Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

374 IV. SPECIAL POPULATIONScommon medical and psychiatric comorbidities. The degree of psychopathologymay be severe enough that a useful therapeutic alliance is impossible, and boththe veracity of the complaints and adherence to prescribed therapies becomemajor problems. Some patients cannot be treated with any potentially abusabledrug.Careful assessment is again critical to appropriate management. The typesof drugs abused, the extent of the consequences, and the comorbidities must beclarified. An understanding of the past psychiatric condition of the patient canprovide a context for therapeutic decisions. For example, sociopathy is relativelycommon among a subset of addicts (Hill, Haertzen, & Davis, 1962; Hill,Haertzen, & Glaser, 1960), and information about the occurrence of sociopathicbehaviors prior to the diagnosis of chronic pain can inform the decisionto treat with potentially abusable drugs. Straightforward questioning about illegalpractices may yield surprisingly frank answers, from which an assessment ofthese behaviors can be made.Categories of Patients with PainPatients with pain can be categorized in several clinically meaningful ways.Some distinctions are particularly relevant to the selection of treatmentapproaches.Most patients who require opioid therapy present with acute monophasicpain that may accompany trauma or a procedure and is expected to be selflimited.When severe, the short-term administration of an opioid drug is widelyconsidered to be medically appropriate treatment. Surveys suggest that thesepain syndromes are often undertreated (Edwards, 1990; Perry & Heidrich,1982).Recurrent acute pains also are extremely prevalent. They include commonpainful disorders, such as headache and dysmenorrhea, and many diseases associatedwith periodic flares, including sickle-cell anemia, inflammatory boweldisease, and some arthritides or musculoskeletal disorders. The preferred treatmentof these recurrent pains varies with the diagnosis and severity. The use ofopioid therapy is conventional practice for some, such as the pain of sickle-cellanemia. The decision to implement a trial should be based on an assessment ofpain characteristics and risks, rather than on diagnosis alone.A third category is chronic pain associated with cancer or other progressivemedical disease. Opioid therapy is considered to be the major therapeuticapproach for patients with moderate or severe cancer pain (American PainSociety, 2003; Portenoy & Lesage, 1999), and pain associated with advancedmedical illness of other types, including pain due to AIDS.The role of opioid therapy in chronic pain syndromes of other types is lesswell accepted (see below). These syndromes include numerous disorders associatedwith nonprogressive organic lesions, such as osteoarthritis and various