Opioids, pain and addiction - practical strategies

1. Addiction can occur with the repeated exposure of a biogenetically predisposed person to an addictive substance or behaviour. 2. In the patient with pain on opioid therapy, use the '4 Cs' to diagnose addiction. 3. Screening and risk stratification of all patients considered for opioid therapy is a key element of 'universal precautions' in pain management. 4. There are a number of established and new screening tools including the CAGE, Opioid Risk Tool and Screener and Opioid Assessment for Patients with Pain, which can be utilized in the office setting. 5. There are a number of potential ambiguous drug- related behaviours that should trigger a reevaluation by the clinician. 6. Treating the higher-risk patient with opioids requires more assessment, more structure and more monitoring. Written opioid prescribing agreements and urine drug testing can be helpful strategies. 7. Essential documentation includes the '6As': Analgesia, Activity, Adverse effects, Ambiguous drug behaviours, Affect and Adequate prescription information.