The interface between pain and drug abuse and the evolution of strategies to optimize pain management while minimizing drug abuse.

Pain management is facing continued undertreatment of pain despite a growing problem with prescription opioid abuse. This has created a tension among prescribers and feelings of helplessness with regards to what constitutes appropriate practice. This article provides a review of pain management efforts and focuses on two key areas of potential interest. First, the emergence of prescreening tools for identifying appropriate candidates for opioid therapy are introduced and discussed, including the Opioid Risk Tool (ORT), the Screener and Opioid Assessment for Patients with Pain (SOAPP), and the Pain Assessment and Documentation Tool (PADT). In addition to these screening efforts, a novel concept of "in and out of the box" prescribing is presented, focusing on five areas of concern for judging whether one's prescribing patterns are matching peer prescribing patterns. While more work needs to be done, the discussion of these areas should offer some questions for self analysis by physicians regarding their prescribing patterns. Overall, the authors must embrace the concept of rational pain management and assess patients for risk both before writing the first opioid prescription for them and thereafter. In addition, we must remember that good pain management should lead to some decreases in pain perception for the patient combined with a corresponding increase in ability to function. By reviewing these tools and proposed novel guidelines for in/out of the box prescribing and adopting them into practice as appropriate, the physician will take a significant step in providing effective pain management while minimizing risk of opioid misuse.