Patient-Centered Care Balances Pain and Addiction Concerns

When will we ever learn? Extremes never work; rather, somewhere near the center of options lies the potential solution. Perhaps centering our patient care on the actual patient has been the answer all along.

The opioid crisis has reverberated throughout our society. An American dies approximately every 6 minutes from a drug overdose,¹ while an American baby is born dependent on opioids approximately every 15 minutes.² Although the vast majority of overdose deaths stem from illegal opioid substances,¹ the conversations and concerns have rippled into countless pharmacy conversations. One thing remains a constant: the absolute need for all health care professionals to utilize best practices when prescribing opioids (or any controlled substance) within a diverse pain management or any treatment plan. That’s just common sense for providing safe and effective patient care, particularly for our patients in pain and/or recovery.

Some people, by far the minority, still struggle with considering substance use disorder—or addiction—a disease or a medical condition, beyond simplistic bad choices being made. Health care professionals need to check their opinions at the door and provide patient care to everyone in need in a manner that preserves their universal professional mantra of “Do no harm.” If a person experiences a 10th opioid overdose, would harm be done if that person is not revived with an opioid antagonist such as naloxone? Consider if someone choosing to eat high-fat, high-calorie, high-sugar food every day has multiple heart attacks, continually needing nitroglycerin to be saved. Would harm be done if a 10th nitro refill were refused to be dispensed?

Medications for opioid use disorder (MOUDs), including methadone, naltrexone, and buprenorphine, are improving and saving lives every single day across the globe, but a health care professional never proceeds with blind faith for any substance on this planet. MOUDs have shown success, but as with all medications, there are concerns. Buprenorphine has been in the spotlight for its observed misuse and abuse, which, as with any and every controlled substance, is an undeniable possibility, and it’s even stated in the package insert. That does not mean we should avoid its utilization, but it does mean that we can emphasize respect for its pharmacology. Stigma can overpower common sense, and to combat that, the term "community redistribution" emerged as a means to avoid the diversionary terms of misuse and abuse when a person is merely seeking treatment, often without even realizing it. Regardless of the terminology, MOUDs are valuable in improving and saving lives for those in recovery.

At the same time, over 1 billion people suffer from chronic pain, including approximately 100 million Americans, which is more than those affected by diabetes, heart disease, and cancer combined. Approximately 75 million Americans, 1 of every 4, have suffered from pain that lasts longer than 24 hours, and millions more suffer from acute pain. Chronic pain is the most common cause of long-term disability.³

Over the course of the past few decades, opioid medications have jumped from opiophobia to opiophilia and back. With respect to pain management, it’s been the best of times and the worst of times. The delicate balance between restrictions and openness aims to prevent unintended consequences, which, in the opioid crisis, means remembering not to facilitate people leaving our health care supply chain to enter the illicit substance supply chain.

Regardless of the Omnibus Budget Reconciliation Act of 1990 or the federally mandated corresponding legal responsibility for prescribers and dispensers to ensure a proper diagnosis and scope of practice,^4,5 shouldn’t the professional expectation be to offer patient counseling proactively? While we’re at it, one can take a moment to recognize opioid best practices, which I take the liberty of grouping into 3 categories, including patient education, treatment selection, and adherence and diversion monitoring, as illustrated in Table.

Let’s touch on a few of these best practices. Besides "baby aspirin," is there a worse term in health care than "medicine cabinet"? Clinicians should remind patients to store all medications (not just controlled substances) in lockable safe boxes to keep them away from everyone and avoid the humidity and temperatures of a bathroom.

Regarding medication disposal, the US Environmental Protection Agency recommends Drug Enforcement Agency drug takeback days or the removal of identifiers and mixing with undesirable substances, but certainly never flushing a medication down the toilet.⁶ The FDA agrees but lists approximately 4 dozen controlled substances that should be flushed down the toilet when attempting disposal.^7,8 One would expect harmony among the recommendations, but at least pharmacies can also register to become sites for the disposal of controlled substances.⁹

Treatment selection will typically begin with a diagnosis, which can often be complicated on the pain frontier, but for starters, the pain scale that I use for my patients in pain is the Defense and Veterans Pain Rating Scale (DVPRS), which combines the best of the best approaches to common pain scales, including color, emotional faces, and, of course, numbers.¹⁰ However, there are 4 powerful questions added that assess a patient’s activity, sleep, mood, and stress. Clinicians may be unable to help change a patient’s pain number; however, affecting at least 1 of these items is an impactful SMART (specific, measurable, achievable, relevant, time-bound) goal.

As for mental health screenings, the succinct Patient Health Questionnaire (PHQ)–2 asks 2 questions, including the frequency of having little or no interest in doing things and feeling down, depressed, or hopeless.¹¹ If one screens a risk in the PHQ-2, a clinician can administer the PHQ-9 further to assess the need for a mental health professional referral.¹² Additionally, opioid risk screenings should be used for all patients under consideration for or already receiving opioid therapy. There are many validated tools readily available for clinicians; some are to be administered by the health care provider, while the patient may complete others.¹³

With respect to drug interaction screenings, let’s dive into the most infamous opioid and benzodiazepine interactions. If someone has a health care professional license, that person knows that the combination of an opioid and benzodiazepine comes with inherent sedation and respiratory depression risks. Alas, what to do when inheriting a patient already utilizing both a benzodiazepine and an opioid, as action is needed regardless of how long the combination has been used? When tapering is agreed upon, it must be gradual unless there are other concomitant safety concerns, keeping in mind that rapid tapers of opioid medications can cause very negative effects; rapid tapers of benzodiazepines can result in death from seizures. Take action, but start low and go slow, with the consultation of multiple health care professionals when possible.

