Chronic Opioid Treatment, Addiction and Pseudo-Addiction in Patients With Chronic Pain
By David A. Fishbain, M.D.
February 1, 2003
Dr. Fishbain is professor of psychiatry and adjunct professor of neurosurgery and anesthesiology at the University of Miami School of Medicine and the University of Miami Comprehensive Pain and Rehabilitation Center.
What Are Aberrant Drug-Related Behaviors?
In 1994, Portenoy described a group of operational aberrant drug-related phenomenon that he felt characterized the definition of addiction as exemplified by its three aspects: 1) loss of control over drug use; 2) compulsive use; and 3) continued use despite harm. These behaviors are presented in Table 1 and can alert the physician to the possibility of addiction. Using a checklist for these behaviors, 388 patients with chronic pain maintained on opioids were monitored (Passik et al., 2002). The prevalence ranged from a high of 13.3% for unsanctioned dose escalation to a low of 1.1% for drug hoarding. It is interesting to note that the prevalence of behaviors that would clearly indicate addiction, such as injecting oral formulations and concurrent abuse of illicit drugs, was only at 1.5% and 1.9%, respectively. Passik et al. (2002) concluded that the incidence of aberrant drug-related behaviors was low. These behaviors do not necessarily represent addiction, but may be representative of other syndromes or diagnoses such as addiction, pseudo-addiction due to inadequate analgesia, other psychiatric diagnoses (encephalopathy, borderline personality disorder, depression, anxiety) (Portenoy, 1996). Because of this differential diagnosis, it is unknown which aberrant drug-related behaviors or what combination is predictive of true addiction. Understanding the Concept of Pseudo-Addiction
The concept of pseudo-addiction can only be understood within the context of aberrant drug-related behavior. Pseudo-addiction is operationally defined as aberrant drug-related behaviors that make patients with chronic pain look like addicts. However, these behaviors stop if opioid doses are increased and pain improves (Weissman and Haddox, 1989). This indicates that the aberrant drug-related behaviors were actually a search for relief, i.e., pseudo-addiction. However, it is to be noted that there is little specific evidence for the concept of pseudo-addiction, which originated from one case report (Weissman and Haddox, 1989). Outside of one large-scale study reported as an abstract (McCarberg and Laskin, 2001), no studies on pseudo-addiction exist. In this study of 500,000 patients, 316 were identified as problem opioid patients. Most of these patients, however, appeared to be pseudo-addicts. There is also some collateral evidence for the pseudo-addiction concept. Arthritic rats appeared to self-administer opioids at rates required to control their pain, rather than for the rewarding effects of the drug (Colpaert et al., 2001). This indicates that the two behaviors may also be separated in humans.
It is almost impossible to differentiate a patient with chronic pain with addiction who escalates the dose of medication to obtain euphoria from a nonaddicted patient with under-treated pain, since both will exhibit aberrant drug-related behaviors (Weaver and Schnoll, 2002). The best approach for physicians is to provide more pain medication and to observe the patient for aberrant drug-related behaviors and some of the characteristics listed in Table 2.
Although the pseudo-addiction concept lacks significant scientific support, it has nevertheless become widely accepted within the pain-physician community. As such, this concept has now become a focus in some medicolegal cases (Fishbain, 2002). Thus, psychiatrists who do chronic opioid pain treatment, or who are planning to, should be aware of this concept and address it in their patient notes. Conclusion
The central concept of this review is as follows: The pain literature has identified a possible clinical problem (pseudo-addiction) that can only be understood within the context of pain and aberrant drug-related behaviors. This concept awaits adequate scientific scrutiny, but appears to be clinically relevant.
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