“Pseudoaddiction” is one of the standard beats every article on the opioid crisis has to hit. Pharma companies (the story goes) invented a concept called “pseudoaddiction”, which looks exactly like addiction, except it means you just need to give the patient more drugs. Bizarrely gullible doctors went along with this and increased prescriptions for their addicted patients. For example, from a letter in the Wall Street Journal:
Neuroscientists define addiction in terms of complicated brain changes, but ordinary doctors just go off behavior. The average doctor treats “addiction” and “drug-seeking behavior” as synonymous. This paper lists signs of drug-seeking behavior that doctors should watch out for, like:
– Aggressively complaining about a need for a drug
– Requesting to have the dose increased
– Asking for specific drugs by name
– Taking a few extra, unauthorised doses on occasion
– Frequently calling the clinic
– Unwilling to consider other drugs or non-drug treatments
– Frequent unauthorised dose escalations after being told that it is inappropriate
– Consistently disruptive behaviour when arriving at the clinic
You might notice that all of these are things people might do if they actually need the drug. Consider this classic case study of pseudoaddiction from Weissman & Haddox, summarized by Greene & Chambers:
I maintain that the normal human thought process is “Since this kid is screaming in pain, looks like I guessed wrong about the right amount of painkillers for him, I should give him more.”
The official medical-system approved thought process, which Greene & Chambers are defending in this paper, is “Since he is displaying signs of drug-seeking behavior, he must be an addict trying to con you into giving him his next fix.” They never come out and say this. But they define pseudoaddiction as meaning not that, and end up saying “in conclusion, we find no empirical evidence yet exists to justify a clinical ‘diagnosis’ of pseudoaddiction.” More on this later.
The concept of “pseudoaddiction” was invented as a corrective to an all-too-common tendency for doctors to assume that anyone who seems too interested in getting more medications is necessarily an addict. It was invented not by pharma companies, but by doctors working with patients in pain, building upon a hundred-year-long history of other doctors and medical educators trying to explain the same point.
And in case you think this is a weird ivory tower debate that doesn’t influence real clinical practice, I offer you these cases from my own experience. Stories slightly changed or merged together to protect patient privacy:
Case 1: Mary is an elderly woman who undergoes a surgery known to have a painful recovery process. The surgeon prescribes a dose of painkillers once every six hours. The painkillers last four hours. From hours 4-6, Mary is in terrible pain. During one of these periods, she says that she wishes she was dead. The surgeon leaps into action by…calling the on-call psychiatrist and saying “Hey, there’s a suicidal person on my ward, you should do psychiatry to her or something.” I am the on call psychiatrist. After a brief evaluation, I tell the surgeon that Mary has no psychiatric illness but needs painkillers every four hours. The surgeon lectures me on how There Is An Opioid Crisis, Y’Know, and we can’t negotiate with addicts and drug-seekers. I am a consultant on the case and can’t overule the surgeon on his own ward, so I just hang out with Mary for a while and talk about things and distract her and listen to her scream during the worst part of the six-hour cycle. After a few days the surgery has healed to the point where Mary is only in excruciating pain rather than actively suicidal, and so we send her home.
Case 2: Juan is a middle-aged man with depression who is using Geodon for antidepressant augmentation. This is kind of a weird choice, and has theoretical potential to interact poorly with some of his other medications, but nothing else has worked for him and he’s done great for ten years. He switches psychiatrists. The new psychiatrist is really worried about the theoretical interaction, so he tells him that he can’t take Geodon anymore and switches him to something else. Juan falls into a deep depression. He asks to have Geodon back and the doctor says no. Juan yells at the psychiatrist and says he is ruining his life. The psychiatrist diagnoses him with a personality disorder and anger management problems, and tells him to attend therapy. Juan actually does this for a while, but eventually wises up and switches doctors to me. I put him back on Geodon and within a month he’s doing great again. Note that Juan displayed every sign of “drug-seeking behavior” even though Geodon is not addictive.
