Against Against Pseudoaddiction

https://slatestarcodex.com/2019/09/16/against-against-pseudoaddiction/

by jerf • 7 years ago

258 136 7 years ago

hinkley• 7 years ago

One of the definitions of addiction that seems to be common around addiction specialists is that an addict will chose behavior that negatively impacts their life in obvious ways.

There's a separate set of questions that have been asked and I'd still really like to see the answers be tracked down. What is it about some people that they can try some chemicals once and abandon them, while lots of other people simply cannot stop? Is it genetic, philosophical, or environmental?

If it's nurture, can we spread these tools around more widely? If there's a nature component, can we identify metabolic pathways and support detox?

jhayward2• 7 years ago

an addict will chose behavior that negatively impacts their life

I think that "addict will choose" is a problematic way to say what you are saying. There is a lot of very gray area about the concept of choice when the organ that chooses is the thing that is being injured.

It's not clear at all that "choice" - in the moralistic, Protestant ethic US society is based on sense - is actually something that can be usefully ascribed to most human behavior.

darawk2• 7 years ago

Usually it's defined in a self-normalizing way, though. Addiction is when the addict themselves believes that the behaviors are detrimental to their own life, but cannot bring themselves to stop engaging in them.

tachyonbeam• 7 years ago

What is it about some people that they can try some chemicals once and abandon them, while lots of other people simply cannot stop? Is it genetic, philosophical, or environmental?

Like most things, it's probably a combination of genetics and environment. From what I've observed, it really seems like some drugs mesh with some brain chemistries and not others. Case in point: when I was a young teenager, I wanted to be cool, and I tried smoking cigarettes with the cool kids. I've probably smoked 50 cigarettes in my life. At no point did I ever feel the pull of nicotine. It just never did anything to me. That's surprising because I know a lot of people who quickly got hooked and can't quit even if they want to. I've also tried pot: it makes me terribly paranoid and is a sure fire way to ruin my day, so pot has negative appeal to me.

On the other hand, I was also in the rave scene for a while. I've tried stimulants such as amphetamines and MDMA as well as ketamine. Those drugs all had a definite pull on me. I had to take a step back at some point because I was using them every weekend and it was starting to take a toll on my work. I eventually realized that I was going dancing not because I liked it that much, but because I was subconsciously trying to put myself in situations where I would do drugs (early signs of addiction IMO, and I'm glad I noticed).

I think that when a chemical tickles your reward center in the right way, your brain starts subtly adjusting your behavior so you get that stimulus again. It will slowly creep up on you. If you aren't careful, you can lie to yourself, not notice what's happening, or not want to notice. If you're in a position where you don't like your life very much, it's easy to give in to that pull. I know that when I discovered party drugs, I was in a vulnerable place: I had low self esteem, my girlfriend and I had just broken up, I had very few friends, I was bored with my life, and I felt like going raving and taking MDMA was the only way I could feel connected with other people. The drugs filled a void in my life. They did add a lot of novelty and excitement too, and it took me a while to realize that they were making things worse, not better.

jschwartzi• 7 years ago

Yeah, this is my experience too. I've tried MDMA on occasion and at various purities. It's fun but doesn't really have much pull for me because usually I'm already in the place MDMA is putting me but naturally. There are some fun effects but nothing that makes me want to go out and buy it.

Cigars on the other hand are something that have an immense amount of pull for me, and even just thinking about smoking a cigar after several weeks without one is rekindling a desire to go to the smoke shop. And that tells me that I absolutely should not go to the smoke shop. Cigarettes don't have the same pull for me because I can't get stoned off my ass with a cigarette.

colechristensen3• 7 years ago

Is it genetic, philosophical, or environmental?

All of the above, and none of them can completely dominate the others.

joe_the_user• 7 years ago

Despite this article involving some things lucidly explained, I have trouble understanding the overall implications.

I think I understand that:

Pain and conditions have somehow become more common since, 1990 and the prescription of opioids has increased since that time.

So now we a situation where:

Some Patients and some other people are becoming addicted to opioids and abusing the prescription system as much as they can, also dying.

Other patients are still being under-prescribed. These patients may also belligerently demand more drugs, like addicts. One can say "they're not addicts, they just seem like it and they actually do need more drugs." This is "pseudoaddiction", near as I can make out.

The one thing I find very puzzling or annoying, is why anyone want to even use the very confusing term "pseudoaddiction" and especially be "against against" it. Jeesh. The situation seems like it could best be handled by saying "banish the jargon and look at the situation".

astine2• 7 years ago

"The one thing I find very puzzling or annoying, is why anyone want to even use the very confusing term "pseudoaddiction" and especially be "against against" it. Jeesh. The situation seems like it could best be handled by saying "banish the jargon and look at the situation"."

The author explains his reasoning in the article:

"Others seem to kind of equivocate between “pseudoaddiction is fake” vs. “[the phenomenon described by the word pseudoaddiction] is real, but there’s no point in having a separate word for it.” The latter would be reasonable if there weren’t so many people saying the former. Because people are constantly misdiagnosing real distress as addiction, we need a word for when that happens, and pseudoaddiction is as good as any other."

nitePhyyre• 7 years ago

Which is rather silly because he used the correct, non made up, word right there in that sentence. Misdiagnosis.

There's absolutely no benefit to say "they are suffering because of pseudoaddiction" instead of saying "they are suffering because their pain was misdiagnosed as addiction."

whiddershins2• 7 years ago

He’s being against against it because people are currently using the term, saying they are against it, and then making medical decision that hurt people based on that.

This is what he is against. Unnecessary harm due to people worrying about the supposed nonsense of the term.

scrumper• 7 years ago

Very interesting!

