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

386 IV. SPECIAL POPULATIONSas methylphenidate, modafinil, or dextroamphetamine) (Bruera, Fainsinger,MacEachern, & Hanson, 1992). Given the potential for stimulant abuse andnew side effects, the use of such a drug requires careful assessment of risks versusbenefits, and appropriate monitoring if treatment is initiated. Nausea or othergastrointestinal symptoms, such as anorexia or bloating, occur commonly earlyin therapy and are usually managed with a antiemetic. Because the experienceof side effects with one opioid does not predict the occurrence of the samesymptoms with another one, opioid rotation is always an option for the treatmentof a challenging side effect.5. Risk assessment and management. Extensive experience in the managementof cancer pain has suggested that long-term opioid therapy of an olderpopulation with no prior history of substance abuse is rarely associated with denovo development of abuse or addiction. Similarly, very large surveys ofpatients who receive opioids to treat acute pain indicate that this therapy has avery low risk of precipitating addiction. These reassuring experiences, however,do not mean that the long-term administration of opioids to all populationscarries a low risk of abuse, addiction, or diversion. Indeed, given the base ratesof addiction in the population at large, the reality that neither the prevalencenor the pattern of aberrant drug-related behaviors during pain therapy areknown, and the experience of pain specialists who commonly encounter drugabuse in the referred population they treat, it is prudent to perform an assessmentof risk in all patients. Based on this assessment, treatment can be structuredin a way that facilitates monitoring and assists the patient who needs helpin controlling drug use.The most consistent predictor of misuse and abuse during opioid therapyappears to be a history of substance abuse. Surveys have begun to identify otherpredictors and develop validated methods for categorizing risk (Adams et al.,2004; Chabal, Erjavec, Jacobson, Mariano, & Chaney, 1997; Coambs & Jarry,1996; Compton, Darakjian, & Mitto, 1998; Friedman, Li, & Mehrotra, 2003).There is presently no single, well-accepted measure or risk profile. In additionto a history of drug abuse, factors that may raise a “red flag” include a report bythe patient about concern related to control of the medication, a family historyof drug abuse, a personal or family history of significant psychiatric disease,problematic behaviors with other prescribed drugs, a criminal record, and frequentautomobile accidents.Based on this assessment, the clinician should categorize the patient bydegree of perceived risk. Proactive strategies for prescribing should be applied insome combination for those whose risk is perceived to be relatively high (Table17.4). These strategies may include a written agreement defining the parametersof acceptable behavior; urine drug screening; frequent visits; various rulesconcerning pill counts, concurrent treatment for addiction or other psychiatricdisease, and response to lost prescriptions; no use of short-acting drugs; and similarapproaches. For the person who is perceived to be at relatively limited risk,