Doctors at Georgetown School of Medicine and Mt. Sinai Hospital in Toronto have published a good editorial in the Annals of Internal Medicine about the need for better strategies to identify and prevent chronic pain patients from abusing opiate drugs.

Two strategies are currently being used:

1. The pain-patient contract, which basically requires patients to agree to consult only with that doctor (preventing doctor-shopping) and to adhere to the dosing schedule set up by the physician (i.e., not buy extra drugs off the street; not steal drugs or forge prescriptions; etc.). As if an addict in the throes of obsession would suddenly remember, “Oh right!—I signed that contract months ago (where did I put it again?), I CAN’T take those extra drugs.” If physicians think this piece of paper would prevent a pain patient from becoming addicted, then physicians do not understand addiction.

2. The urine drug-screen, which I always thought tested for drugs other than those prescribed (my doctor told me so), but maybe it measures for heightened drug-levels? To tell you the truth, I don’t know what the urine drug-screen does.

And the authors don’t know either—they say there’s little evidence that either of these tools does any good, and in fact they may create more stigma for pain patients without addiction problems who need pain treatment and don’t want to prove they’re not addicts by peeing into a cup every month.

One problem is the medical establishment/industry’s inability to define “addiction.” Even the panel rewriting the DSM V can’t figure out how to define it. The doctors write:

To paraphrase Supreme Court Justice Potter Stewart, although drug misuse and addiction are difficult to define, we all assume that we will know them when we see them. This attitude has had a devastating effect on clinical practice and research at the interface of pain and addiction.

They’re talking about that old standard about the meaning of pornography: “I can’t define it, but I know it when I see it.”

They add that a recent review on the safety of the use of opiates to manage chronic non-cancer pain noted the scarcity of addiction-related data and concluded that if there was no data, then addiction must not have been a problem. The editorial argues that addiction is a big problem that has remained hidden because of difficulties in diagnosing it when it intersects with pain management. We all know a junkie when we see her on the street, right?—but it’s harder to recognize the addict in the doctor’s office because she’s, like, not begging for money.

I know my doctor thought I had some kind of “problem” with my drugs. I think she lacked the tools to diagnose and treat me definitively, as an addict. She sends the people she thinks are “real addicts” to the psychiatric hospital. I don’t think she wanted to do that to me, however much I deserved it, and for that I am grateful to her. She was willing to help me taper, but instead I hired a detox doctor. He was what I needed. I could never taper off a full-agonist.

If you were on a panel advising these doctors, what strategies would you give them to identify the addicts in their offices?