The differential diagnosis for a patient reporting “pain” includes physical causes (broken leg, sciatica, pseudo addiction); psychological causes (depression, anxiety, hypochondriasis, somatization disorder, etc.); spiritual causes (impending death, grief); secondary gain / malingering / criminal intent (desire for attention, disability benefit, or financial gain from pain medications) and substance use disorder.

A very commonly requested educational pain topic encloses differentiating the patient in pain from the patient with a substance use disorder.

Substance use disorder assessment.
Assess in the following areas:
• Loss of control of drug use (has no partially filled med 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 meds).
• Drug taking reliability (frequently takes extra doses, does not use meds as prescribed).
• Abuse of other drugs (current/past abuse of prescription or street drugs).
• Contact with drug culture (family or friends with substance abuse disorders).
• Cooperation with treatment plan (does not follow-up with referrals or use of non-drug treatments).

One positive item from the list does not establish a substance use disorder. Instead, the diagnosis rests on a pattern of behavior that includes several positive findings.

See reference for more information

Adapted from Weissman DE. Is it pain or addiction? Palliative Care Network of Wisconsin. Fast facts and concepts #68. Internet. Accessed on January 5, 2019