So my understanding from this is that "psuedoaddiction" is a name for the concept that a patient agitating for drugs is doing so not because they're addicted, but because they actually need the drug to ease their symptoms. In other words, someone rolling around on the floor moaning in pain and screaming for oxy may be doing so because they're actually in a lot of pain, as opposed to acting because they need a fix.

As a term it's pretty unfortunate. And this is the point of the article: the notion that "pseudoaddiction" is an unscientific pharma sales technique has made it difficult for those in need of medication to get enough of it.

The author cites examples of insulin and non-addictive antidepressants too, lest you think it's all about opiates. They make a strong, frustrated case.

samename• 7 years ago

I'm not sure how one would go about addressing this problem. While it could be argued that Big Pharma pushed for psuedoaddiction more than necessary, that doesn't necessarily discount what the patients were saying. From the article, it sounds like a doctor with experience with the patient could distinguish between addiction and psuedoacction well, but the doctor also wants to avoid bureaucratic oversight and risk causing harm to their patient.

kelnos4• 7 years ago

The question I have (as a complete lay-person) is: can't we develop effective painkillers (and other useful drugs) that aren't addictive at all? Is there something inherent about the types of things these treat that makes it really hard to avoid using addictive substances?

mrosett• 7 years ago

Based on the examples he gives, physicians seem to have a disappointingly unsophisticated response to the word “addiction” or to any signs that point in the direction of it. Even if you are physically dependent on a drug and respond poorly to having it withdrawn, you’re not addicted in the clinical sense unless you’re engaging in problematic behavior. That nuance seems to be lost on far too many doctors amidst the current moral panic.

I wish that we could have a more nuanced response to the true horrors of the opioid epidemic. But perhaps even highly trained doctors aren’t capable of more discretion. To be pessimistic and reductionist, the only options are “make drugs harder to get across the board” or “make them easier to get” and we’ve chosen the former. That may help with the opioid crisis, but it has its own costs.

chongli• 7 years ago

Based on the examples he gives, physicians seem to have a disappointingly unsophisticated response to the word “addiction”

That's because the incentives are not in proportion to the disincentives. Doctors are highly trained, yes, but they adjust their level of discretion in response to liability risk. If the current legal regime treats addiction like the black plague then doctors are going to avoid enabling addicts like the plague, even if that means leaving a lot of legitimate patients in severe pain.

nullc• 7 years ago

Humans sometimes draw conclusions which are overly reductive.

"This person is an addict" is a very tidy and convenient explanation for a multitude of symptoms which would otherwise be vexing to analyze and treat, and it also is a not-that-improbable answer in terms of the base rate.

Keep in mind that these examples are cherry picked failures. Actually, when you consider that they're presumably the worst cases the author personally knew of-- they're surprisingly not that bad. None of them featured the patient being killed by police officers as a result of misdiagnosis of addicition and especially poor handling by the hospital...

Even if we had chosen "make them easier to get" you'd still probably be able to find examples of laughably false addiction diagnoses resulting in poor care...

l_t9• 7 years ago

Devil's advocate position (mostly from a book, "Dreamland", about this topic):

"Pseudoaddiction" is deliberately defined such that it's indistinguishable from actual addiction. The concept was popularized by Purdue Pharma, who were trying to market OxyContin.

At the time, providers were averse to prescribing opioids because of addiction concerns. Purdue created the "pseudoaddiction" term to teach providers that just because someone looks addicted, you can keep prescribing them opioids anyways.

At the same time, they lied with statistics to tell doctors that opioids only caused "true" addiction in less than 1% of cases.

Thus, the brunt of the message was that if you see addiction, there's a 99% chance that it's not real addiction.

Many doctors were convinced. Now the nation is dealing with an opioid epidemic driven by OxyContin.

Pseudoaddiction exists. But actual addiction also exists, and it's more dangerous and more likely to happen. Being afraid to diagnose "addiction" because of "pseudoaddiction", is just FUD.

l_t9• 7 years ago

Beyond the devil's advocacy, my personal opinion is that the industry is currently swung too-heavily towards prescribing opioids. We need to swing back the other way. The trick will be not swinging too far, which is I think the brunt of this article's intent.

jnbiche6• 7 years ago

currently swung too-heavily towards prescribing opioids

Ah, you would have been right about 10-15 years ago. Things have dramatically changed since then. I'm assuming you've not had any contact with the medical system requiring opiates for you or your relatives in recent years. Now, we've swung far, far too far to the other extreme, to the point that my WWII vet, community leader, church deacon grandfather was brutally undertreated for pain while he was dying of cancer. This is very typical now.

Either that, or the medical system is very different in Silicon Valley or wherever you live.

munk-a4• 7 years ago

Opioids aren't a great painkiller anyways - they're just a painkiller that can be patented.

tlb• 7 years ago

The article suggests that there isn't an easy way of distinguishing pseudoaddiction and actual addiction, no matter how the definition is clarified. It depends on how much pain the patient is experiencing, which is only truly knowable by the patient.

l_t9• 7 years ago

Exactly, which is why it's such a valuable concept for opioid marketing. The line between addiction and pseudoaddiction is vague. Doctors can't judge it; nobody can judge it. Only the patient -- and the patient wants the drugs in this scenario.

jnbiche6• 7 years ago

I think ultimately it (obviously) should be the doctor's call. But we've swung to such an extreme now that most people with severe chronic pain are undertreated or (more likely) untreated. I'm convinced that we're 5 years away from yet another backlash when we realize how many people with truly shitty, excruciating conditions are being forced to live in medieval medical conditions due to the current opiate hysteria.

