Utah Addiction Center

The Patient in Recovery who is at Risk from Medical Pain Management

Harriet is a 51 year old married woman with a past history of alcohol and cocaine abuse. She has been attending AA and NA meetings regularly and does not report urges to drink or use drugs during the 4 years you have been her primary care physician. She needs carpal tunnel surgery and the typical regimen during recovery is oxycodone 15 mg per day.




A. How would you approach the patient (either cooperative or resistant)?
(The goal is to develop a positive, non-judgemental rapport with the patient?)

  1. Use your rapport.

  2. Don't be afraid to explore the issue of pain medications being prescribed for people with a previous history of addiction.Display compassion and concern. 

  3. Display compassion and concern.

  4. Use a neutral, matter of fact, tone of voice.

  5. Acknowledge it may be difficult for the patient to engage in this discussion.  

  6. Be nonjudgmental. The more nonjudgmental you are the more likely the patient is to reveal information.

  7. Be redundant. If your questions are not being completely answered ask again.

B. What data do you need to collect or what initial screening should be done?  (The goal is to gather relevant history and barrier information.) 

  1. Given the patient's history of alcohol and cocaine addiction, prescribing an addictive medication may trigger a relapse with her previous drugs of choice or may trigger a new addiction to opioids.

  2. According to the Diagnostic and Statistical Manual of Mental Disorders, an addiction is defined by the biopsychosocial consequences of use, not just frequency and amount. Ask the following questions regarding a history of the use of any opioid or opiates. If she reports a positive history ask the following questions:

    • a. When did you first use? How often? How much?

    • b. How did you stop using?

    • c. Did you develop a tolerance?

    • d. Have you been prescribed opiates for pain? Did you abuse the medication? Did you run out of prescriptions early or report your pills as stolen?

    • e. Given that her primary report is alcohol and cocaine, did she relapse to drinking or using after getting a prescription for opiates in the past.

    • f. Did your opiate use ever cause problems related to work, school, family obligations, or violations of the law?

    • g. How do you feel about being prescribed an opiate medication after your surgery?

    • h. Do you want to consider taking another medication to manage your post-surgery pain?

If the person becomes resistant or uncooperative try to reassure the patient that you are gathering this information to provide the best care for his health. If the patient remains resistant then ask them what they would like to do, ask them if you could ask about this issue again next time, and schedule a follow-up appointment. It is likely that fear and stigma is contributing to the patient being in the pre-contemplation stage of change.

C. What other medications/drugs is the patient using?

  1. Review the patient's medication use to look for interactions or contraindications in a patient who may be prescribed Oxycodone.

  2. Review medications from any other prescribers. If you suspect the patient is minimizing or omitting other sources of medication, do a search on the Utah State Controlled Substance Database.

D. What is the pattern of patient's medication/drug use?

(The goal is to determine when, how often, and under what kind of stress/pain conditions is the patient using/abusing the prescribed medications or other drugs.)
N/A 

E. What internal/external obstacles and biases might the patient face?

(The goal is to determine how receptive/resistant the client will be to a discussion regarding his/her drug use. The physician needs to be aware of the internal/external stigma and biases that the patient faces. The physician will need this information to determine how best to approach the patient.)

  1. Fear that her pain won't be treated. (Keep in mind that individuals with addictions may still have real pain that needs to be treated.)

  2. Fear of a relapse.

  3. Fear of a development of an addiction to opiates or the belief that she couldn't possibly develop an addiction to opiates.

  4. Embarrassment and shame

  5. Fear of being judged by others who believe that nobody who has previously had an addiction, regardless to what substance, could safely take opiates without developing an addiction

  6. The patient's belief that her prescription drug use is not problematic

  7. Lack of insurance for treatment

F. What internal/external obstacles and biases might the physician face?

  1. Belief that addiction is a moral issue and not a medical issue.

  2. Belief that because the patient has remained abstinent for four years and continues to participate in AA and NA she couldn't possible develop an addiction to an opiate at this time in her life.

  3. Belief that people with addictions don't deserve to be treated for their pain.

  4. Belief that treating pain among people with addictions will always cause a relapse.

  5. The patient is an adult and any discussion about this is paternalistic.

  6. Physician's discomfort with addressing substance abuse issues

  7. Time constraints

  8. Physician's family history causes countertransference (misperceptions based on personal experiences).

G. What do you do now?

(This provides the physician with the information he/she needs to provide appropriate referral/treatment services.)

  1. Discuss evidence for concern (previous addiction and any biopsychosocial concerns identified in part B)

  2. Display compassion (Remember that addiction is a life threatening disease thus show the same sensitivity as you would for identifying any other life-threatening illness, such as cancer.)

  3. Provide reassurance.

  4. Asses the patient's current coping skills and social support. High functioning, healthy decision making, and a healthy social support network decreases the likelihood of the patient developing an addiction to opiates or relapsing to a previous addiction. A two or more year period of abstinence suggests that many of the previous dysfunctional patterns of behaviors have been addressed and resolved.

  5. Together discuss the pros and cons of being prescribed opiates.

  6. If the patient would like to be prescribed an opiate discuss strategies she will implement to avoid misuse. For example, she may increase the number of NA meetings she attends per week, share the fact that she is being prescribed an opiate with loved ones who will agree to express any concerns regarding changes in her behavior or actions. Furthermore, develop a plan to prescribe for only one week and reassess pain at that time. Encourage her to report any concerns that her pain is not being treated adequately and reassure her that such concerns alone will not be perceived as drug seeking behavior.

  7. Address the stigma associated with having an addiction by reassuring the patient that this is a medical illness and not a question of moral character

  8. Physician can initiate discussion of a plan for participation in physical therapy and weight loss program, and discuss potential barriers to following through.

  9. If it is determined that the patient is not experiencing pain but does have an opioid addiction, consider prescribing Suboxone for detoxification or maintenance treatment and coordinate with a substance abuse treatment provider.

H. How does the physician make a referral?

If Oxycotone is prescribed, monitor the patient for abuse. Referral is not appropriate at this time.

I. When and how should the physician follow up with the patient?

(This provides the physician with the opportunity to coordinate with other services provides to deliver comprehensive services for the patient. It also provides the physician the opportunity to take an active role in the patient's substance abuse problems. The physician can treat/oversee the substance abuse problem as any other medical condition that can have a positive outcome.)

Patient follow-up: 

  1. Discuss patient's progress toward reducing or eliminating her back pain. Continue to monitor the patient's use of pain medications.

  2. Monitor patient as you would any other post-operative patient.

  3. Prescribe minimum amount of Oxycodone that, in your experience, would cover the period of acute, severe pain (wound healing) and encourage the patient to call if the severe pain lasts longer than normal.