The drug-seeking patient in the emergency room.

Drug-seeking patients include recreational drug abusers, addicts whose dependence occurred through abuse or the injudicious prescription of narcotics, and pseudoaddicts who have chronic pain that has not been appropriately managed. Opioids produce euphoria in some patients, providing the motivation for abuse, which can be detrimental even with occasional use. Even in the absence of overt euphoria, opioids are highly self-reinforcing and can be problematic in a large number of patients, requiring that acute care physicians exercise caution in whom they are administered.

The psychology of pain.

Emotional and evaluative issues are very important in the evaluation and treatment of pain. Treating the physical pain alone can leave these issues unresolved, and possibly exacerbate them through reinforcement. Understanding the impact of fear, expectations, and attention can help physicians deal more effectively with acute pain.

Management of chronic pain in the acute care setting.

Chronic nonmalignant pain requires evaluation and treatment different from acute pain. The pathophysiology is different, and there is commonly some degree of psychosocial dysfunction. Opioids tend to be much less effective as analgesics for chronic pain, and may increase the sensitivity to pain when given long-term.