Once again, the number of deaths from prescription opiates is dwarfed by the number of opiate deaths from illegal opiates. There's not even a comparison. And the vast majority of the opiate deaths from illegal substances are from fentanyl and related substances, which are notoriously hard to dose and/or frequently spiked and/or passed off as drugs of lesser potency. Imagine the deaths we could prevent if we (as in Europe) allowed addicts to dose themselves with supervised, clean, hygienic, pharmaceutical-grade heroin while offering them treatment to get off of them if they so desired.

Edit: I looked up current data and it looks like prescription opiates like oxycontin account for about 1/3 of opiates deaths. Maybe not quite "dwarfed" like I claimed above, but a definite minority of opiate deaths are caused by prescription narcotics. And given the current growth rate of deaths from illegal opiates, it could easily be only 10% in the next 1-2 years: https://www.cdc.gov/drugoverdose/epidemic/index.html

narrator• 7 years ago

When you give something a name, somehow it becomes more real in people's mind. You can also then build a whole superstructure of advocacy and theory on top of that false concept which a large amount of paid advocates and academics become invested in.

A lot of modern economics that justifies endless financial engineering follows this model.

jnbiche6• 7 years ago

Pseudoaddiction exists. But actual addiction also exists, and it's more dangerous and more likely to happen.

Many people kill themselves over chronic untreated or undertreated pain. I've seen studies showing that people with chronic pain kill themselves at twice the rate of those without chronic pain (even that seems low to me) [0] and various other similar studies. Assuming this is true, and that the two are causally related, then opiate deaths and suicide deaths due to chronic pain are in the same order of magnitude.

If you any of you are unfortunate to end up with a condition that causes significant chronic nerve pain, you'll quickly understand how this can be.

0. https://annals.org/aim/fullarticle/2702061/chronic-pain-amon...

jotakami• 7 years ago

To add to your argument, “addiction” is not a cause of death, it is a risk factor for various unnatural causes such as suicide and overdose. The same could be said for chronic pain, but it is pretty easy to understand why chronic, untreated pain would lead to suicide. The connection between addiction and suicide is much more complex, and may have more to do with the reality of being an addict in modern society than the medical consequences of the addiction itself.

l_t9• 7 years ago

I don't want to detract from your point about sympathy for chronic pain. But you can't mainline oxycodone into everyone who claims to have chronic pain, because that system is easily abused, as we've seen. A more nuanced approach is needed. We need a balance, and IMO we need to improve our ability to objectively measure pain instead of relying on a 1-10 scale.

I am curious about your conclusion that "opiate deaths and suicide deaths due to chronic pain are in the same order of magnitude", though. According to my simple Googling, opioids are the cause of death for 21.7 per 100,000 people in the US, while suicide is only 14 per 100,000. So per your link, chronic pain suicide is about 10% of that, or 1.4 per 100,000. That means opioid deaths are about 10-15x more common, or am I missing something?

edit: I'm realizing my understanding of this debate is significantly out-of-date. So I apologize if anything I've written seems tone-deaf, that wasn't my intention.

munk-a4• 7 years ago

As someone married to someone with chronic pain... Opioid pain killers tend to be ineffective anyways - they will provide a window of pain killing that is longer than other substances (when taken within safe limits) on the order of months but their efficacy is not unlimited and even being willing to heavily addict yourself to Oxy is likely going to cease helping your pain after half a year. This is part of the cause of this epidemic, people were _entirely falsely_ prescribed an ineffective medication that has heavy side effects.

My spouse managed to get a medical supply of mj and that has helped her get back into life, given her pain source is from arthritis and a few other issues it'll probably never be a thing she'll be without but the few studies out there on mj have a positive view of long term pain treatment on it.

Chronic pain is a very serious condition that can ruin lives, it is extremely disgusting to see what has happened with Oxy and heavier penalties are needed.

DanBC2• 7 years ago

Many people kill themselves over chronic untreated or undertreated pain.

The answer is to give people access to better treatment for pain.

That isn't giving them opioids.

They end up addicted to opioids, with a bunch of side-effects caused by opioids, and they're still in pain. Their functioning is decreased.

https://www.england.nhs.uk/south/2019/06/25/seans-story/

https://www.bbc.co.uk/programmes/b04wv052

jdminhbg• 7 years ago

"Pseudoaddiction" is deliberately defined such that it's indistinguishable from actual addiction.

The point of the article is that it's the other way around -- addiction is defined in a way that includes plenty of non-addicts. It's like the old D.A.R.E. pamphlets that tell you to watch out for teens who are sullen, sleep late, distrust authority, etc.

l_t9• 7 years ago

Yeah, I think the article presents a good point, logically speaking. But I think it's brash to ignore the history of the "pseudoaddiction" term, which is a tool of FUD.

Of course it exists and makes sense, this was marketed to doctors. They're not dumb. Pseudoaddiction is real and important, which is why it's such a good marketing tool.

It's a really tough problem. That's why I think considering both sides is incredibly important. I'm not trying to bash the article, just provide a different perspective on why pseudoaddiction might have been bashed in the press.

edit: Apparently reading a book doesn't make me an expert! I'm realizing that it's actually pseudoaddiction that's getting bashed right now. Which makes sense, given the context of the article. I was still thinking about it from the lens of opioids being over-prescribed but it seems the pendulum has swung in the other direction. Sorry for muddying the discussion.

f5thesystem2• 7 years ago

Many doctors were convinced.

