals for, 54


patient education about, 54


POC testing benefits and limitations 


(exhibit), 52


results of, 52–54


specific substance identification tests, 52


talking with patients about aberrant urine 


drug testing results (exhibit), 53


talking with patients who are resistant to 


urine drug testing (exhibit), 55


tips for clinicians, 53


types of, 51–52


unexpected results, 53
 

V
 

VA/DoD Clinical Practice Guideline for the 


Management of Opioid Therapy for 


Chronic Pain, 65
 
109 

Index

Valproic acid

anxiety treatment, 39

Van Ameringen, M.

anticonvulsant treatment for anxiety, 39

Venlafaxine 

anxiety treatment, 39

depression treatment, 39 

W 

Withdrawal 

addiction specialists and, 63

depression and, 10

reward response and, 8

symptoms of, 10, 61

Workplace safety

clinician and patient protection, 59

plans for, 59

World Health Organization

pain ladder, 47 

111 

csAT TIps and publications Based on TIps 

What Is a TIp? 

Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that 

brings together clinicians, researchers, program managers, policymakers, and other Federal and non-Federal experts to reach consensus on state-of-the-art treatment practices. TIPs are developed under CSAT’s 

Knowledge Application Program to improve the treatment capabilities of the Nation’s alcohol and drug 

abuse treatment service system. 

What Is a Quick Guide? 

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized 

booklet. Each Quick Guide is divided into sections to help readers quickly locate relevant material. Some 

contain glossaries of terms or lists of resources. Page numbers from the original TIP are referenced so 

providers can refer back to the source document for more information. 

What Are KAp Keys? 

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening 

instruments, checklists, and summaries of treatment phases. Printed on coated paper, each KAP Keys set 

is fastened together with a key ring and can be kept within a treatment provider’s reach and consulted 

frequently. The Keys allow you—the busy clinician or program administrator—to locate information easily and to use this information to enhance treatment services. 

ordering Information 

Publications may be ordered for free at http://store.samhsa.gov. To order over the phone, please call 

1-877-SAMHSA-7 (1-877-726-4727) (English and Español). Most publications can also be downloaded at http://www.kap.samhsa.gov. 

TIP 1 	 State Methadone Treatment Guidelines— 

Replaced by TIP 43 

TIP 2* 	 Pregnant, Substance-Using Women— 

BKD107 

TIP 3 	 Screening and Assessment of Alcohol- and 

Other Drug-Abusing Adolescents—Replaced 

by TIP 31 

TIP 4 	 Guidelines for the Treatment of Alcoholand Other Drug-Abusing Adolescents— 

