Critical Re-Analysis of Psuedo-addiction

[drusso]

Against Against Pseudoaddiction

I. “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&#8221…

slatestarcodex.com

"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."

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[lobelsteve]

Scott Alexander

Scott Alexander is the pen-name of LessWrong-rationalist blogger and psychiatrist Scott Alexander Siskind. Alexander began writing on LessWrong under the name Yvain, and then branched out into his own blog, Slate Star Codex (a near-anagram of "Scott Alexander"). SSC became one of the top-tier...

rationalwiki.org

 

[Gauss]

"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 the doctor inventors who published the term sure did take a lot of money from said pharma companies

 

[Aether2000]

What a bizarre rant by Scott Alexander! Leave it to a psychiatrist to exhibit such thought processes....

 

[Ducttape]

herein lies the problem in one sentence, by his own words:

You might notice that all of these are things people might do if they actually need the drug.


anyone who feels they need the drug goes beyond simple pain management.

the term need directly implicates a psychiatric basis.

his cases also frankly are poor quality

Case 1 - acute pain. not an appropriate example at all.

case 2 - case of psychiatric mismanagement, not at all related to addiction. not opioid issue.

Case 3 - he is making massive assumptions about the doctor's intent. and there is a huge component about financial reimbursement on the doctor's part, which clearly affects the doctor's judgement. not opioid issue.

Case 4 - psychiatric issues with patient and acute changes in opioid dose that might not have been indicated. a legacy patient that first should never have been started on opioids but also shouldn't have had meds stopped without good reason. it is the failure of the psychiatrist that he did not catch up on the underlying psychiatric issues too. nothing would have stopped the psychiatrist from prescribing the patient's opioids.

Case 5 - a patient that never should have been on chronic opioids. for dental pain of all things. the first dentist bought in to the "opioids do no harm" mantra of Big Pharma paid doctor shills.

Case 6 - not opioid. benzo dependent.

through all these examples, he is conflating dependence and addiction. its surprising as a psychiatrist that he keeps conflating the 2.

 

[Ducttape]

I saved Case 7 separately.

advocating someone take an extra trazodone or two is one thing. to conflate this with opioids, and having a patient take an extra OxyContin 80 just because he is having more pain that night will lead to significant undesirable consequences far beyond an extra trazodone. in terms of need, a patient needs to take opioids only as directed.

 

[Orin]

The argument being made here for pseudoaddiction is an old one that that it really is a phenomena afflicting the observer/provider/physician/society and not the patient. It obviously makes sense when you remove the opioid from the issue, as the examples of insulin, geodon, etc are meant to show above.

Pseudoaddiction: Fact or Fiction? An Investigation of the Medical Literature - PMC

Tremendous growth in opioid prescribing over two decades in the USA has correlated with proportional increases in diversion, addiction, and overdose deaths. Pseudoaddiction, a concept coined in 1989, has frequently been cited to indicate that ...

www.ncbi.nlm.nih.gov

I prefer to just tell my patients to quit being jerks just because the system is broken, but pseudoaddiction sounds more science-y when the patient is being a belligerent advocate for themselves.

It still isn't the drug's fault, but maybe if they just got an FDA indication for the disease of suffering, opioids would be on-label for everything?

 

[drusso]

I saved Case 7 separately.

advocating someone take an extra trazodone or two is one thing. to conflate this with opioids, and having a patient take an extra OxyContin 80 just because he is having more pain that night will lead to significant undesirable consequences far beyond an extra trazodone. in terms of need, a patient needs to take opioids only as directed.

Are you saying pseudo-addiction is a contested & disputed concept (with evidence both for and against it) or is it settled science (like Kepler's laws of planetary motion)?

 

[Ducttape]

I'm saying that using the diagnosis of pseudo-addiction to justify a patient misusing opioid medication, against medical advice, thus jeopardizing patient safety, the doctor patient relationship, and the doctor's professional license is not appropriate.

 

[drusso]

I'm saying that using the diagnosis of pseudo-addiction to justify a patient misusing opioid medication, against medical advice, thus jeopardizing patient safety, the doctor patient relationship, and the doctor's professional license is not appropriate.

Sounds like there is a lot of uncertainty around this phenomenon. Definitely NOT Kepler's laws of planetary motion...

 

[Gauss]

Sounds like there is a lot of uncertainty around this phenomenon. Definitely NOT Kepler's laws of planetary motion...

negative. I'm very certain pseudoaddiction is a BS term invented by academics needing something to publish to reach their next rank. call it undertreatment or tolerance or addiction. pseudo? GTFO

 

[Ducttape]

No uncertainty.

Does undertreated pain exist? Yes no doubt.

Does bad physician management exist? Yes no doubt.

Does inappropriate use and taking drugs the wrong way exist? Yes no doubt.

Is it acceptable as a physician to allow patients to misuse and abuse prescriptions that have significant legal ramifications, essentially allow patients to take drugs any way they want to? No.

No uncertainty

 

[drusso]

No uncertainty.

Does undertreated pain exist? Yes no doubt.

Does bad physician management exist? Yes no doubt.

Does inappropriate use and taking drugs the wrong way exist? Yes no doubt.

Is it acceptable as a physician to allow patients to misuse and abuse prescriptions that have significant legal ramifications, essentially allow patients to take drugs any way they want to? No.

No uncertainty

How could anyone even question the concept?

 

[SeniorWrangler]

There’s no evidence in the literature. If there was even one study where someone identified pseudoaddiction patients, upped their doses and reported six month outcomes... doesn’t exist!

Also, this term just serves to create a distinction between deserving pain and undeserving addiction patients that is not really a helpful way to look at pain clinic patients.