Fuck those doctors. They should have their medical license revoked for being fucking stupid and gullible.

kelnos4• 7 years ago

Your tone is a bit inflammatory, but I can't help but agree a bit. If someone who is selling you something is doing so by trying to convince you of a medical phenomenon that you (as a doctor) aren't familiar with, it's the height of irresponsibility to just accept that at face value. It shouldn't be a secret in the medical community that big pharma sales can be... unsavory.

munk-a4• 7 years ago

Also, and more importantly, fuck those drug reps - and if they were ignorant then fuck our society that has come to accept CYOAism so widely. It is your job as an employee to be aware of the effects your labour is having on others - if you're working in a paper mill that is dumping chemicals into a river it's not enough to hope folks downstream don't get sick.

kelnos4• 7 years ago

But actual addiction also exists, and it's more dangerous and more likely to happen.

Not sure that's obvious, or true. The article itself recounts two situations where the patients denied meds they needed became suicidal, and a third where if the patient hadn't pushed the issue to get his meds (insulin), he would have died.

l_t9• 7 years ago

Yeah, I was wondering who would call me out on that! I'm not aware of any good studies that compare addiction vs. pseudo-addiction.

It's definitely not obvious, because a lot of doctors were convinced to the contrary.

By the way -- I'm not saying those individuals in the article aren't important, but whitewashed "case studies" that are full of snark and biased language and have no sources or timeframes, are not the best sources of evidence. In particular, the "pain management" space is rapidly evolving in the US and without timeframes, many of those anecdotes have negative utility.

I'm not saying "pseudoaddiction" doesn't exist, obviously, but we need statistical arguments that are more nuanced than "does it exist or not."

edit: I'm realizing that my understanding of this debate is out of date. So I'd like to apologize if my stance seems insensitive to what's going on right now w.r.t. opioid prescriptions. My gut feeling is that addiction is a bigger problem, but that varies depending on how freely opioids are prescribed. If opioids are under-prescribed then pseudoaddiction becomes a larger problem, for sure. Being dumb, I just assumed they were still being over-prescribed...

Scarblac• 7 years ago

And I guess that there are also a lot of cases that the right dose, that the patient really needs for his excruciating pain, will lead to addiction as an unwanted side effect. After long enough, it's going to be both.

tempestn4• 7 years ago

Isn't it basically known at this point that insufficient pain medication is very likely to encourage addition? Specifically, if pain medication wears out before the next scheduled dose, so that the patient experiences significant pain and therefore is looking forward to their next does for relief from that pain... well, it seems obvious that that would be a perfect recipe to strengthen dependency on that drug. IIRC that was one of the main criticisms of Oxycontin, that it was claimed to have a longer efficacy period than it actually did, so too-long dosing periods were prescribed, resulting in this effect. (Not to mention all the unnecessary discomfort between doses itself.)

simplecomplex3• 7 years ago

Research on drug addiction points to socioeconomic and cultural factors predicting addiction, not consuming the drug.

See the work of Johann Hari. People become addicts because they’re unhappy with their lives and their environment, not because opioids are inherently addictive. Which shouldn’t be surprising to anyone who has experienced addiction.

tempestn4• 7 years ago

I'm sure that's a factor, but it seems unlikely to me it's the only one. All else being equal, going through a repetitive cycle of pain/craving and relief throughout recovery seems likely to encourage addiction as well. Which of course isn't to say that everyone who experiences that will become addicted, or that those who do won't skew toward those who are facing other difficulties in life, but from what I've read it does have an effect. And it fits my common sense, not that one should rely on that in absence of real evidence.

jakeinspace• 7 years ago

Well, yes for opiates I believe that's largely true. But I will say that as somebody going through chronic pain and anxiety for the first time, I can definitely see how my meds for those respective conditions could lead to a dependency despite an otherwise good social/support network and job.

jnbiche6• 7 years ago

People become addicts because they’re unhappy with their lives and their environment,

You know what's one thing that makes people very unhappy with their lives? Severe chronic pain. Aside from the pain, it also removes a great deal of agency and self-efficacy from their lives. They can't control the pain, the medical system is basically out of their control, and now there's a societal hysteria about opiates.

Beyond that, what you're describing it the difference between addiction and dependency. Any flesh and blood human will become dependent on opiates after a few weeks. It's why doctors have you taper off opiates and other meds that cause dependency.

Although even that distinction seems to be going by the wayside in the current hysteria.

refurb3• 7 years ago

This is very true. One needs to consider both physical addiction and psychological addiction.

If you give 100 people high doses of Oxycotin for a month, all 100 will exhibit withdrawal symptoms when the drug is stopped. However, 80 of those will probably suffer through it and not crave the drug after that, 17 will willingly continue to use the drug to avoid the withdrawal symptoms and 3 will (if possible) escalate the dose to the point they care about nothing else.

That's the psychological part of it.

And yes, I made those numbers up, but you get the point.

l_t9• 7 years ago

Yep -- OxyContin has a timed-release coating and by preventing the "peaks and valleys" of opiate use, it was supposed to minimize addiction. This was a major selling point for doctors, which turned out be based on falsified data.

The thing is, I don't think any studies have actually validated that concept? If you say "it's basically known", I'm curious what evidence you have for that statement. Are there studies where people have been prescribed more opioids but been less addicted because they finally have "sufficient" medication?

tempestn4• 7 years ago

I didn't say, "It's basically known." I said, "Isn't it basically known?" I'm just going from memory, probably of news articles. I would be interesting to know what follow-up research has been done as well.

adamsb62• 7 years ago

Anecdotal from a history of more than a few surgeries: I think the OxyContin is actually less addictive. A pain relieving dose of a non time release opioid will last about four hours. I’ve had pain bad enough that it prevents sleep. To get a good eight hours of sleep I would need to take a much higher dose, and that puts you pretty deep into euphoria. Some people will keep chasing that feeling.

