Guest Blogging at Points for a third day, Helen Keane addresses the need for some refinements in the concept of “drug dependence.”
In my previous post I talked about the need to distinguish pain patients from addicts in the pain clinic. Both may be dependent on opiates, but the addict manifests aberrant drug-seeking behavior and an unhealthy obsession with drugs. However the problem of legitimate pain patients who behave like addicts has lead to a refinement of the addicted/non-addicted binary.
“Pseudoaddiction” is a concept developed by pain specialists in the 1990s to describe desperate drug-seeking, produced not by true drug addiction, but by the under-treatment of pain. The behaviour of patients exhibiting pseudoaddiction mimics the out of control conduct of the addicted: they may increase their dose without approval, complain aggressively, or lie to get more drugs and turn to street drugs or doctor shopping to increase their supply. Pseudoaddiction looks like addiction but it is not addiction. In cases of pseudoaddiction, the drug-seeking behaviours cease once the pain is properly controlled, thereby confirming the absence of true addiction.
But what are the salient differences between pseudoaddiction and addiction? A key factor which separates the pain patient and the addict is their access to drugs. The influence that a steady, quality-controlled and legal supply of drugs can have on the behaviour of a drug-dependent individual is not explicitly addressed in the concept of psuedoaddiction and its model of aberrant but non-addictive drug-seeking. Pseudoaddiction is an iatrogenic syndrome produced by a drug supply issue. In pseudoaddiction, the patient’s supply is insufficient to treat their pain, and the result is addictive acting-out in order to get more drugs. Once supply is adequate, bad behaviour stops. But many of the destructive manifestations of ‘true’ addiction are also related to the need to ensure an adequate supply of drugs. For many ‘street addicts’ obtaining drugs is a high-risk and all-consuming enterprise.
Reflecting on pseudoaddiction, pain specialists Passik and Kirsh note that it is ‘a somber realization that patients can be pushed to uncharacteristic ways of behaving, which are driven by our failure to optimally treat them’.[i] The same ‘somber realization’ could surely be extended to addiction. How would the line between psuedoaddiction and addiction be drawn in the context of Methadone Maintenance Therapy where the disorder being treated is addiction? Does the illicit drug-seeking of an MMT patient who is receiving an inadequate dose represent pseudoaddiction or addiction? The fact that their drug-seeking may cease if their methadone dosage is increased suggests iatrogenic pseudoaddiction, but the fact that they are being treated for addiction undermines this possibility. Addicts are defined as those for whom erratic and anti-social behaviour is characteristic, therefore any addictive behaviour they exhibit is interpreted as the real thing whatever its cause.
Next Up: Addicted Brains