Case 3: This one courtesy of Zvi. Zvi’s friend is diabetic. He runs out of insulin and asks his doctor for more. The doctor wants to wait until his next free appointment in a few weeks before prescribing the insulin. Zvi’s friend points out that he will die unless he gets more insulin now. The doctor gets very angry about this and spends a long phone call haranguing Zvi’s friend about how inconvenient it is that he’s demanding the insulin now rather than at a more convenient time. Zvi’s friend has to threaten the doctor with a lawsuit before the doctor finally relents and gives him the insulin. I like this story because, again, insulin is not addictive, there is no way that the patient could possibly be doing anything wrong, but the patient still gets treated as a drug-seeker. The very act of wanting medication according to the logic of his own disease, rather than at the doctor’s convenience, is enough to make his request suspicious.
Case 4: John is a 70 year old man on opioids for 30 years due to a mining-related injury. He is doing very well. I am his outpatient psychiatrist but I only see him once every few months to renew meds. He gets some kind of infection, goes to the hospital, and due to normal hospital incompetence he doesn’t get his opioids. He demands his meds, and like many 70 year old ex-miners in terrible pain, he is not diligently polite the whole time. The hospital doctors are excited: they have caught an opioid addict! They tell his family and outpatient doctors he cannot have opioids from now on, then discharge him. He continues to be in terrible pain. At first he sneaks pills from an extra bottle of opioids he has at home, but eventually he uses all those up. After this, he is still in terrible pain with no reason to expect this to ever change, and so he quite reasonably shoots himself in the chest. This is the first point in this entire process at which anyone attempts to tell me any of this is going on, so I get a “HEY DID YOU KNOW YOUR PATIENT SHOT HIMSELF? DOESN’T SEEM LIKE YOU’RE DOING VERY GOOD PSYCHIATRIST-ING?” call. The patient miraculously survives, eventually finds a new pain doctor, and goes on to live a normal and happy life on the same dose of opioids he was using before.
Let’s look at those warning signs of addiction again:
– Aggressively complaining about a need for a drug
– Requesting to have the dose increased
– Asking for specific drugs by name
– Taking a few extra, unauthorised doses on occasion
– Frequently calling the clinic
– Unwilling to consider other drugs or non-drug treatments
– Frequent unauthorised dose escalations after being told that it is inappropriate
– Consistently disruptive behaviour when arriving at the clinic
Parroting Big Pharma’s excuses about FDA oversight and black-box warnings only discounts how companies like Johnson & Johnson engaged in pervasive misinformation campaigns and even promoted a theory of “pseudoaddiction” to encourage doctors to prescribe even more opioids for patients who displayed signs of addiction.Or from CBS:
But amid skyrocketing addiction rates and overdoses related to OxyContin, Panara claimed the company taught a sales tactic she now considers questionable, saying some patients might only appear to be addicted when in fact they’re just in pain. In training, she was taught a term for this:“pseudoaddiction.”
“So the cure for ‘pseudoaddiction,’ you were trained, is more opioids?” Dokoupil asked.
“A higher dose, yes,” Panara said.
“Did this concept of pseudoaddiction come with studies backing it up?”
“We had no studies. We actually — we did not have any studies. That’s the thing that was kind of disturbing, was that we didn’t have studies to present to the doctors,” Panara responded.
“You know how that sounds?” Dokoupil asked.
“I know. I was naïve,” Panara said. (...)Let me confess: I think pseudoaddiction is real. In fact, I think it’s obviously real. I think everyone should realize it’s real as soon as it’s explained properly to them. I think we should be terrified that any of our institutions – media, academia, whatever – think they could possibly get away with claiming pseudoaddiction isn’t real. I think people should be taking to the streets trying to overthrow a medical system that has the slightest doubt about whether pseudoaddiction is real. If you can think of more hyperbolic statements about pseudoaddiction, I probably believe those too.
