What your doctor thinks when you talk about pain

INSIDER INFORMATION: Opiate Prescriptions – from drugs-forum.com – Richard_smoker, Mar 21, 2006

Interested in what your psychiatrist &/or pain control doc is thinking when you tell him you’re in pain?

Perhaps you will be shocked when you read what’s going through his mind. If you know what’s best for yourself (pun intended), then you will read the ‘suggestions’ herein very carefully.

Here it is. 2 back-to-back articles copied starting on pg. 1282, JOURNAL OF PALLIATIVE MEDICINE. Volume 8, Number 6, 2005.

Is It Pain or Addiction? – DAVID E. WEISSMAN, M.D. 

THE SINGLE MOST REQUESTED educational topic by physicians concerning pain surrounds differentiating the patient in pain versus the patient with a substance abuse disorder.

The key to proper assessment lies in understanding

(1) the definitions of tolerance, physical and psychological dependence (a.k.a. addiction),
(2) the components of an addictions assessment and
(3) the differential diagnosis of the symptom of “pain.”


Tolerance: the need to increase a drug to achieve the same effect. In clinical practice, significant opioid tolerance is uncommon. Tolerance may be present in the pain patient or the patient with a substance abuse disorder; by itself it is not diagnostic of addiction.

Physical dependence: development of a withdrawal syndrome when a drug is suddenly discontinued or an antagonist is administered. Many patients taking opioids long term become physically dependent; their presence cannot be used to differentiate the pain patient from the patient with a substance abuse disorder.

Psychological dependence (addiction): overwhelming involvement with the acquisition and use of a drug, characterized by: loss of control, compulsive drug use, and use despite harm.

Data suggest that opioids used to treat pain rarely leads to psychological dependence.


Note: one positive item from the list does not establish a substance abuse disorder, rather, the diagnosis rests on a pattern of behavior that includes several positive findings.

-if you do any of these, it is considered very BAD!

Assess for addiction in the following domains:

  • Loss of control of drug use (has no partially filled medication bottles; will not bring in bottles for verification);
  • Adverse life consequences—Use despite harm (legal, work, social, family);
  • Indications of drug-seeking behavior (reports lost/stolen meds, requests for high-street value medications);
  • Drug taking reliability (frequently takes extra doses, does not use medications as prescribed);
  • Abuse of other drugs (current/past abuse of prescription or street drugs);
  • Contact with drug culture (family or friends with substance abuse disorder); and
  • Cooperation with treatment plan (does not follow- up with referrals or use of nondrug treatments).


The differential diagnosis for a patient reporting “pain” includes:

  • physical causes** (broken leg, sciatica, pseudoaddiction);
  • psychological (depression, anxiety, hypochondriasis, somatization disorder);
  • spiritual (impending death, grief);
  • substance abuse; and
  • secondary gain/malingering/criminal (desire for attention, or disability benefit or financial gain).

**Dick’s Notes: You might want to remember that in the U.S., opiates and opioids are ONLY prescribed for ONE of these reasons: PHYSICAL CAUSES

Sees KL, Clark HW: Opioid use in the treatment of chronic pain: Assessment of addiction. J Pain Symptom Manage 1993;8:257–264.
Palliative Care Center, Froedtert Hospital, Milwaukee, Wisconsin. Fast Facts and Concepts*FAST FACTS AND CONCEPTS 1283
Savage SR: Addication in the treatment of pain: significance, recognition and management. J Pain Symptom Manage 1993;8:265–278.
Eisendrath SJ: Psychiatric aspects of chronic pain. Neurology 1995;45:S26–S34.
Passik SD, Kirsh KL, Portenoy RK: Understanding aberrant drug-taking behavior: Addiction redefined for palliative care and pain management settings. In: Berger
AM, Portenoy RK, Weisman DE (eds): Principles and
Practice of Supportive Oncology Updates. Philadelphia, PA: Lippincott Williams & Wilkins, 1999;2:1–12.

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