All patients and caregivers, if not all of society, need education on opioid antagonists’ administration. Opioid μ antagonists utilized in overdoses include nalmefene and naloxone as both injectable and nasal formulations. Nalmefene exhibits a longer half-life and stronger opioid μ receptor affinity than naloxone, which can be debated as both an advantage and a limitation. However, most of the opioid μ antagonist products available are naloxone medications available via prescription, OTC, or harm-reduction programs.

Urine drug monitoring, an umbrella term for both urine drug screening (UDS) and urine drug testing (UDT), is an important tool for medication adherence monitoring and the detection of illicit substance use. UDS is lower cost, yet the qualitative examination is generally called “presumptive.” UDT is higher cost, yet the quantitative examination is generally referred to as "confirmatory."

Prescription drug monitoring programs are a useful tool in monitoring medication adherence and avoiding drug diversion yet are not a panacea for preventing drug abuse and diversion. Health care professionals continually encounter situations balancing drug diversion prevention with ensuring appropriate patient care. The National Opioids Settlement documents the most granular controlled substance red flags to date, while concretely stating that an observed red flag in and of itself does not automatically facilitate a reason not to dispense a prescription medication; however, the red flag(s) must be mitigated and documented whether dispensing or not.¹⁴

Lastly, let’s touch on the reality that some patients in recovery can also experience pain, and that pain needs to be addressed beyond the MOUD, which is most likely already being used. If one has a bucket of water sufficiently watering a garden, the bucket will no longer suffice once the garden grows larger. It’s that simple; then come the pharmacological considerations of increasing the buprenorphine dosage or adding a lipophilic opioid such as hydromorphone, fentanyl, and so on.

These patient scenarios escalate quickly, so I invite you to continually stay abreast of all things pain management, substance use disorder, and drug diversion prevention via the Pain Guy website (www.painguy.us) with particular attention to the “headlines” and “resources” tabs as a one-stop shop for all respective materials and guidelines, such as the 2022 CDC Opioid Guideline Update.¹⁵

Patients are not alone; rather, we, as health care professionals, are right there with them, keeping them at the core of it all. Remember to not only tell a patient how much you care but show it as well. What better way to do so than to always practice within the scope of opioid best practices? Today, tomorrow, and always. Every patient.

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REFERENCES

1. Drug overdose deaths: facts and figures. National Institute on Drug Abuse. August 2024.Accessed August 19, 2025. https://nida.nih.gov/research-topics/trends-statistics/overdosedeath-rates

2. Novel technologies for infants with neonatal opioid withdrawal syndrome. HEAL Initiative, National Institutes of Health. May 7, 2021. Accessed August 28, 2025. https://heal.nih.gov/news/stories/technologies-neonatal-opioid-withdrawal

3. Chronic pain. The Lancet. May 27, 2021. Accessed August 28, 2025. https://www.thelancet.com/series-do/chronic-pain

4. Purpose of issue of prescription. 21 USC §1306.04 (2025). Accessed August 2025. https://www.ecfr.gov/current/title-21/chapter-II/part-1306/subject-group-ECFR1eb5bb3a23fddd0/section-1306.04

5. Omnibus Budget Reconciliation Act of 1990, S 3209, 101st Cong (1990). Accessed September 4, 2025. https://www.congress.gov/bill/101st-congress/house-bill/5835

6. Household medication disposal. US Environmental Protection Agency. Updated August 7, 2025. Accessed August 28, 2025. https://www.epa.gov/household-medication-disposal

7. Where and how to dispose of unused medicines. FDA. Reviewed April 16, 2025. Accessed August 28, 2025. https://www.fda.gov/consumers/consumer-updates/where-and-howdispose-unused-medicines#steps

8. Safe disposal of medicines. FDA. Reviewed October 31, 2024. Accessed August 28, 2025. https://www.fda.gov/drugs/buying-using-medicine-safely/safe-disposal-medicines

9. Drug disposal information. US Drug Enforcement Administration. Accessed August 28, 2025. https://www.deadiversion.usdoj.gov/drug_disposal/drug-disposal.html

10. Buckenmaier CC 3rd, Galloway KT, Polomano RC, McDu e M, Kwon N, Gallagher RM. Preliminary validation of the Defense and Veterans Pain Rating Scale (DVPRS) in a military population. ^{Pain Med}. 2013;14(1):110-123. doi:10.1111/j.1526-4637.2012.01516.x

11. Kroenke K, Spitzer RL, Williams JBW. The Patient Health Questionnaire-2 (PHQ-2). 1999. Accessed August 28, 2025. https://aidsetc.org/sites/default/fi les/resources_fi les/PHQ-2_English.pdf

12. Kroenke K, PHQ-9 (Patient Health Questionnaire-9). MDCalc. Accessed August 28, 2025. https://www.mdcalc.com/calc/1725/phq9-patient-health-questionnaire9

13. Garofoli M. Ask the expert: what types of risk screening tests are available to clinicians prescribing opioid therapy?. ^{Pract Pain Manag}. 2018;18(8):10-12.

14. National Opioids Settlement. Accessed August 28, 2025. https://nationalopioidsettlement.com/

15. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain - United States, 2022. MMWR Recomm Rep. 2022;71(3):1-95. doi:10.15585/mmwr.rr7103a1