Neuroscientists define addiction in terms of complicated brain changes, but ordinary doctors just go off behavior. The average doctor treats “addiction” and “drug-seeking behavior” as synonymous. This paper lists signs of drug-seeking behavior that doctors should watch out for, like:
– Aggressively complaining about a need for a drug
– Requesting to have the dose increased
– Asking for specific drugs by name
– Taking a few extra, unauthorised doses on occasion
– Frequently calling the clinic
– Unwilling to consider other drugs or non-drug treatments
– Frequent unauthorised dose escalations after being told that it is inappropriate
– Consistently disruptive behaviour when arriving at the clinic
You might notice that all of these are things people might do if they actually need the drug. Consider this classic case study of pseudoaddiction from Weissman & Haddox, summarized by Greene & Chambers:
The 1989 introduction of pseudoaddiction happened in the form a single case report of a 17-year-old man with acute leukemia, who was hospitalized with pneumonia and chest wall pain. The patient was initially given 5 mg of intravenous morphine every 4 to 6 h on an as-needed dosing schedule but received additional doses and analgesics over time. After a few days, the patient started engaging in behaviors that are frequently associated with opioid addiction, such as requesting medication prior to scheduled dosing, requesting specific opioids, and engaging in pain behaviors (e.g., moaning, crying, grimacing, and complaining about various aches and pains) to elicit drug delivery. The authors argued that this was not idiopathic opioid addiction but pseudoaddiction, which resulted from medical under-treatment (insufficient opioid dosing, utilization of opioids with inadequate potency, excessive dosing intervals) of the patient’s pain. In describing pseudoaddiction as an “iatrogenic” syndrome, Weissman and Haddox inverted the traditional usage of iatrogenic as harm caused by a medical intervention. In pseudoaddiction, iatrogenic harm was described as being caused by withholding treatment (opioids), not by providing it.Greene & Chambers present this as some kind of exotic novel hypothesis, but think about this for a second like a normal human being. You have a kid with a very painful form of cancer. His doctor guesses at what the right dose of painkillers should be. After getting this dose of painkillers, the kid continues to “engage in pain behaviors ie moaning, crying, grimacing, and complaining about various aches and pains”, and begs for a higher dose of painkillers.
I maintain that the normal human thought process is “Since this kid is screaming in pain, looks like I guessed wrong about the right amount of painkillers for him, I should give him more.”
The official medical-system approved thought process, which Greene & Chambers are defending in this paper, is “Since he is displaying signs of drug-seeking behavior, he must be an addict trying to con you into giving him his next fix.” They never come out and say this. But they define pseudoaddiction as meaning not that, and end up saying “in conclusion, we find no empirical evidence yet exists to justify a clinical ‘diagnosis’ of pseudoaddiction.” More on this later.
The concept of “pseudoaddiction” was invented as a corrective to an all-too-common tendency for doctors to assume that anyone who seems too interested in getting more medications is necessarily an addict. It was invented not by pharma companies, but by doctors working with patients in pain, building upon a hundred-year-long history of other doctors and medical educators trying to explain the same point.
And in case you think this is a weird ivory tower debate that doesn’t influence real clinical practice, I offer you these cases from my own experience. Stories slightly changed or merged together to protect patient privacy:
Case 1: Mary is an elderly woman who undergoes a surgery known to have a painful recovery process. The surgeon prescribes a dose of painkillers once every six hours. The painkillers last four hours. From hours 4-6, Mary is in terrible pain. During one of these periods, she says that she wishes she was dead. The surgeon leaps into action by…calling the on-call psychiatrist and saying “Hey, there’s a suicidal person on my ward, you should do psychiatry to her or something.” I am the on call psychiatrist. After a brief evaluation, I tell the surgeon that Mary has no psychiatric illness but needs painkillers every four hours. The surgeon lectures me on how There Is An Opioid Crisis, Y’Know, and we can’t negotiate with addicts and drug-seekers. I am a consultant on the case and can’t overule the surgeon on his own ward, so I just hang out with Mary for a while and talk about things and distract her and listen to her scream during the worst part of the six-hour cycle. After a few days the surgery has healed to the point where Mary is only in excruciating pain rather than actively suicidal, and so we send her home.
