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May 24, 2008 - 5 comments
PAIN TOPICS
What is Pseudoaddiction?
Thomas E. Quinn, MSN, RN, AOCN
This article first appeared in Pain Relief Connection Vol 2 #1, January 2004. “Pain Topics” and Pain Relief
Connection are services of MGH Cares About Pain Relief,
http://www.massgeneral.org/painrelief
Pseudoaddiction is the term for an iatrogenic syndrome that appears to mimic behaviors that are commonly
believed to be associated with addiction. It may present in a patient with or without a history of or risk
factors for drug abuse or true addiction. It usually occurs with acute pain, including acute pain that is
overlaid on a chronic pain condition. It is characterized by a climate of distrust and conflict between the
patient and the care team related to the use of opioids for pain. Its etiology is pain that is inadequately
treated, leading to patient demands for opioid analgesia that are interpreted by the care team as being
excessive. The result is a progressive cycle of patient complaints of inadequate pain relief, sometimes
accompanied by exaggerated pain behaviors, and care team resistance to providing opioids, sometimes
compounded by avoidance and isolation of the patient.
In published case reports of pseudoaddiction, the patient’s report of pain is not believed, despite the presence
of a progressive disease or painful condition, or the potential for tolerance due to prior opioid use is not taken
into consideration by the care team. Inadequate analgesia is therefore inevitable due to either a dose that is
too low or a dosing interval that is too long. There is a tendency in such cases to provide even less analgesia,
further exacerbating the problem. In the case of Pseudoaddiction, “drug seeking” behavior is incorrectly
interpreted as evidence of addiction; it is more accurate it see it as “relief seeking” behavior.
The “treatment” for pseudoaddiction is to redesign the analgesic regimen so that analgesics are provided at
an appropriate dose and dosing interval. Ongoing and thorough pain assessment with corresponding
adjustment of dose (i.e., titrating to effect), as with any patient, is essential. Frank discussion with the patient
about the goals of pain treatment and the care team’s concerns are key to re-establishing a therapeutic
relationship between the patient and the care team. As David Weissman puts it, “pseudoaddiction is
something that we do to patients through our fears and misunderstanding of pain, pain treatment, and
addiction. . . Any time there is a suggestion, because of escalating pain behaviors, that a patient on opioids
may be ‘addicted,’ pseudoaddiction should be ruled out.”*
To learn more about pseudoaddiction, see (cited articles are available in Treadwell Library; Journal
of Palliative Medicine is also available free online via
MAGIC
on MGH computers)
1. Kowal N. What is the issue: pseudoaddiction or undertreatment of pain? Nursing
Economics 1999;17(6):348-349
2. Porter-Williamson K, Heffernan E, Von Gunten CF. Pseudoaddiction. Journal of Palliative
Medicine 2003;6(6):937-939
3. Weissman DE, Haddox JD. Opioid pseudoaddiction--an iatrogenic syndrome. Pain
1989;36(3):363-366
4. Weissman DE. Understanding pseudoaddiction Journal of Pain and Symptom Management
1994;9(2): 74
5. *Weissman DE. Pseudoaddiction.
http://www.eperc.mcw.edu/edmats/detail.cfm?matl_id=333&query_id=&srchType=edmats
&secSrchType=fastFact&sessn_id=5849682845650567882571529
(free registration
required at
http://www.eperc.mcw.edu
, then click on ‘Fast Facts and Concepts’ and navigate
to #069, Pseudoaddiction). Accessed 18 Jan 2004.
MAGIC catalog at Treadwell Library:
http://magic.mgh.harvard.edu/
What is Pseudoaddiction?
Thomas E. Quinn, MSN, RN, AOCN
This article first appeared in Pain Relief Connection Vol 2 #1, January 2004. “Pain Topics” and Pain Relief
Connection are services of MGH Cares About Pain Relief,
http://www.massgeneral.org/painrelief
Pseudoaddiction is the term for an iatrogenic syndrome that appears to mimic behaviors that are commonly
believed to be associated with addiction. It may present in a patient with or without a history of or risk
factors for drug abuse or true addiction. It usually occurs with acute pain, including acute pain that is
overlaid on a chronic pain condition. It is characterized by a climate of distrust and conflict between the
patient and the care team related to the use of opioids for pain. Its etiology is pain that is inadequately
treated, leading to patient demands for opioid analgesia that are interpreted by the care team as being
excessive. The result is a progressive cycle of patient complaints of inadequate pain relief, sometimes
accompanied by exaggerated pain behaviors, and care team resistance to providing opioids, sometimes
compounded by avoidance and isolation of the patient.
