In the journey to help patients recover from chronic pain and disability, clinicians must be vigilant for signs of an evolving opioid use disorder (OUD). It is not uncommon for a pain practice to inherit patients with a pre-existing OUD, but it is also common for substance use disorders to occur in patients under the long-term care of a pain specialist.

In the authors’ clinical experience, the following approaches (also summarized in Table I) and sample dialogues may be helpful when navigating patient discussions surrounding opioid use disorder.

Use DSM Criteria

Accurately diagnosing an SUD is the first step. Being familiar with the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria for opioid use disorder, in particular, is crucial. Following these criteria can help to reduce the pitfall of over-diagnosing a use disorder based on subjectivity and allow for documentation of the clear rationale for treatment if addiction pharmacotherapy is to be utilized. Also, if a clinician has better knowledge of the specific criteria met, it will allow for a more conducive discussion with the patient about having OUD.

Objective signs are important, such as dates of early refills, or trends noticed on the prescription drug monitoring program (PDMP). Sometimes, collateral information from friends or family is helpful because a patient may be ashamed to discuss their misuse and may minimize the symptoms of a use disorder. When family is involved, it is important to give the impression that the questions being asked are not intended to conspire with the family member against the patient but to reframe the process as an effort to get additional information to come up with a successful and safe treatment plan.

Use the Right Phrases

Specific word choices can be crucial to maintain rapport with the patient while reducing defensiveness during discussion of a suspected opioid use disorder. Avoid using words such as “abuse” or “addict” as they can be stigmatizing and carry a judgmental connotation.

Normalizing the potential risk of tolerance and/or developing a substance use disorder may help a patient feel less shameful and more likely to engage in further exploration of their relationship to the pain medication. For example, consider a phrase such as “Anybody who is on an opioid medication for months at a time is likely to develop physiological tolerance to medication.” Also, if a patient has a family history of an opioid use disorder, it may be explained that the risk is increased.


Mind Your Body Language

The words that are conveyed to a patient are only part of the overall communication; the clinician’s body language is also important to self-monitor. If a clinician is feeling a sense of frustration or even anger toward a patient, subtle body cues (eg, changes in eye contact, tone of voice, or posture) may be perceived by the patient as confrontation despite the clinician’s good intentions.

Sample Conversation with a Patient about Medication Overuse


Patient: Unfortunately, I have a hard time going 3 hours without my medication.

Clinician: You have concerns that your body feels like it needs the medication, and I wonder if you ever feel an urge at times to take more than prescribed.

Patient: Yeah, sometimes the pain gets so bad that I take double the prescribed dose. I can’t keep doing that.


Patient: Unfortunately, I have a hard time going 3 hours without my medication.

Clinician [arms crossed]: It sounds like you may be addicted to the medication. Do you feel like you abuse the medication?*

Patient: No, I’m not an addict! I’m just in a lot of pain! You don’t understand.

*Use of stigmatizing language with confrontational body language

Look for Underlying Psychiatric Conditions

Identifying underlying psychiatric conditions is also an integral part of a pain management or addictions assessment. Many individuals with chronic pain are prone to depression, and depression itself can exacerbate the perception of pain. Helping a patient to understand the relationship between anxiety and depression with their pain perception can be therapeutic and may help one to feel that their provider is invested in their overall well-being as a person, not just being seen as a “pain patient.”


Patient: I have so much pain that I can’t do anything, and that gets me all depressed.

Clinician: It’s been certainly tough for you adjusting to this change in functionality. How else has chronic pain affected your life?

Patient: Well, I feel like I can’t provide for my family and I feel useless. On top of that, I went through all these traumas from years ago that I haven’t even dealt with. When I feel sad, I feel more pain and I want to take more pain medication.

Clinician: I understand how physical and emotional pain may be affecting your well-being and make you want to take more medication. If you are OK with it, could we explore some of your stressors in more detail?


Patient: I have so much pain that I can’t do anything, and that gets me all depressed.

Clinician: It’s likely that it’s from all the pain medication that is making you feel depressed.

Patient: But I’ve had depression well before I even started taking these medications

Clinician: Yes, and if you stop taking these medications, it will help you to feel better because they are central nervous system depressants.

Share Risks in an Objective Manner

It’s also important to explain upfront how chronic opioids can impact overall health. Discussing this relationship in a caring, objective manner may lead a patient to feel that the benefit of the medication is then outweighed by the risk. Instead, educating the patient about the potential risks of long-term opioid treatment may be helpful, as some may not be aware of concepts such as opioid-induced hyperalgesia, and how that may contribute to a perpetual cycle of dose escalations that adversely reduce a patient’s ability to tolerate pain long-term.

Motivational interviewing can be an important tool to help a patient to reflect upon the pros and cons of opioid medication and thinking about what change could look like. Some may be aware of the detrimental effects of chronic opioid medication but have not yet been able to verbalize or reflect upon those risks.

The use of open-ended and nonjudgmental questions can help elicit the nuances of a patient’s perception. In exploring the patient’s relationship with their pain medication, we suggest using the acronym “OARS” as a guide on how to interview a patient.

  • Open questions
  • Affirmations
  • Reflective listening
  • Summary reflections

The OARS interview style embodies motivational interviewing. Motivational interviewing is not a therapy that is done on someone but rather an interview style that is done with someone. The goal is to help empower a patient to make their own decisions toward change (ie, addiction treatment). More detail on how to conduct motivational interviewing in a pain management setting.

