title: Practical guide to the management of acute and chronic pain in the presence of drug tolerance for the healthcare practitioner.
abstract: BACKGROUND
  Drug tolerance has been on the rise in recent years worldwide, and consequently, pain management in our population has become challenging.
  
  
  METHODS
  Discussed in this review are commonly abused drugs and considerations for treating acute and chronic pain states in patients with substance disorders.
  
  
  RESULTS
  After marijuana, alcohol, and tobacco, the most widely abused substances are oxycodone (Oxycontin), diazepam (Valium), and methylphenidate (Ritalin). Urine testing can detect metabolites of drugs used by patients and is useful for assessing drug abuse, medication diversion, and drug interactions. The comprehensive treatment of pain in a patient with addictive disorder or tolerance must address 3 issues: the patient's addiction, any associated psychiatric conditions, and the patient's pain. Eliciting a detailed history of drug abuse-illicit drugs as well as prescription drugs-and ascertaining if the patient is currently enrolled in a methadone maintenance program for the treatment of drug addiction is vital.
  
  
  CONCLUSIONS
  Medical observation, supportive care, multidisciplinary pain management, and timely interventions as necessary are the keys to safe outcomes in these patients.
authors.affiliation: Department of Anesthesiology, Yale University School of Medicine, New Haven, CT.
authors.forename: Nalini
authors.initials: N
authors.lastname: Vadivelu
authors.affiliation: Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.
authors.forename: Harman
authors.initials: H
authors.lastname: Singh-Gill
authors.affiliation: Undergraduate, University of Connecticut, Storrs, CT ; Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA.
authors.forename: Gopal
authors.initials: G
authors.lastname: Kodumudi
authors.affiliation: Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA ; Undergraduate, Stanford University, Palo Alto, CA.
authors.forename: Aaron Joshua
authors.initials: AJ
authors.lastname: Kaye
authors.affiliation: Department of Anesthesiology, Harvard School of Medicine and Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA.
authors.forename: Richard D
authors.initials: RD
authors.lastname: Urman
authors.affiliation: Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA ; Department of Pharmacology, Louisiana State University Health Sciences Center, New Orleans, LA.
authors.forename: Alan David
authors.initials: AD
authors.lastname: Kaye
keywords: Drug tolerance; pain management; substance-related disorders