In published case reports of pseudoaddiction, the patient’s report of pain is not believed, despite the presence
of a progressive disease or painful condition, or the potential for tolerance due to prior opioid use is not taken
into consideration by the care team. Inadequate analgesia is therefore inevitable due to either a dose that is
too low or a dosing interval that is too long. There is a tendency in such cases to provide even less analgesia,
further exacerbating the problem. In the case of Pseudoaddiction, “drug seeking” behavior is incorrectly
interpreted as evidence of addiction; it is more accurate it see it as “relief seeking” behavior.
The “treatment” for pseudoaddiction is to redesign the analgesic regimen so that analgesics are provided at
an appropriate dose and dosing interval. Ongoing and thorough pain assessment with corresponding
adjustment of dose (i.e., titrating to effect), as with any patient, is essential. Frank discussion with the patient
about the goals of pain treatment and the care team’s concerns are key to re-establishing a therapeutic
relationship between the patient and the care team. As David Weissman puts it, “pseudoaddiction is
something that we do to patients through our fears and misunderstanding of pain, pain treatment, and
addiction. . . Any time there is a suggestion, because of escalating pain behaviors, that a patient on opioids
may be ‘addicted,’ pseudoaddiction should be ruled out.”*
To learn more about pseudoaddiction, see (cited articles are available in Treadwell Library; Journal
of Palliative Medicine is also available free online via
MAGIC
on MGH computers)
1. Kowal N. What is the issue: pseudoaddiction or undertreatment of pain? Nursing
Economics 1999;17(6):348-349
2. Porter-Williamson K, Heffernan E, Von Gunten CF. Pseudoaddiction. Journal of Palliative
Medicine 2003;6(6):937-939
3. Weissman DE, Haddox JD. Opioid pseudoaddiction--an iatrogenic syndrome. Pain
1989;36(3):363-366
4. Weissman DE. Understanding pseudoaddiction Journal of Pain and Symptom Management
1994;9(2): 74
5. *Weissman DE. Pseudoaddiction.
http://www.eperc.mcw.edu/edmats/detail.cfm?matl_id=333&query_id=&srchType=edmats
&secSrchType=fastFact&sessn_id=5849682845650567882571529
(free registration
required at
http://www.eperc.mcw.edu
, then click on ‘Fast Facts and Concepts’ and navigate
to #069, Pseudoaddiction). Accessed 18 Jan 2004.
MAGIC catalog at Treadwell Library:
http://magic.mgh.harvard.edu/
Posted this because on the surface it just appears to state what is common sense. But if you look past that and the stigma of addiction, is it really just coincidental that people without controlled chronic or severe physical pain behaviorally act the same as a person actively addicted to a narcotic? Even to the point of considering suicide when it's not controlled?
"Unrelieved pain can bring about emotional and psychological effects, such as impaired sleep, loss of appetite, anxiety, frustration, anger, isolation, and depression. As pain continually goes unrelieved, pain lowers self-esteem and can even result in thoughts of suicide.7,8"
"Desperation resulting from unsuccessful attempts to find physicians to adequately treat pain eventually leads to patients feeling a low sense of self worth that ultimately leads to depression. One patient wrote to the National Foundation for the Treatment of Pain, 'I’m not living. I’m existing.'"
"The National Foundation for the Treatment of Pain received a letter from a patient who has been in pain for 13 years. She said, "Suicide isn’t a matter of consideration, it’s only a matter of time. The constant pain robs me of the strength to go on. I told my husband two months ago that I didn’t know how much longer I could stand it—how much longer I could search or wait for help…It is absolutely unacceptable for any cancer, leukemia, or chronic pain patient to have to consider a ‘Kevorkian’ method due to the lack of a pain pill.'"
"Desperation resulting from unsuccessful attempts to find physicians to adequately treat pain eventually leads to patients feeling a low sense of self worth that ultimately leads to depression. One patient wrote to the National Foundation for the Treatment of Pain, 'I’m not living. I’m existing.'"
"The National Foundation for the Treatment of Pain received a letter from a patient who has been in pain for 13 years. She said, "Suicide isn’t a matter of consideration, it’s only a matter of time. The constant pain robs me of the strength to go on. I told my husband two months ago that I didn’t know how much longer I could stand it—how much longer I could search or wait for help…It is absolutely unacceptable for any cancer, leukemia, or chronic pain patient to have to consider a ‘Kevorkian’ method due to the lack of a pain pill.'"
