Drug dependency assessment should include information not only on illicit drug use, but also on personal habits and prescription medication use. A patient who takes two tablets of hydrocodone and acetaminophen three times daily will be quite different from a patient who takes six tablets of hydrocodone and acetaminophen once daily. The patient who daily takes everything at once will have a much higher opioid tolerance than a patient who takes the six tablets in divided doses.
Alcohol use is frequently missed by clinicians because the patient either does not consider two evening cocktails unusual or is afraid or embarrassed to tell the clinician the truth. Too often, the clinician finds out about the patient's alcohol usage only after the patient starts to experience withdrawal. By then, more aggressive therapeutic and medical interventions may be required, which could easily have been prevented with appropriate medications. At the earlier stages of withdrawal, the patient may only complain of spasms or unrelieved pain in addition to agitation and restlessness. Frequently, the clinicians attribute these symptoms to pain and give more opioids without success. However, appropriate assessment of and judicious use of benzodiazepines by patients with alcohol withdrawal can quickly bring the patient's pain and anxiety under control. The correct assessment will require clinician persistence in pursuing the clinical clues and the assistance of the patient's family members.
Similar withdrawal symptoms can also occur with sedatives, anticonvulsants such as clonazepam and carbamazepine, and muscle relaxants such as carisoprodol (11-13,127). Frequent nicotine and caffeine use is also an important consideration in pain management. Nicotine abstinence symptoms can cause restlessness, palpitation, and irritability, and caffeine abstinence can precipitate headaches.
Clinical opioid dependency can occur from chronic opioid exposure. Clinical management may require the clinician to find alternative agents for pain control while slowly tapering the patient's opioid use. In some cases, the patient's tolerance and dependency may exceed the usefulness of the opioid's analgesic effects. Therefore, tapering the patient off the opioid and finding alternative pain management methods may become the primary objective of pain management.
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