Pain management is an important and emerging field of medicine. Appropriately prescribing and managing controlled substances for pain is unfortunately fraught with risk of litigation, regulatory intervention, manipulation by drug abusers, and misunderstanding by the public. Chronic pain is a pervasive and widespread phenomenon which must be adequately treated while at the same time minimizing diversion and abuse of powerful but effective substances. This article outlines useful recommendations for the appropriate use of controlled substances in pain management, and it also defines a legal standard of care.

Physicians should not fear administrative or criminal scrutiny from the Federal Government if they are prescribing a controlled substance to a patient for a legitimate medical purpose and in the usual course of professional practice. Federal administrative and criminal action against a physician with controlled substance privileges is rare; however, this action is warranted when a physician practices outside the bounds of established standards.

Addiction Treatment: A Psychiatrist’s Perspective
David A. Gross, MD, Distinguished Fellow of the American Psychiatric Association

This paper will review the clinical, empirical and heuristic observations provided by many years of front line treatment of patients with severe addictive disorders. This discussion would not be complete if it did not include some of the historical challenges facing a psychiatrist trying to serve this unique population. For reasons outlined in this paper, acceptance by the recovering community can be problematic.

Of critical importance is the concept of the multi-diagnosis approach to victims of substance abuse. Essentially gone are the days of the pure alcoholic. Substance abuse comorbid with other major psychiatric disorders has become the norm. Substance abuse and co-occurring bipolar disorder, depression, attention deficit hyperactivity disorder, social anxiety disorder, other anxiety disorders, insomnia and psychosis will be reviewed. The toxic impact of illicit drugs on the brain will be stressed. Clinical cases will be reviewed in throughout this paper with reference to the diagnostic and therapeutic approaches for special patient populations.

Chronic pain is one of the most challenging problems facing physicians today. In recent years it has been recognized that a compartmentalized approach to managing these patients results in unsatisfactory outcomes. A more integrated approach using a multidisciplinary model results in more efficient resource utilization. Interventional pain procedures are one of the tools available to help alleviate chronic pain. Epidural steroid administration and facet injections are basic techniques with a long history in the treatment of chronic pain. Cancer-related pain is also amenable to interventional therapies in select patients. With an ever increasing number of interventions targeting various anatomic structures, interventional pain practitioners continue to refine and explore where these techniques fit into clinical practice.

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