How to Use OARS in Practice

Ask open-ended questions

  • Instead of saying, “Does taking opioids affect you?” (elicits a “yes” or “no” response as a closed-ended question)
  • Ask, “How does taking opioids affect you?” (encourages elaboration and is an open-ended question)


  • Use statements and gestures that recognize a patient’s strength and empowers them to change.
  • Say, “You seem very thoughtful about monitoring how your emotional distress affects your H4 pain.”


  • Accurately reflect, rephrase, and repeat what the patient is saying, including on an emotional level. Doing so requires active listening and subsequent statements that may foster a patient’s motivation to change. For example:
  • “So, you feel that the use of pain medication is leading to feelings of guilt due to the loss of other priorities.”
  • “You’re wondering how life would be different if you were able to take less pain medication.”
  • “It sounds like you are concerned about the effects of your usage on your family relationships.”
  • Good summarizing statements are often a steppingstone toward change, as the patient is also hearing back from the clinician a recap of what the patient was already expressing. It helps to follow a summarizing statement with a follow-up question. For example: “On one hand, you feel that the pain medications temporarily reduce your pain. At the same time, you are most concerned about the sedating effects and the cost of buying additional medication off the street when you run out early. Is there anything else you want to add?”
Maintain Boundaries and Rapport

When a patient becomes ready to try addiction treatment for OUD, then it’s appropriate to discuss next steps and transitions, including tapering and the use of pharmacological options which themselves have analgesic properties. Note that the involvement of opioids in addiction treatment may make some patients hesitate to try the treatment. While tapering and medication for opioid use disorder are outside the scope of this article, care should be tailored to reduce risk.

If the patient is not ready to accept treatment for a use disorder, then it is important to maintain engagement and rapport with the patient utilizing the techniques presented herein, while also acknowledging and communicating one’s threshold and boundaries for safe prescribing practices. In fact, there are studies that suggest an inverse correlation between patient satisfaction and mortality. If there are concerns about a patient’s mortality risk with a specific combination of requested medication, it’s important to empathize with patient concerns but also to specifically set consistent boundaries that specific medications or doses will not be prescribed for certain reasons. These boundaries are helpful not only to help reduce risk of harm to the patient but may also help reduce the risk of burnout for the clinician.

Sample Conversation with a Patient about Dose Increases


Patient (with suspected use disorder): I don’t think the pain medication is working. I know my body, and I’m running out early. Can I have a dose increase?

Clinician: The pain’s been really rough on you and at the same time we want to treat it in a safe manner. While a dose increase would have too much risk involved, I’d be happy to discuss additional treatment options that may help and can be utilized longer-term safely. Would you be interested in hearing about those options?

Patient: I mean, I still prefer to have a dose increase. But I guess it wouldn’t hurt to hear what’s available.


Patient [with suspected use disorder]: I don’t think the pain medication is working. I know my body, and I’m running out early. Can I have a dose increase?

Clinician: I don’t think that’s going to be helpful and it’s too risky.

Patient: You are just concerned about your license. You know that you are leaving me in this excruciating pain. I will just have to find another doctor then.

List of Approaches
Table I: Recommended Approaches to Identify a Substance Use Disorder in a Patient.
Approach DO DON’T
Interview style Empowering and nonconfrontational communication, in the spirit of motivational interviewing (using “OARS”) Confront or threaten
Choice of words Use words such as: use disorder, positive urine result, misuse Use words such as: addict, dirty urine, abuse
Communication style Monitor one’s body language and internal feelings. Avoid eye contact or type while giving a diagnosis.
Information from interview/collateral Utilize objective information as part of reflection toward patient. Sources may include PDMP and pharmacy records, including dates of early refills, urine toxicology results, family collateral (if permitted), and other observed signs. Relay subjective information back to patient without objective data, such as “You seem addicted” or “You are overusing.”
Psychoeducation Discuss concepts such as tolerance and opioid induced hyperalgesia and respiratory depression, after patient gives permission. Provide this information in a confrontational/instructional manner.
Boundaries Set consistent, caring boundaries. Be inconsistent or overly firm; doing so may lead to increased risk for both patient and provider.
Safety Discuss naloxone kit and lock-box for medication.
DSM-5 criteria for SUD Know and utilize DSM criteria in assessments; this may help to prevent over-diagnosing a use disorder. Make a diagnosis off subjective criteria, one’s own internal feelings about a patient, or on “med-seeking” behaviors alone.
Psychiatric symptoms Explore the relationship between pain and emotional state (eg, depression can affect cravings). Note that some antidepressants may treat both depression and chronic pain symptoms. Assume that a patient’s SUD is always driven by addiction itself or “manipulative behavior.”
Toxicology testing/drug monitoring Know how to utilize toxicology testing, including risks of false positives and negatives in each substance class. Assume all positive urine toxicology results means a use disorder.

Final Points

In summary, introducing the concept of opioid use disorder or another substance use disorder with a patient can be challenging. Educating the patient about the condition and potential treatment choices should be facilitated using non-confrontational strategies and careful choice of words. Providing factual information, combatting stigma, and helping a patient engage in proper treatment can go a long way in establishing and maintaining rapport for future follow-up and care.