There is, thus, no perfect way to assess risk. Use of an objective tool plus or minus urine drug testing does shift the weight toward a more objective assessment. The best example I can provide is that roughly 40 percent of patients presenting with a vaso-occlusive crisis are found to have ADRB—not surprising given the poor pain management most receive. In the Annals of Internal Medicine (2008;148:94), it was reported that 30 percent of patients with sickle cell disease experienced pain on at least 95 percent of days. When properly treated, however, only about 2 percent are found to have an addiction disorder, demonstrating that almost all ADRB seen is due to poor pain control in that population. One BMJ study found that only three of 1,900 patients with sickle cell disease were also suffering from addiction. Fishbain et al (Pain Med. 2008;9:444-459) show that, in patients with no past or current addiction problems, the risk of addiction from long-term opioid use is 0.19 percent, whereas the rate of ARDB is 11 percent. This, again, demonstrates the need to recognize that for the large majority of patients ADRB is not associated with addiction but rather with poor pain control.

We, as clinicians, cannot judge in a few minutes why the patient is manifesting ADRB; unfortunately, most of us see ADRB and assume it is due to diversion or addiction when in the large majority of cases it is due instead to oligoanalgesia. To help us better judge, validated tools and objective testing should be to what we turn.

—Jim Ducharme, MD, CM, FRCP
Hamilton, Ontario