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

17. Pain and Addiction 375nerve injuries. They also include many syndromes defined solely by the patternof pain and associated symptoms, including chronic daily headache syndrome,fibromyalgia, chronic pelvic pain of unknown origin, and many cases of backand neck pain. A small subgroup has pain and disability that is perceived by theclinician to be primarily related to psychopathology. These patients are characterizedin psychiatric parlance as having a somatoform disorder (American PsychiatricAssociation, 2000), usually a pain disorder. More generically, the term“chronic pain syndrome” is often applied, denoting a chronic pain associatedwith a high level of disability and psychiatric comorbidity. Finally, somepatients with chronic pain have no identifiable medical or psychiatric syndrome;these pains are best termed “idiopathic” (Arner & Myerson, 1988).PAIN ASSESSMENT AND MANAGEMENTThe skills required to treat pain in any patient population include the ability toperform a comprehensive assessment and select a treatment strategy based onthe diagnostic formulation. If drug therapy is used for pain, competent managementdepends on the ability to implement state-of-the-art prescribing principles.For opioid pharmacotherapy, the latter skills must be accompanied by thecapacity to perform an assessment of the risks associated with misuse, abuse,addiction and diversion, and the ability to manage these risks over time. Theseskills are particularly needed in the population of chronic pain patients with ahistory of substance abuse.Pain AssessmentChronic pain is a complex, multidimensional phenomenon. It is commonly associatedwith other symptoms and disturbances in function. It is best conceptualizedas a chronic illness that can be managed but seldom cured. The goals of therapyusually relate to comfort, functional restoration, and improved quality of life.Given this complexity, comprehensive pain assessment requires historytaking that focuses on the pain complaint, its consequences, prior treatments,relevant comorbidities, and other elements in a routine history. The characteristicsof the pain include intensity, temporal features, location, quality, and provokingor relieving factors. Intensity should be measured, usually with a verbalrating scale (e.g., “mild,” “moderate,” “severe”) or a numerical scale (e.g., “0–10”). The selection of the specific metric is less important than its regular applicationover time. Pain quality is assessed by eliciting verbal descriptors, such as“sharp,” “burning,” “lancinating,” or “dull.” The temporal pattern includesonset, course (progressive, stable, or fluctuating) and daily pattern.The history also must characterize the impact of the pain and specificallyquery both physical and psychosocial functioning. The objective is to under-