With OxyContin I could take a normal dose before bed and sleep through the night.

cwkoss4• 7 years ago

I recently had a bad reaction to a (non-narcotic) prescribed drug, and it got me thinking about how we could improve use of pharmaceuticals.

1. We don't measure the patients metabolism of a drug at all. Individuals bodies process drugs differently and have different side effects. It seems that differences in reactions could be related to different metabolic pathways being used, resulting in more or less toxic byproducts. Could a urine or blood test a few hours after the first dose be an effective mechanism for screening for likelihood of side effects based on the metabolic byproducts detected? Could this test be effective at detecting these byproducts at dosages below what would cause side effects? Could this be incorporated into a "home drug test" style urine dip that patient could do themselves at home without returning to doc?

2. Dosage is too one-size-fits-all. AFAICT, the drug I was given is usually prescribed at the same dose to slightly-underweight me as they would a larger patient double my weight. For these fixed-dosage drugs, it seems like lower-weight patients will have higher risk of side effects and higher-weight patients will have higher risk of dosing at sub-therapeutic levels.

3. Drug half-life is assumed to be nearly constant across the population. Even more than dosage, many drugs have a constant X times per day, but only dosage is adjusted. For people with atypical metabolism of that drug, the effective duration could vary drastically. Patients with slow metabolisms could develop side effects at low dosages if taken over a long enough period.

I'd love to see pharma move towards a model where patients are started at a sub-therapeutic level to test for allergy, then have a urine test to screen for toxic metabolites, then pills are portioned in to small enough increments that the patient can gradually titrate up the dose: start at 1/100th a dose, if no problems go to 1/10, then 1/5, then 1/4, then 1/2, then 3/4, then full dose. If at any point the patient feels like its 'working' they pause dose increases. I really wonder if I had been on half the dosage or frequency if I would have had all of the therapeutic benefits without the gnarly side effects.

whatshisface• 7 years ago

I'd love to see pharma move towards a model where patients are started at a sub-therapeutic level to test for allergy, then have a urine test to screen for toxic metabolites, then pills are portioned in to small enough increments that the patient can gradually titrate up the dose: start at 1/100th a dose, if no problems go to 1/10, then 1/5, then 1/4, then 1/2, then 3/4, then full dose. If at any point the patient feels like its 'working' they pause dose increases.

How long would this take? It might work for some medications, but someone with horrible chronic pain might not want to wait.

neoplatonian• 7 years ago

"We don't measure the patients metabolism of a drug at all. Individuals bodies process drugs differently and have different side effects. It seems that differences in reactions could be related to different metabolic pathways being used, resulting in more or less toxic byproducts. Could a urine or blood test a few hours after the first dose be an effective mechanism for screening for likelihood of side effects based on the metabolic byproducts detected? Could this test be effective at detecting these byproducts at dosages below what would cause side effects? Could this be incorporated into a "home drug test" style urine dip that patient could do themselves at home without returning to doc?"

Strangely, just the other day I met someone in Cambridge (UK) who is moving forward with a startup solving this EXACT problem.

Let me know if you want me to connect.

rq1• 7 years ago

I’m not a medical doctor, so correct me if I’m wrong: opioid and drug tolerance is nowhere mentioned or only once in the article, but seems one of the reasons behind this pseudo addiction behaviour in several described cases, no?

Another question that comes to my mind is: if uncertain or under circumstantial evidence, would it be morally more acceptable to point to someone’s addiction at the risk of letting that person really suffer?

jimbokun• 7 years ago

"Has the medical community and psychiatry in particular grown over-accustomed — even ‘addicted’ to overusing, academically endorsing, and clinically propagating, the proxy diagnoses of ‘pseudoaddiction’ and ‘self-medication’ to avoid dealing with addiction itself? If so, what forces have contributed to this phenomenon? Do doctors believe these constructs help them avoid heaping the criminalizing stigma of ‘addiction’ onto their patients? Do these constructs excuse doctors from dealing with addiction, when so many of us, and most detrimentally, psychiatrists, don’t know how to treat it, or can’t get paid for doing so, or, are so often accustomed to prescribing addictive drugs for a wide variety of indications? Have there been too many incentives, and too many effective marketing campaigns from corporate interests that manufacture and sell addictive drugs like nicotine, opioids, benzodiazepines and stimulants, that have over-inflated their medicinal attributes to doctors and the public, while minimizing their addictive downsides?"

A string of five consecutive sentences ending with a question mark.

This seems similar to the "journalistic" technique of ending a head line with a question mark. So you have plausible deniability about claiming "X", you are just innocently raising the possibility "X?" for consideration.

But the headline gets clicks because the human brain sees "X?" but remembers "X" and repeats it, making it conventional wisdom.

So this journal article seems to be using a similar technique. Putting "?" at the end of each sentence, but never answering the question with strong evidence one way or another, just introducing the claim to the reader, who will come away vaguely remembering "pseudoaddiction is causing doctors to over prescribe opiods."

jnbiche6• 7 years ago

So you have plausible deniability about claiming "X", you are just innocently raising the possibility "X?" for consideration

I don't think there's much question after reading this article what the author thinks. He was fairly explicit about it.

Edit: Please disregard this response. I misread (or rather, failed to carefully read) the quote. Thanks to user zaroth for pointing it out.

zaroth• 7 years ago

To be clear, the author of the post (“Scott”) in this case is quoting from a journal article against pseudoaddiction which Scott finds highly dubious.

The highlighted string of theoretical questions from the article IMO greatly bolsters Scott’s case.

