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