Replaced by TIP 32 

TIP 5 Improving Treatment for Drug-Exposed 

Infants—BKD110 

TIP 6* Screening for Infectious Diseases Among 

Substance Abusers—BKD131 

Quick Guide for Clinicians QGCT06

KAP Keys for Clinicians KAPT06 

TIP 7 	 Screening and Assessment for Alcohol and 

Other Drug Abuse Among Adults in the 

Criminal Justice System—Replaced by TIP 44 

TIP 8	 Intensive Outpatient Treatment for Alcohol 

and Other Drug Abuse—Replaced by TIPs 46 

and 47 

TIP 9 Assessment and Treatment of Patients With 

Coexisting Mental Illness and Alcohol and 

Other Drug Abuse—Replaced by TIP 42 

TIP 10 Assessment and Treatment of CocaineAbusing Methadone-Maintained Patients— 

Replaced by TIP 43 

TIP 11* Simple Screening Instruments for Outreach 

for Alcohol and Other Drug Abuse and 

Infectious Diseases—BKD143 

Quick Guide for Clinicians QGCT11 

KAP Keys for Clinicians KAPT11 

TIP 12 Combining Substance Abuse Treatment 

With Intermediate Sanctions for Adults in 

the Criminal Justice System—Replaced by TIP 

44 

TIP 13 Role and Current Status of Patient 

Placement Criteria in the Treatment of 

Substance Use Disorders—BKD161 

Quick Guide for Clinicians QGCT13 

Quick Guide for Administrators QGAT13 

KAP Keys for Clinicians KAPT13 

*Under revision 
112 

TIP 14 Developing State Outcomes Monitoring 

Systems for Alcohol and Other Drug Abuse

Treatment—BKD162 

TIP 15 Treatment for HIV-Infected Alcohol and 

Other Drug Abusers—Replaced by TIP 37 

TIP 16 Alcohol and Other Drug Screening of 

Hospitalized Trauma Patients—BKD164 

Quick Guide for Clinicians QGCT16 

KAP Keys for Clinicians KAPT16 

TIP 17 Planning for Alcohol and Other Drug Abuse 

Treatment for Adults in the Criminal Justice 

System—Replaced by TIP 44 

TIP 18 The Tuberculosis Epidemic: Legal and 

Ethical Issues for Alcohol and Other Drug

Abuse Treatment Providers—BKD173 

Quick Guide for Clinicians QGCT18 

KAP Keys for Clinicians KAPT18 

TIP 19 Detoxification From Alcohol and Other 

Drugs—Replaced by TIP 45 

TIP 20 Matching Treatment to Patient Needs in 

Opioid Substitution Therapy—Replaced by 

TIP 43 

TIP 21 Combining Alcohol and Other Drug Abuse 

Treatment With Diversion for Juveniles in 

the Justice System—(SMA) 08-4073

Quick Guide for Clinicians and 

Administrators QGCA21 

TIP 22 LAAM in the Treatment of Opiate 

Addiction—Replaced by TIP 43 

TIP 23 Treatment Drug Courts: Integrating 

Substance Abuse Treatment With Legal

Case Processing—(SMA) 08-3917

Quick Guide for Administrators QGAT23 

TIP 24 A Guide to Substance Abuse Services for 

Primary Care Clinicians—(SMA) 08-4075

Concise Desk Reference Guide BKD123 

Quick Guide for Clinicians QGCT24 

KAP Keys for Clinicians KAPT24 

TIP 25 Substance Abuse Treatment and Domestic 

Violence—(SMA) 08-4076

Linking Substance Abuse Treatment and 

Domestic Violence Services: A Guide for 

Treatment Providers MS668 

Linking Substance Abuse Treatment and 

Domestic Violence Services: A Guide for 

Administrators MS667 

Quick Guide for Clinicians QGCT25 

KAP Keys for Clinicians KAPT25 

TIP 26 Substance Abuse Among Older Adults— 

(SMA) 08-3918

Substance Abuse Among Older Adults: A 

Guide for Treatment Providers MS669 

Substance Abuse Among Older Adults: A 

Guide for Social Service Providers MS670 

Substance Abuse Among Older Adults:

Physician’s Guide MS671 

Quick Guide for Clinicians QGCT26 

KAP Keys for Clinicians KAPT26 

TIP 27 Comprehensive Case Management for 

Substance Abuse Treatment—(SMA)

08-4215 

Case Management for Substance Abuse 

Treatment: A Guide for Treatment Providers 

MS673 

Case Management for Substance Abuse 

Treatment: A Guide for Administrators 

MS672 

Quick Guide for Clinicians QGCT27 

Quick Guide for Administrators QGAT27 

TIP 28* Naltrexone and Alcoholism Treatment— 

Replaced by TIP 49 

TIP 29 Substance Use Disorder Treatment for 

People With Physical and Cognitive

Disabilities—(SMA) 08-4078

Quick Guide for Clinicians QGCT29 

Quick Guide for Administrators (SMA) 

08-3592 

KAP Keys for Clinicians KAPT29 

TIP 30 Continuity of Offender Treatment for 

Substance Use Disorders From Institution to 

Community—(SMA) 08-3920

Quick Guide for Clinicians QGCT30 

KAP Keys for Clinicians KAPT30 

TIP 31 Screening and Assessing Adolescents for 

Substance Use Disorders—(SMA) 08-4079

See companion products for TIP 32. 

TIP 32 Treatment of Adolescents With Substance 

Use Disorders—(SMA) 08-4080

Quick Guide for Clinicians QGC312 

KAP Keys for Clinicians KAP312 

TIP 33 Treatment for Stimulant Use Disorders— 

(SMA) 06-4209

Quick Guide for Clinicians QGCT33 

KAP Keys for Clinicians KAPT33 

*Under revision 
113 

TIP 34 Brief Interventions and Brief Therapies for 


Substance Abuse—(SMA) 07-3952


Quick Guide for Clinicians QGCT34 


KAP Keys for Clinicians KAPT34
 

TIP 35 Enhancing Motivation for Change in 


Substance Abuse Treatment—(SMA)