But then again, I think it would be really hard to find an SSC post which I strenuously disagreed with. And any SSC post on moral panic and media narratives is a sure 100% winner.

cwkoss4• 7 years ago

Isn't it preferable for writers to pose lower-confidence beliefs in the form of a question instead of as a definitive statement?

paulsutter2• 7 years ago

"Under-dosed" would avoid most of the trouble. If someone said "Maybe the patient isn't an addict, maybe they're under-dosed", anyone could understand this. Nobody would have philosophical debates about nuances between "under dosed" and "addicted", whereas it's no surprise people are skeptical when contrasting "pseudoaddiction" vs "addiction".

The author says "pseudoaddiction is as good [a term] as any other", but I disagree. Most of the trouble he describes could be avoided by using a more descriptive term. "Pseudoaddiction" doesn't even refer to the patient, it's about second-guessing a diagnosis, which makes it really difficult to contrast.

noodlenotes• 7 years ago

I agree. The prefix "pseudo" implies that there is some normal behavior (addiction) and faked behavior (pseudoaddiction). But it's the other way around. Wanting medication for legitimate reasons should be the normal behavior and faking it (addiction) the pseudo behavior.

cat199• 7 years ago

not defending the term or the pharma behavior, but pseudo can also mean 'similar to' or 'having the appearance of', especially in an academic context

TheSpiceIsLife• 7 years ago

Here in Australia, addiction is a real medical diagnosis.[1]

Drug addiction is a real problem that often calls for initial treatment with controlled dosing of a drug in the same class.

1. https://www.healthdirect.gov.au/what-is-addiction

kelnos4• 7 years ago

A commenter on the post says something similar, and the author replied that it's about more than just dosage: https://slatestarcodex.com/2019/09/16/against-against-pseudo...

paulsutter2• 7 years ago

Surely there’s an even better descriptive name than “under-dosed”, I just meant it as an example of a more descriptive name.

Pseudo-addiction is a bad bad term. I get my brain into an inception-level loop if I try to contrast pseudo-addiction to addicting, even clearly knowing the definitions.

std_throwaway• 7 years ago

But the term "under-dosed" suggests an error on the doctor's part. We can't accept that.

bonoboTP• 7 years ago

Yes, if the doctor admits to a mistake, they are open to getting sued.

ohazi• 7 years ago

Speaking of dubious medical shenanigans... did you know that the "Medical Advertising Hall of Fame" is a real thing?

https://www.mahf.com/

I came across this after reading yesterday's story on the Purdue bankruptcy. I'm not easily phased, but jeez... seriously?

refurb3• 7 years ago

Looking at their award winners, it looks like a lot of those ads were aimed at doctors, which makes it a little less concerning.

ianbicking• 7 years ago

I couldn't find the link, but some years ago I listened to a talk on the Cato Daily Podcast (https://www.cato.org/archives/type/multimedia/category/9390) from a doctor, describing his experience with opioids. The doctor said that, having read medical literature, he believed that exponential increases in opioid dosage were an appropriate response. So (exact mathematics aside) if a dose wasn't sufficient for a patient, then you double the dosage. And double it again, and again, and again as necessary. This was not the conventional wisdom, so he was prescribing much much higher doses than was typical.

Was this approach to dosing correct? Maybe? It was unclear to me if people eventually reached an appropriate dosage and then held steady.

From there of course patients sought him out for their pain management, people who had constant chronic pain, because he was willing to offer a treatment other doctors were not.

Eventually there was concern about opioids, and this doctor's very high prescriptions quickly became noticed. He was shut down. Without access to the pain treatment he was willing to provide (and other doctors were not) several of his patients committed suicide.

I still don't know what I think about the whole story. What is a manageable amount of pain? Are individuals able to identify the boundary between pain management and... whatever other experience we consider to be an inappropriate use of opioids? Because you could be "addicted" to opioids while only using them for pain management, i.e., only trying to achieve a comfortable existence.

If we believe individuals can self-determine the boundary between appropriate and inappropriate use, how then do we trust individuals to report on this? Especially if we believe that addiction makes a person untrustworthy, maybe even to themselves.

And how do we rate pain, when for so many cases it is genuinely subjective? Like, we have no way to see what pain a person experiences except for them to tell us, maybe relating it to a more objective experience (like: does this hurt more or less than a bee sting?) (Does everyone even have shared experiences that cover the necessary range of pain?)

I don't really buy Cato's relatively extreme perspective on this (that we should let people do whatever they feel is right, and that all the harm is from restrictions that lead people to dangerous substitutes). But there's clearly some hard philosophical questions here to consider.

mindslight2• 7 years ago

Whenever you hear the term "drug seeking behavior", imagine instead you're hearing a term "food seeking behavior" being used to describe someone at a grocery store. People "seek" things they think they need, duh.

People wouldn't "seek" drugs at the doctor if they could simply buy them at the store. Even if you believe the current regime of controlling access is worthwhile (debatable), then you still have to accept that many patients are going to apply themselves to solving their own problems more than any doctor during a half an hour visit. They may not necessarily be correct, but it is a better default attitude than removing their agency.

Tangentially but not really, I feel like a large part of this outrage fest against Purdue Pharma is a media-scapegoat to deflate attention from 1. Ongoing price gouging by the rest of the pharmaceutical industry and 2. The large spike in street opioids even before the fentanyl epidemic, likely due to invading Afghanistan.

emiliobumachar• 7 years ago

The large spike in street opioids even before the fentanyl epidemic, likely due to invading Afghanistan.

Sorry, that flew over my head. How would the invasion have caused the spike?

mindslight2• 7 years ago

https://en.wikipedia.org/wiki/CIA_involvement_in_Contra_coca...

cwkoss4• 7 years ago

It would be really interesting to do a "UBI"-like study where a select group of chronic pain-managed patents are given full control of their prescribed drug and dose for ~6 months and study if they have worse outcomes than a control group under normal pain management guidelines.

