Red Flags and the Standard of Care

Aberrant Drug-Related Behaviors and the Standard of Care for Pain Management; Alexander DeLuca; War on Doctors/Pain Crisis blog of the Pain Relief Network; 2007-07-17.

Aberrant Drug-Related Behaviors (ADRBs) are commonly referred to in slang vernacular as “red flags.” But when complex human behaviors are lumped together in this way and seen primarily as indicators of “addiction”, or as triggers for investigation of a physician, they are being sorely misunderstood.

As Dr. Frank Fisher explains in “Interpretation of ‘Aberrant’ Drug-Related Behaviors,”¹ while some of these are highly suggestive of a substance use disorder, for example injection of oral preparations or the selling of prescribed medications, other behaviors strongly suggest undertreatment of chronic pain, for example, complaining about need for higher doses, obtaining additional pain medication from family or friends, and unsanctioned dose increases.

In evaluating any given patient’s behaviors, the clinical literature must serve as medical context:

ADRB is very common in clinical pain practice being noted in about 45% of opioid-treated patients in two recent, independent and mutually-replicating, studies.² ³
Overwhelmingly, research has failed to show that chronic opioid therapy is associated with any significant level of addiction outcomes. This is consistent finding over decades.⁴ ⁵ ⁶ ⁷ [See also: Chronic Pain in Veterans]
Rampant undertreatment of pain is a national scourge exacting a terrific toll on both the public health and on our national financial health.⁸ ⁹ ¹⁰ ¹¹
A study of 100 pain specialists attending a meeting found both that “an experienced group of pain clinicians does not view ADRBs uniformly” and that “average rankings suggest clinicians seem to view illegal behavior [not medical consequences] as the most worrisome.”¹²

In summary, in opioid-treated chronic pain populations, ADRBs are very common, addiction as a consequence of treatment is very uncommon, undertreatment of chronic pain is very common, and pain experts lack uniformity in interpreting the relative importance and significance of various ADRBs.

Given this context, leaping to a conclusion that any particular behavior is caused by substance abuse or diversion of prescribed medication is unwarranted and represents a failure to employ a proper medical evaluation process. Applying common medical differential diagnosis analysis (medical thinking) to ADRBs that arise in clinical practice is the medical standard of care. Undertreatment of pain is overwhelmingly more common than substance abuse in the chronic pain population, and is therefore the most likely diagnosis in the differential for the majority of ADRB’s arising in the clinical practice of pain management.

Undertreatment of pain is the diagnosis to be primarily ruled-out when confronted by ADRBs in the clinical practice of pain medicine.

Footnotes

Fisher,F. Interpretation of Aberrant Drug-Related Behaviors. J. Amer. Phys. Surg.; 9(1): 25-28; 2004. Available. ↩
Passik,S.D., Kirsh,K.L., Whitcomb,L. Monitoring outcomes during long-term opioid therapy for noncancer pain: Results with the pain assessment and documentation tool. J Opioid Manage;1(5):257–66; 2005. ↩
Webster LR Predicting aberrant behaviors in opioid-treated patients. Preliminary validation of the opioid risk tool.; Pain Med; 6(6):432–42; 2005. ↩
Medina JL, Diamond S. Drug dependency in patients with chronic headaches. Headache; 17(1):12-14; 1977 ↩
Medina JL, Diamond S. A headache clinic’s experience: Diamond Headache Clinic, Ltd. NIDA Res Monogr; 36:130-136; 1981. ↩
Moulin DE, Amireh R, Sharpe WKJ, Boyd D, Merskey H, Iezzi A. Randomized trial of oral morphine for chronic non-cancer pain. The Lancet; 347(8995):143-146; 1996. ↩
Ballantyne JC, Mao J. Medical Progress: Opioid Therapy for Chronic Pain. New England Journal of Medicine 2003; 349[^20]:, 1943-1953. Available ↩
Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to common pain conditions in the US workforce. JAMA; 290(18):2443-2454; 2003. Available ↩
Meyer RJ. The Need for Effective Pain Relief - Statement by Robert J. Meyer, Director, Center for Drug Evaluation and Research, Food And Drug Administration. Before the U.S. House of Representatives Committee on Government Reform, Subcommittee on Criminal Justice, Drug Policy and Human Resources; 2004. Available ↩
Carr DB, Jacox A. Acute Pain Management: Operative or Medical Procedures and Trauma - a Clinical Practice Guideline. Report of the Agency of Healthcare Quality and Research, Washington DC, 1992. ↩
JCAHO. Joint Commission Focuses on Pain Management. Report of the Joint Commission on Accreditation of Healthcare Organizations, Washington DC, 1999. ↩
Passik,S.D.; Kirsh,K.L.; Whitcomb,L.; Dickerson,P.K.; Theobald,D.E. Pain clinicians’ rankings of aberrant drug-taking behavior. J Pain Palliat.Care Pharmacotherapy; 16(4); 39-49; 2002. Available ↩