Pain and addiction: managing risk through comprehensive care

The use of controlled substances, including opioids, in people who may suffer from concurrent substance use disorders presents challenges to the healthcare professional. Pain and addiction can coexist either as a continuum or separate comorbid conditions. Success in the treatment of either condition requires an approach that encompasses the biopsychosocial needs of the patient. In pain management, controlled substances can be either the problem or the solution, depending on the healthcare professional's training and perspective. Not all patients on opioid pharmacotherapy do well. Some, with inadequate treatment responses, may actually improve on discontinuation of their opioids. Therefore, in any trial of pharmacotherapy, there must be a clear exit strategy as part of the treatment plan. The goal of this article is to explore the importance of making reasoned clinical decisions when faced with aberrant behavior, which is when the patient steps outside the boundaries of the agreed on treatment plan and is established as early as possible in the doctor-patient relationship. In this case, it is essential to separate the "motive" from the "problematic behavior" when trying to interpret the implications of aberrant behavior rather than simply applying a diagnostic label of addiction, which may or may not be correct.