One could make the argument that insufficient dosage would increase the chance of the patient seeking drugs outside of the pharmaceutical system. How does the magnitude of the risk of using impure black market drugs compare to the risk of overprescription? Fentanyl cuts are extremely dangerous. Would the average pain-managed patient choose to increase their dose perpetually, or do they reach a plateau? What percentage of patients would have their lives ruined by carte blanche prescriptions? 80% would certainly justify our current regime, but if it's only ~5%, perhaps those 5% already have identifiable confounding risks that could be screened out. Perhaps those 5% would seek drugs on the black market anyways, and thus giving them access to a clean source would be a legitimate harm reduction intervention.

Similarly, I wonder if anyone has ever studied giving prescription opiates to heroin users. It seems like if they could get ~80% of their normal dose legally and without hassle, some might voluntarily choose to stop purchasing from the black market. Heck, I'd imagine many would tolerate quite a bit of hassle, could probably get them to discuss their long term plan for treatment with a health profession before getting each refill. "Do you intend to take opiates forever? Is there anything I can do to help you taper your dose? No? well here's your refill, lets talk again in a couple weeks."

the_gipsy2• 7 years ago

I've found that a lot of doctors have this attitude of letting patients suffer, as if a bit of pain is good for you. I can't help but think it's also an ego thing, never let the stupid patient have a say in what could be right for him. After all, the patient hasn't studied medicine.

The good thing is that there are now more studies of pain. It's subjective and not measurable. Sure we can't give out morphine like vitamin supplements, but there's no need for unnecessary pain.

KenanSulayman• 7 years ago

a bit of pain is good for you

But this is it. A bit of pain is good for you. That applies to everything in life.

colechristensen3• 7 years ago

Attitudes towards pain are cultural and can vary wildly.

"letting patients suffer" is a very telling sign of one attitude, but it isn't the only one, and not necessarily right or wrong.

Wanting to avoid discomfort at all costs is a very American trait as is its opposite attitude glorifying discomfort. There are more than two directions.

prepend3• 7 years ago

Not to delve too deeply into relativism and who can truly know right and wrong, but I think that as a cultural aspect letting patients suffer is bad and if a culture accepts that it may be an area for improvement within that culture.

Of course there are situations where suffering is necessary or cannot be prevented, but I don’t think preventing suffering and pain is a very American trait.

the_gipsy2• 7 years ago

The attitude stems from the belief that if you suffer in this life, you'll be rewarded in the next.

Western culture as a whole has moved on, not only the american.

hoseja• 7 years ago

Yep, sounds like doctors. That's what you get when you take compassion out of medicine and replace it with cash.

peterwwillis• 7 years ago

tl;dr "you should treat reporting on medical, scientific, and social scientific topics as having less than zero credibility"

Well, yeah. You should treat all reporting as having zero credibility. Otherwise people will believe anything they read, especially if more than one source reports it. This is a logical fallacy.

A lot of people have reported being abducted by aliens. So far, not much proof. But if the biggest media companies all reported tomorrow that a guy in Kansas got abducted by aliens, everyone would just buy it immediately.

Nothing is true until it has been proven.

mnm1• 7 years ago

Addict or pseudoaddict, the solution is the same. Give them a supervised dose as necessary and provide support and encouragement for them to stop if they wish. Anything else and the patient will turn to the black market. It's that simple. You want to stop people dying, provide them with opiates so they don't get fentanyl laced garbage from some street dealer. Anything else is, frankly, just torturing the patient, often in the name of morality when this is not at all a moral issue. One day people will realize this. Until then, addicts will die by the thousands. Some places have already realized this (Portugal, Switzerland, Vancouver BC, and even the US before the war on drugs started early last century).

peteretep2• 7 years ago

Addict or pseudoaddict, the solution is the same. Give them [it]

Exactly. If someone shows up at your clinic wanting drugs that you think they're addicted to -- especially ones that are cheap generic -- are you really preventing harm by not giving it to them?

projektfu4• 7 years ago

Unfortunately we carry a second responsibility to help the DEA control drugs, and the scope of our liability is ill-defined. We need to make medically justifiable choices at each point to retain the privilege of legally prescribing or dispensing controlled substances. I will err on the side of not dispensing opioids to someone I don’t know or a case I’m not familiar with.

kunday4• 7 years ago

I agree with you on principle. In real terms but a PCP who sees you regularly is more likely to take steps towards tapering dosage. If you see someone for the first time and you ask for a particular medication that's scheduled, unless they call the previous PCP to get old diagnosis and dosage etc to make sure things are in order.

PS: I'm not in the states, but in Australia, where things are quite different.

Edit: fix grammar and typo

kunday4• 7 years ago

Yup! I am still lost with the approach to treating opioid addiction.

For example, benzodiazepine class drugs have a very defined dosage reduction schedule and it's never discontinued right away just because of drug seeking behavior. Same with anti-depressants(the Wellbutrin kind) where dependance Is very real and expected.

anm895• 7 years ago

Theoughout my life, I've ended up on opiate painkillers a handful of times, after broken bones or surgeries or whatnot. I have absolutely no history of addiction and never used them innapropriately but I realized how effective the pain relief was and id save them in case I have a snowboarding or mountain biking accident and don't want to go begging for meds for this exact reason.

So finally I run out over time and then later that summer I severely sprain my ankle rock climbing. I'm in excruciating pain which has to be pretty obvious to the urgent Care I'm at and I'll I'm thinking about is how to act as responsible and non addictey as possible so I can get a few pills and the next week won't be a living nightmare. So I drop the question and the mood instantly changes. I'm treated with suspicion for the rest of the appointment and the conversation is quick to the point of being rude.