It's just that time after time, I hear the exact same words from people that happen to suffer from addiction as from people that happen to suffer from chronic pain. If one thinks about it and draws a correlation between the emotions of a person in chronic pain and a person that became addicted to something outside of chronic pain as being analogous... it points more toward a common factor biochemically in the brain between the two. It's as if the brain does not differentiate between physical and emotional distress at a basic level. Which makes sense in the context that biochemically, the same medications that positively effect physical pain perception also positively effect feeling of emotional well-being.
And even beyond medications, natural endorphins (endogenous opiates) and most other neurotransmitters actively work to both relieve physical distress as well as relieve emotional distress *at the same time* with the *same action* on brain cells.
The phenomenon of Pseudoaddiction only blurs the line further between dependency and addiction and behaviorally adds more support to the theory of addiction being an actual disease state or more specifically arising from a disease state (often chemically based depression/anxiety), in exactly the same manner that dependency and rising tolerance results in for chronic pain sufferers.
The phenomenon of Pseudoaddiction only blurs the line further between dependency and addiction and behaviorally adds more support to the theory of addiction being an actual disease state or more specifically arising from a disease state (often chemically based depression/anxiety), in exactly the same manner that dependency and rising tolerance results in for chronic pain sufferers.
I like to think that it's us that are different. We are weaker yet stronger. We cannot make the right choices at the right times like some people yet some of us can manage to get out of the hump of being addicted/not making right decisions. How is that possible? Can you really compare a person who has gone through addiction to one who was smart enough but KNOWINGLY smart enough to understand that shouldnt risk taking the drug in the first place. It's hard to say and to compare, like when I first did oxies I was with my friends drunk at a party. If I didn't do it that one time would I have had another life or would I be on some other drug in a state of depression or well being? I beleive oxies revived me in a way nothing else could. Brought me to the bottom and I'm climbing back up again. I realize my destructive behaviors and said no more! But I think it just had to be significant. Something like a horrible withdrawal or maybe like 10 of them to really wake me up you know.
I think it's all a huge mathematical equasion between chance, environement and also your willpower. Eventually you will be offered drugs at different states of mind and eventually some will be weeded out and some will go unoticed, but is that problem and destructive behavior just going to fuel into gambling or maybe some other kind of addiction if one is never introduced to drugs, who knows. I like to think I have control and that helps me so no I don't beleive in God.
That reminds me... It's funny I watched a movie the other night it was called revolver. I just realized it kinda has a lot to do with addiction. I'm the kinda person who needs control. So I really thought I had control with oxies, but realized I didn't. The movie kind of shows you how the laws of thinking you're in control ultimately effect you in being "unreasonably dumb and open to mistakes". It makes you learn how if you make an oponent in Chess think he is control by feeding him and him following ur plan then you are dominating but making him think HE IS. that is the key, but never put ur guard down because maybe hes the one in control and ur just following his destructive plan. Life's never over and there'll always be one more step, as we "in control" people dont like to think. Oxy plays damn good chess but hes only a pill, I have the complexity of a human being. in other words I look at the big picture and see comfort in knowing that I am much stronger than a little pill.
I think it's all a huge mathematical equasion between chance, environement and also your willpower. Eventually you will be offered drugs at different states of mind and eventually some will be weeded out and some will go unoticed, but is that problem and destructive behavior just going to fuel into gambling or maybe some other kind of addiction if one is never introduced to drugs, who knows. I like to think I have control and that helps me so no I don't beleive in God.
That reminds me... It's funny I watched a movie the other night it was called revolver. I just realized it kinda has a lot to do with addiction. I'm the kinda person who needs control. So I really thought I had control with oxies, but realized I didn't. The movie kind of shows you how the laws of thinking you're in control ultimately effect you in being "unreasonably dumb and open to mistakes". It makes you learn how if you make an oponent in Chess think he is control by feeding him and him following ur plan then you are dominating but making him think HE IS. that is the key, but never put ur guard down because maybe hes the one in control and ur just following his destructive plan. Life's never over and there'll always be one more step, as we "in control" people dont like to think. Oxy plays damn good chess but hes only a pill, I have the complexity of a human being. in other words I look at the big picture and see comfort in knowing that I am much stronger than a little pill.
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