Case 2: Juan is a middle-aged man with depression who is using Geodon for antidepressant augmentation. This is kind of a weird choice, and has theoretical potential to interact poorly with some of his other medications, but nothing else has worked for him and he’s done great for ten years. He switches psychiatrists. The new psychiatrist is really worried about the theoretical interaction, so he tells him that he can’t take Geodon anymore and switches him to something else. Juan falls into a deep depression. He asks to have Geodon back and the doctor says no. Juan yells at the psychiatrist and says he is ruining his life. The psychiatrist diagnoses him with a personality disorder and anger management problems, and tells him to attend therapy. Juan actually does this for a while, but eventually wises up and switches doctors to me. I put him back on Geodon and within a month he’s doing great again. Note that Juan displayed every sign of “drug-seeking behavior” even though Geodon is not addictive.
Case 3: This one courtesy of Zvi. Zvi’s friend is diabetic. He runs out of insulin and asks his doctor for more. The doctor wants to wait until his next free appointment in a few weeks before prescribing the insulin. Zvi’s friend points out that he will die unless he gets more insulin now. The doctor gets very angry about this and spends a long phone call haranguing Zvi’s friend about how inconvenient it is that he’s demanding the insulin now rather than at a more convenient time. Zvi’s friend has to threaten the doctor with a lawsuit before the doctor finally relents and gives him the insulin. I like this story because, again, insulin is not addictive, there is no way that the patient could possibly be doing anything wrong, but the patient still gets treated as a drug-seeker. The very act of wanting medication according to the logic of his own disease, rather than at the doctor’s convenience, is enough to make his request suspicious.
Case 4: John is a 70 year old man on opioids for 30 years due to a mining-related injury. He is doing very well. I am his outpatient psychiatrist but I only see him once every few months to renew meds. He gets some kind of infection, goes to the hospital, and due to normal hospital incompetence he doesn’t get his opioids. He demands his meds, and like many 70 year old ex-miners in terrible pain, he is not diligently polite the whole time. The hospital doctors are excited: they have caught an opioid addict! They tell his family and outpatient doctors he cannot have opioids from now on, then discharge him. He continues to be in terrible pain. At first he sneaks pills from an extra bottle of opioids he has at home, but eventually he uses all those up. After this, he is still in terrible pain with no reason to expect this to ever change, and so he quite reasonably shoots himself in the chest. This is the first point in this entire process at which anyone attempts to tell me any of this is going on, so I get a “HEY DID YOU KNOW YOUR PATIENT SHOT HIMSELF? DOESN’T SEEM LIKE YOU’RE DOING VERY GOOD PSYCHIATRIST-ING?” call. The patient miraculously survives, eventually finds a new pain doctor, and goes on to live a normal and happy life on the same dose of opioids he was using before.
Let’s look at those warning signs of addiction again:
– Aggressively complaining about a need for a drug
– Requesting to have the dose increased
– Asking for specific drugs by name
– Taking a few extra, unauthorised doses on occasion
– Frequently calling the clinic
– Unwilling to consider other drugs or non-drug treatments
– Frequent unauthorised dose escalations after being told that it is inappropriate
– Consistently disruptive behaviour when arriving at the clinic
In Case 1, Mary requested her dose of painkiller be increased (from once per six hours to once per four hours). In Case 2, Juan asked for a specific drug by name (Geodon), and was unwilling to consider other drugs. In Case 3, Zvi’s friend frequently called the clinic (to get them to refill his insulin). In Case 4, John showed consistently disruptive behavior in the hospital and took extra unauthorized doses. Etc.