08-4212 


Quick Guide for Clinicians QGCT35 

KAP Keys for Clinicians KAPT35 

TIP 36 Substance Abuse Treatment for Persons 


With Child Abuse and Neglect Issues—
 

(SMA) 08-3923


Quick Guide for Clinicians QGCT36 

KAP Keys for Clinicians KAPT36 

Helping Yourself Heal: A Recovering Woman’s 

Guide to Coping With Childhood Abuse 


Issues (SMA) 08-4132


Available in Spanish: PHD981S 


Helping Yourself Heal: A Recovering Man’s 


Guide to Coping With the Effects of 


Childhood Abuse (SMA) 08-4134


Available in Spanish: PHD1059S 

TIP 37 Substance Abuse Treatment for Persons 


With HIV/AIDS—(SMA) 08-4137


Quick Guide for Clinicians MS678 


KAP Keys for Clinicians KAPT37 


Drugs, Alcohol, and HIV/AIDS: A Consumer 


Guide (SMA) 08-4127 


Drugs, Alcohol, and HIV/AIDS: A Consumer 


Guide for African Americans (SMA) 07-4248
 

TIP 38 Integrating Substance Abuse Treatment and 


Vocational Services—(SMA) 06-4216


Quick Guide for Clinicians QGCT38
 

Quick Guide for Administrators QGAT38 


KAP Keys for Clinicians KAPT38
 

TIP 39 Substance Abuse Treatment and Family 


Therapy—(SMA) 08-4219


Quick Guide for Clinicians QGCT39
 

Quick Guide for Administrators QGAT39
 

TIP 40 Clinical Guidelines for the Use of 


Buprenorphine in the Treatment of Opioid


Addiction—(SMA) 07-3939


Quick Guide for Physicians QGPT40

KAP Keys for Physicians KAPT40 

TIP 41 Substance Abuse Treatment: Group 


Therapy—(SMA) 05-3991


Quick Guide for Clinicians QGCT41
 

TIP 42 Substance Abuse Treatment for Persons 


With Co-Occurring Disorders—(SMA)


08-3992
 

Quick Guide for Clinicians (SMA) 07-4034


Quick Guide for Administrators QGAT42
 

KAP Keys for Clinicians (SMA) 08-4036 


TIP 43 	 Medication-Assisted Treatment for Opioid


Addiction in Opioid Treatment Programs—
 

(SMA) 08-4214


Quick Guide for Clinicians QGCT43 


KAP Keys for Clinicians (SMA) 07-4108 


TIP 44 Substance Abuse Treatment for Adults in the 


Criminal Justice System—(SMA) 05-4056


Quick Guide for Clinicians QGCT44
 

KAP Keys for Clinicians (SMA) 07-4150 


TIP 45 Detoxification and Substance Abuse 


Treatment—(SMA) 08-4131


Quick Guide for Clinicians (SMA) 06-4225


KAP Keys for Clinicians (SMA) 06-4224 


Quick Guide for Administrators (SMA) 


06-4226 


TIP 46 Substance Abuse: Administrative Issues in 

Outpatient Treatment—(SMA) 06-4157


Quick Guide for Administrators (SMA) 


07-4232 


TIP 47 Substance Abuse: Clinical Issues in 


Outpatient Treatment—(SMA) 06-4182


Quick Guide for Clinicians (SMA) 07-4233


KAP Keys for Clinicians (SMA) 07-4251
 

TIP 48 Managing Depressive Symptoms in 


Substance Abuse Clients During Early


Recovery—(SMA) 08-4353 


TIP 49 Incorporating Alcohol Pharmacotherapies 


Into Medical Practice—(SMA) 09-4380


Quick Guide for Counselors (SMA) 10-4542


KAP Keys for Clinicians (SMA) 10-4544


Quick Guide for Physicians (SMA) 10-4543
 

TIP 50 Addressing Suicidal Thoughts and Behaviors 


in Substance Abuse Treatment—(SMA)


09-4381
 

TIP 51 Substance Abuse Treatment: Addressing the 


Specific Needs of Women—(SMA) 09-4426
 

*Under revision 
114 

TIP 52 Clinical Supervision and Professional 

Development of the Substance Abuse 

Counselor—(SMA) 09-4435 

TIP 53 Addressing Viral Hepatitis in People With 

Substance Use Disorders—(SMA) 11-4656 

TIP 54 Managing Chronic Pain in Adults With or in 

Recovery From Substance Use Disorders— 

(SMA) 12-4671 
HHS publication no. (SmA) 12-4671
 

printed 2012
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and mental Health Services Administration 

center for Substance Abuse Treatment