The heightened interest in pain management is making the need for appropriate boundary setting within the clinician-patient relationship even more apparent. Unfortunately, it is impossible to determine before hand, with any degree of certainty, who will become problematic users of prescription medications. With this in mind, a parallel is drawn between the chronic pain management paradigm and our past experience with problems identifying the "at-risk" individuals from an infectious disease model. By recognizing the need to carefully assess all patients, in a biopsychosocial model, including past and present aberrant behaviors when they exist, and by applying careful and reasonably set limits in the clinician-patient relationship, it is possible to triage chronic pain patients into three categories according to risk. This article describes a "universal precautions" approach to the assessment and ongoing management of the chronic pain patient and offers a triage scheme for estimating risk that includes recommendations for management and referral. By taking a thorough and respectful approach to patient assessment and management within chronic pain treatment, stigma can be reduced, patient care improved, and overall risk contained.

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The use of urine drug testing (UDT) has increased over recent years. UDT results have traditionally been used in legal proceedings under supervision of a medical review officer (MRO). In this context, testing has been required by statute or regulation and so is typically not in the "donor's" interest. Physicians, however, can use UDT to assist in monitoring their patient's treatment plan. By using UDT in a patient-centered fashion, both patient and physician interests are maintained. The MRO-based model of testing in the clinical setting can lead to mistrust and a deterioration of the doctor-patient relationship. Clinical testing can enhance the doctor-patient relationship when the results are used to improve communication. A patient-centered model of UDT should be used to improve quality of care. This article discusses why urine is the biological specimen of choice for drug testing; who, when and why to test; testing methods; and, most importantly, interpretation of results.