All of these are drug-seeking behaviors. But I maintain that none of these patients were addicted. The correct action in all of these cases is to listen to the patient’s reasons for wanting the drug, realize that you (the doctor) screwed up, and give them the drug that they are asking for. Although the point that these behaviors can be signs of addiction is well-taken and important, it’s equally important to remember they can be signs of other things too.
Media portrayals of pseudoaddiction portray it as this bizarre contortion of logic: “A patient is displaying signs of addiction, so you should give them more of the drug! Haha, nice try, pharma companies!” But this is exactly what you should do! The real problem lies with anyone who conceptualizes pseudoaddiction as a novel hypothesis that requires proof, rather than as the obvious possibility you have to check for before accusing patients of addiction. (...)
As far as I can tell, the concept started off well-intentioned. But painkiller companies realized that the debate over when to diagnose addiction vs. pseudoaddiction was relevant to their bottom line, and started funding the pseudoaddiction side of it.
I’m not sure how substantial an effort this was. G&C note that of 224 papers mentioning pseudoaddiction, 22 were sponsored by pharma (but that means 202 weren’t). Of a stricter category of 12 papers that focused on arguing for the concept, 4 were sponsored by pharma (but 8 were not). Taking their numbers at face value, the majority of discussion of pseudoaddiction had no pharma company sponsorship. But the image of an expert getting up in front of a medical conference and telling doctors that the solution to opioid addiction was more opioids – something that certainly did happen, I’m not sure how often – was so lurid that it burned itself into the popular consciousness. The media exaggerated this from “basically good idea gets misused” to “doctors invent vicious lies to addict your loved ones” to get more clicks. Experts didn’t want to be the guy saying “well actually” in the middle of an Opioid Crisis, so they kept their mouths shut. Reporters copied each others’ denunciations of ‘pseudoaddiction’ without checking what the term really meant.
Into all this came the drug warriors. It’s hard for me to be angry at addictionologists, because they have a terrible job and are probably traumatized by it. But they really hate drugs and will say whatever it takes to make you hate drugs too. These are the people who gave us articles on how one hit of marijuana will get you addicted forever and definitely kill you, how one hit of LSD will make you go crazy and get addicted and probably kill you, how there can never be any legitimate medical reason for using cannabis, how e-cigarettes are deadly poison, and other similar classics. Sensing that they had the high ground, they wrote a couple of papers about how pseudoaddiction isn’t “empirically proven”, as if this were a meaningful claim. This gave the media the ammunition they needed to declare that pseudoaddiction was always pseudoscience and has now been debunked and well-refuted.
This is just my story, and it’s kind of bulverist. But if you think it’s plausible, I recommend the following lessons:
First, when the media decides to craft a narrative, and the government decides to hold a moral panic, arguments get treated as soldiers. Anything that might sound like it supports the “wrong” side will be mercilessly debunked, no matter how true it is. Anything that supports the “right” side will be celebrated and accepted as obvious, no matter how bad its arguments. Good scientists feel afraid to speak up and question the story, lest they be seen as “soft on the Opioid Crisis” or “stooges of Big Pharma”. This happens again and again on any issue people care about, and I want to reiterate for the nth time that you should treat reporting on medical, scientific, and social scientific topics as having almost zero credibility.
Second, you should stay cautious about bias arguments. Yes, some people pushed pseudoaddiction because they were shills of the opioid companies. But other people pushed pseudoaddiction because it was true. Just because you can generate the hypothesis “maybe people are just shills of the opioid companies” doesn’t mean you’ve disproven pseudoaddiction. And if you focus too hard on the opioid companies’ obvious financial bias, then you’ll miss less obvious but possibly more important biases like those of the drug warriors. Your best bet would have been to just stop worrying about biases and try to figure out what was actually true.
All of these are drug-seeking behaviors. But I maintain that none of these patients were addicted. The correct action in all of these cases is to listen to the patient’s reasons for wanting the drug, realize that you (the doctor) screwed up, and give them the drug that they are asking for. Although the point that these behaviors can be signs of addiction is well-taken and important, it’s equally important to remember they can be signs of other things too.
