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Approach to pain management in a large outpatient clinic population.

Though it is our ethical imperative to minimize discomfort, physicians often struggle to manage pain effectively, mainly due to time constraints, lack of training, and fear of litigation regarding over-prescribing of controlled substances. In addition, physicians also now must face potential litigation for under treatment of persistent pain. This dilemma often leaves the physician with a sense of insecurity and stress. We have provided a brief review of our approach to seek improvement in excluding substance abusers/drug diverters from those in need of aggressive pain management in the internal medicine outpatient clinics of a teaching institution. Multiple combined treatment modalities are usually employed, including physical interventions, evaluation and treatment of concomitant depression and psychosocial issues, pain modulators and analgesics, and consultations as indicated by clinical presentation. Experience and intuition are required in many cases. In our large volume, high complexity clinic setting, we continue to pursue guidelines to improve and streamline screening for substance abuse or the potential for abuse, particularly in younger individuals. In the elderly, since abuse potential is less likely and disease documentation is often more readily apparent, we feel relatively comfortable in initiating careful prescribing of opioid therapy early on. As we become more adept at our approach toward pain management issues, we will attempt some assessment of outcomes by observing changes in several parameters, including numbers of opioid prescriptions and comparative adequacy of pain control over time. National and local pain/addiction information and referral resources are available as follows: http:// www.nationalsubstanceabuseindex .org and http://www.wvupc. org/charleston/painlist.