Evaluate and Treat Comorbid Psychiatric Disorders
The comorbidity of depression, anxiety, and personality disorders in alcoholics and other patients with substance abuse histories is extremely high.The treatment of anxiety and depression can increase patient comfort and possibly diminish the likelihood of relapse.
Prevent or Minimize Withdrawal Symptoms
Clinicians must be familiar with the signs and symptoms associated with abstinence from opioids and other drugs. Many patients with histories of drug abuse consume multiple drugs. A complete drug use history must be elicited to prepare for the possibility of withdrawal. Delayed abstinence syndromes, such as may occur following abuse of some benzodiazepine drugs, may pose a particular diagnostic challenge.
Consider the Impact of Tolerance
Patients who are actively abusing drugs may have sufficient tolerance to influence the use of prescription drugs subsequently administered for an appropriate medical indication. Tolerance is a complex phenomenon, and its impact on clinical management in this context is likely to be highly variable.[6,7] A prospective open-label study compared morphine dosage and effectiveness in AIDS patients with and without histories of substance use. Results demonstrated that both groups benefited, but patients with histories of drug use required higher morphine doses to achieve stable pain control. This study should increase confidence in providing patients with histories of drug use with appropriate pain management.
Apply Appropriate Pharmacologic Principles to Treat Chronic Pain
Individualization of the dose without regard to its size is the most important guideline for long-term opioid therapy and can be problematic in patients with histories of substance abuse. Although it may be appropriate to exercise caution in prescribing potentially abusable drugs to this population, the decision to forego the principle of dose individualization without regard to absolute dose may increase the likelihood of undertreatment.[9,10][Level of evidence: II] The resulting unrelieved pain can lead to the development of aberrant drug-related behaviors. Although these behaviors might be best understood as pseudoaddiction, their occurrence confirms clinicians' fears and encourages even greater caution in prescribing.
This cycle must be recognized and openly acknowledged to the patient and the staff. The request for dose escalation should not by itself be viewed as aberrant drug-related behavior, but the concerns it generates should be discussed. If the clinician perceives that limits on prescribing are necessary to assess or manage a problematic therapy, frequent monitoring and alternative approaches to pain control might be offered. The patient should be given clear guidelines for responsible drug-taking with the expectation that responsible drug-taking on the part of the patient will reassure the physician that dose escalation is appropriate.
Recognize Specific Drug Abuse Behaviors
All patients who are prescribed potentially abusable drugs must be carefully monitored over time for the development of aberrant drug-related behaviors. The need for this monitoring is especially strong when patients have a remote or current history of substance abuse, including alcohol abuse. If there is a high level of concern about such behaviors, monitoring may require relatively frequent visits and regular assessment by significant others who can provide observations about the patient's drug use.