Media portrayals of pseudoaddiction portray it as this bizarre contortion of logic: “A patient is displaying signs of addiction, so you should give them more of the drug! Haha, nice try, pharma companies!” But this is exactly what you should do! The real problem lies with anyone who conceptualizes pseudoaddiction as a novel hypothesis that requires proof, rather than as the obvious possibility you have to check for before accusing patients of addiction. (...)
As far as I can tell, the concept started off well-intentioned. But painkiller companies realized that the debate over when to diagnose addiction vs. pseudoaddiction was relevant to their bottom line, and started funding the pseudoaddiction side of it.
I’m not sure how substantial an effort this was. G&C note that of 224 papers mentioning pseudoaddiction, 22 were sponsored by pharma (but that means 202 weren’t). Of a stricter category of 12 papers that focused on arguing for the concept, 4 were sponsored by pharma (but 8 were not). Taking their numbers at face value, the majority of discussion of pseudoaddiction had no pharma company sponsorship. But the image of an expert getting up in front of a medical conference and telling doctors that the solution to opioid addiction was more opioids – something that certainly did happen, I’m not sure how often – was so lurid that it burned itself into the popular consciousness. The media exaggerated this from “basically good idea gets misused” to “doctors invent vicious lies to addict your loved ones” to get more clicks. Experts didn’t want to be the guy saying “well actually” in the middle of an Opioid Crisis, so they kept their mouths shut. Reporters copied each others’ denunciations of ‘pseudoaddiction’ without checking what the term really meant.
Into all this came the drug warriors. It’s hard for me to be angry at addictionologists, because they have a terrible job and are probably traumatized by it. But they really hate drugs and will say whatever it takes to make you hate drugs too. These are the people who gave us articles on how one hit of marijuana will get you addicted forever and definitely kill you, how one hit of LSD will make you go crazy and get addicted and probably kill you, how there can never be any legitimate medical reason for using cannabis, how e-cigarettes are deadly poison, and other similar classics. Sensing that they had the high ground, they wrote a couple of papers about how pseudoaddiction isn’t “empirically proven”, as if this were a meaningful claim. This gave the media the ammunition they needed to declare that pseudoaddiction was always pseudoscience and has now been debunked and well-refuted.
This is just my story, and it’s kind of bulverist. But if you think it’s plausible, I recommend the following lessons:
First, when the media decides to craft a narrative, and the government decides to hold a moral panic, arguments get treated as soldiers. Anything that might sound like it supports the “wrong” side will be mercilessly debunked, no matter how true it is. Anything that supports the “right” side will be celebrated and accepted as obvious, no matter how bad its arguments. Good scientists feel afraid to speak up and question the story, lest they be seen as “soft on the Opioid Crisis” or “stooges of Big Pharma”. This happens again and again on any issue people care about, and I want to reiterate for the nth time that you should treat reporting on medical, scientific, and social scientific topics as having almost zero credibility.
Second, you should stay cautious about bias arguments. Yes, some people pushed pseudoaddiction because they were shills of the opioid companies. But other people pushed pseudoaddiction because it was true. Just because you can generate the hypothesis “maybe people are just shills of the opioid companies” doesn’t mean you’ve disproven pseudoaddiction. And if you focus too hard on the opioid companies’ obvious financial bias, then you’ll miss less obvious but possibly more important biases like those of the drug warriors. Your best bet would have been to just stop worrying about biases and try to figure out what was actually true.
by Scott Alexander, Slate Star Codex | Read more:
[ed. For an excellent up-to-the-minute example of the opioid hysteria (and political posturing) making people's lives miserable, see also: US attack on WHO 'hindering morphine drive in poor countries' (The Guardian).]
[ed. For an excellent up-to-the-minute example of the opioid hysteria (and political posturing) making people's lives miserable, see also: US attack on WHO 'hindering morphine drive in poor countries' (The Guardian).]
