Pseudo-addiction, is

[101N]

a joke.

1. Pain. 1989 Mar;36(3):363-6. Opioid pseudoaddiction--an iatrogenic syndrome.
Weissman DE1, Haddox JD.
Abstract
A case is presented of a 17-year-old with leukemia, pneumonia and chest-wall pain. Inadequate treatment of the patient's pain led to behavioral changes similar to those seen with idiopathic opioid psychologic dependence (addiction). The term pseudoaddiction is introduced to describe the iatrogenic syndrome of abnormal behavior developing as a direct consequence of inadequate pain management. The natural history of pseudoaddiction includes progression through 3 characteristic phases including: (1) inadequate prescription of analgesics to meet the primary pain stimulus, (2) escalation of analgesic demands by the patient associated with behavioral changes to convince others of the pain's severity, and (3) a crisis of mistrust between the patient and the health care team. Treatment strategies include establishing trust between the patient and the health care team and providing appropriate and timely analgesics to control the patient's level of pain.

2. Pain. 2013 Nov;154(11):2487-93. doi: 10.1016/j.pain.2013.07.033. Epub 2013 Sep 24.
A pharmacoepidemiological cohort study of subjects starting strong opioids for nonmalignant pain: a study from the Norwegian Prescription Database. Fredheim OM1, Borchgrevink PC, Mahic M, Skurtveit S.

Abstract
Clinical studies of short duration have demonstrated that strong opioids improve pain control in selected patients with chronic nonmalignant pain. However, high discontinuation rates and dose escalation during long-term treatment have been indicated. The aim of the present study was to determine discontinuation rates, dose escalation, and patterns of co-medication with benzodiazepines. The Norwegian Prescription Database provides complete national data at an individual level on dispensed drugs. A complete national cohort of new users of strong opioids was followed up for 5 years after initiation of therapy with strong opioids. Of the 17,248 persons who were new users of strong opioids in 2005, 7229 were dispensed a second prescription within 70 days and were assumed to be intended long-term users. A total of 1233 persons in the study cohort were still on opioid therapy 5 years later. This equals 24% of the study cohort who were still alive. Of the participants, 21% decreased their annual opioid dose by 25% or more, whereas 21% kept a stable dose (± 24%) and 34% more than doubled their opioid dose from the first to the fifth year. High annual doses of opioids were associated with high annual doses of benzodiazepines at the end of follow-up. It is an issue of major concern that large dose escalation is common during long-term treatment, and that that high doses of opioids are associated with high doses of benzodiazepines. These findings make it necessary to question whether the appropriate patient population receives long-term opioid treatment.

3. Pain Med. 2015 Apr;16(4):733-44. doi: 10.1111/pme.12634. Epub 2014 Dec 19.
Dose escalation during the first year of long-term opioid therapy for chronic pain. Henry SG1, Wilsey BL, Melnikow J, Iosif AM.
Author information

Abstract
OBJECTIVE:
To identify patient factors and health care utilization patterns associated with dose escalation during the first year of long-term opioid therapy for chronic pain.

DESIGN:
Retrospective cohort study using electronic health record data.

SETTING:
University health system.

SUBJECTS:
Opioid naïve adults with musculoskeletal pain who received a new outpatient opioid prescription between July 1, 2011 and June 30, 2012 and stayed on opioids for 1 year.

METHODS:
Mixed-effects regression was used to estimate patients' rate of opioid dose escalation. Demographics, clinical characteristics, and health care utilization for patients with and without dose escalation were compared.

RESULTS:
Twenty-three (9%) of 246 patients in the final cohort experienced dose escalation (defined as an increase in mean daily opioid dose of ≥30-mg morphine equivalents over 1 year). Compared with patients without dose escalation, patients with escalation had higher rates of substance use diagnoses (17% vs 1%, P = 0.01) and more total outpatient encounters (51 vs 35, P = 0.002) over 1 year. Differences in outpatient encounters were largely due to more non face-to-face encounters (e.g., telephone calls, emails) among patients with dose escalation. Differences in age, race, concurrent benzodiazepine use, and mental health diagnoses between patients with and without dose escalation were not statistically significant. Primary care clinicians prescribed 89% of opioid prescriptions.

CONCLUSIONS:
Dose escalation during the first year of long-term opioid therapy is associated with higher rates of substance use disorders and more frequent outpatient encounters, especially non face-to-face encounters.

4. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesisVowles, Kevin E.a,*; McEntee, Mindy L.a; Julnes, Peter Siyahhana; Frohe, Tessaa; Ney, John P.b; van der Goes, David N.c

Abstract
Abstract: Opioid use in chronic pain treatment is complex, as patients may derive both benefit and harm. Identification of individuals currently using opioids in a problematic way is important given the substantial recent increases in prescription rates and consequent increases in morbidity and mortality. The present review provides updated and expanded information regarding rates of problematic opioid use in chronic pain. Because previous reviews have indicated substantial variability in this literature, several steps were taken to enhance precision and utility. First, problematic use was coded using explicitly defined terms, referring to different patterns of use (ie, misuse, abuse, and addiction). Second, average prevalence rates were calculated and weighted by sample size and study quality. Third, the influence of differences in study methodology was examined. In total, data from 38 studies were included. Rates of problematic use were quite broad, ranging from <1% to 81% across studies. Across most calculations, rates of misuse averaged between 21% and 29% (range, 95% confidence interval [CI]: 13%-38%). Rates of addiction averaged between 8% and 12% (range, 95% CI: 3%-17%). Abuse was reported in only a single study. Only 1 difference emerged when study methods were examined, where rates of addiction were lower in studies that identified prevalence assessment as a primary, rather than secondary, objective. Although significant variability remains in this literature, this review provides guidance regarding possible average rates of opioid misuse and addiction and also highlights areas in need of further clarification.

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[lobelsteve]

Pseudo addiction is a marketing term created by big pharma to attempt to legitimize opiate dose escalation when no need exists.

 

[NJPAIN]

Hence the connection to Haddox - Mr. Big Pharma

 

[drusso]

My understanding of the concept of "psuedo-addiction" relates to my direct experience doing acute pain management and palliative care in the hospital setting. If you are a outpatient pain specialist who lacks this experience, then the concept is likely confusing. In the inpatient setting or palliative care setting, behaviors that imitate addiction might be confused with under-treated pain: Clock-watching, "begging" the RN for medication, hoarding or stealing medication from the patient in the bed next to you, etc...

I think that there is a very narrow application for this concept. Unfortunately, like most all other aspects of our field, very specific terms, tactics, and concepts have become bastardized over time to legitimize laissez faire prescribing of controlled substances.

Yes, Martha, psuedo-addiction exists: And, most of you who haven't done inpatient pain management or palliative care, probably haven't seen a real case of it.

 

[Papa Lou]

it is my opinion that the majority of people that check into the hospital for pain management are in dire need of psychological assistance in dealing with suffering associated with chronic pain. This is their biggest problem. Their second biggest problem is usually inappropriate use of opioids in the outpatient setting. If you correct the second problem a lot of times they work their way through the first. It's very difficult to correct the first without correcting the second beforehand.
Opioids are not some poorly understood horrible enemy. They have their place in certain rare cases of non-cancer chronic pain, but they are rare. People are afraid of NSAIDs b/c of cardiac/kidney/GI complications but they ignore the troubling slippery slope and personality/life changes that often occurs in chronic pain, opioid-managed patients.
This stuff can soil lives just like alcohol can. Some people can handle it, some can't (and I'm referring to patients and prescribing doctors). It's better to err on the side of caution/non-prescribing.

 

[pastafan]

My understanding of the concept of "psuedo-addiction" relates to my direct experience doing acute pain management and palliative care in the hospital setting. If you are a outpatient pain specialist who lacks this experience, then the concept is likely confusing. In the inpatient setting or palliative care setting, behaviors that imitate addiction might be confused with under-treated pain: Clock-watching, "begging" the RN for medication, hoarding or stealing medication from the patient in the bed next to you, etc...

I think that there is a very narrow application for this concept. Unfortunately, like most all other aspects of our field, very specific terms, tactics, and concepts have become bastardized over time to legitimize laissez faire prescribing of controlled substances.

Yes, Martha, psuedo-addiction exists: And, most of you who haven't done inpatient pain management or palliative care, probably haven't seen a real case of it.

Pseudo-addiction for chronic pain, nope. As drusso mentions, I believe it exists in acute pain settings. Look at post-op pain patients. There are those patients that have extremely high opioid requirements versus the "norm" whose behavior fits pseudo-addiction. The key in my mind is that while they require much higher doses of meds than normal the duration of their post-op pain is exactly the same as normal patient having the same operation. These patients have been under-dosed, are in pain, and they have adaptive behaviors. They are not addicted they just have a surgeon that orders the same meds for every patient, does not use adjunct meds, does not believe in PCA or neuraxial analgesia, and lets their patients suffer.