And why? Because I didn't have the correct back story for my pain. And then the doctors put on this self righteous paternalistic act like they are taking the only accepted medical action which is in my interest by not listening to my subjective opinion of my own subjective experience.

What an infuriating experience and one of the first tough lessons I learned in my life about not relying too heavily on the medical system.

missosoup• 7 years ago

Same thing for mental health medication.

The hilarious thing is all the druggies and doc shoppers know exactly what kind of stories to tell to get what they need. It's just honest people with honest issues that suffer.

The entire concept of General Practitioner needs to be overhauled. They are poor at diagnosis and poor at choosing medication regimes. The fact that most come with a 'holier than thou' attitude is just icing on the cake.

I had a GP accuse me of shopping for roids and had to open google and show him that yes corticosteroids are in fact a first line treatment for heel spur.

empath752• 7 years ago

To be honest, wanting opiates for an ankle sprain is a little bit concerning. While painful, there’s nothing about it that typically warrants a potentially addictive substance over just some bedrest and normal pain killers like ibuprofen.

anm895• 7 years ago

Case in point, some paternalistic jerk (that's you), without knowing anything about the situation (my ankle was facing the wrong direction, I couldn't walk for a month, the pain was worse than bones I've broken no question) is going to present some totally subjective opinion regarding the morality of a treatment option as a some kind of medical opinion and claim that it's validity outweighs that of my own experience of my own pain.

Exactly the reason I solve these issues for myself and don't rely solely on the medical system, because I'd run the risk of being reliant on some paternalistic schmuck like you at a time when I need a better option.

If you find that "a little but concerning" and think that I should have to deal with terrible pain because the way I'd prefer to be treated hurts your sensibilities, you can respectfully go fuck yourself.

CPLX• 7 years ago

never used them innapropriately
I’d save them

Worth noting that by the definition a doctor would use these two observations are incompatible.

obituary_latte2• 7 years ago

“Save” as in “not take/require” the entire prescription is not the same as hoarding. And then rarely dipping into the extra supply as needed is not the same as abusing. However, I agree that many (most, probably) doctors probably do see it as unacceptable behavior.

anm895• 7 years ago

I totally acknowledge that many in the medical field would agree.

I never agreed to make them the arbiters of what I can and cannot put in my own body.

lacker3• 7 years ago

Honestly, and I say this with no judgment, I think you are treading a dangerous path. It isn’t like you’re a bad person for keeping some opioids around in case you feel some pain later. But opioids are really dangerous drugs. A lot more dangerous than anyone realized a couple decades ago.

If I were you, I would throw away my extra opioids and in the future, when you need pain relief, consider avoiding the opioids, even if the doctor says it’s okay. The opioid epidemic is real and even if we don’t know how to stop it, we can at least prevent it from hitting ourselves, by avoiding opioids.

anm895• 7 years ago

I respect your opinion completely. And as long you don't try to forcefully it impose it on me then there's nothing wrong with it.

When arbitrary opinions like this start having real effects on my ability to get treatments or get medications which provide real world benefits to me, then I take serious issue with it.

dcolkitt• 7 years ago

Opiates are also a fun and addictive drug. As long as they exist and are generally available, some percent of the sub-population will abuse them. We can try our best to keep them only for medical use, but once the prescription leaves the pharmacy there's not much you can do. You can't blame the legal manufacturer when that happens, if they took all required steps to keep their drugs in the legal channels. Maybe you think that's true, but that the opiate manufacturers have used their power and influence to over-prescribe their products. That assumes that opiates are over-utilized in American healthcare. And that's a narrative that simply isn't borne out by the data.

Only 0.19% of opiate-treated chronic pain patients without a prior history develop any form of abuse or addiction[1]. And remember these are chronic-pain patients who take tolerance-escalating doses over years or even decades. Virtually no one develops an opiate addiction from following their medically prescribed treatment regiment.

The death rate from prescription opiates has not budged since 2006[2]. The vast majority of opiate overdoses in America are not prescription opiates, but illicit fentanyl, and to a lesser extent heroin and methadone. Nor do chronic pain patients face any major risk of overdose. The fatal overdose mortality rate for long-term opiate-prescribed patients is 17 per 100,000[3]. And that number doesn't exclude the subset of the population engaged in abusive behavior like mixing with alcohol, snorting pills, or hoarding medication.

Finally the sizable majority of prescription drug abusers in this country do not source from a doctor or the healthcare system at all. The vast majority get their drugs either from the black market or a friend or relative. On the National Drug Use Survey only 18% of prescription drug abusers report doctors as their primary source. And among street prostitutes (a high at-risk group) only 5%[4].

All of this goes to show that there is very little evidence of any sort of over-prescription of opiates in America. To begin with the vast majority of the opiate crisis has to do with fentanyl, not prescription drugs. But even when it comes to prescription drug abuse, the intersection with medical users is vanishingly small.

However what there is a major problem in America is untreated chronic pain. 50 million American suffer chronic pain[5]. And 20 million suffer high-impact chronic pain which severely impairs normal life function. More than 10% of suicides are linked to chronic pain[6]. High-dosage opiates are absolutely essential for this group to live any sort of normal life. As long as there are such massive numbers of legitimate pain patients, the law of large numbers guarantees a large supply of diverted opiates. Even under the tightest controls. There's simply no way around that except by denying most of the legitimate patients treatment for their debilitating conditions.

[1] https://www.ncbi.nlm.nih.gov/pubmed/18489635 [2] http://www.ncsl.org/portals/1/documents/health/APeeples0118_... [3] https://annals.org/aim/article-abstract/745518/opioid-prescr... [4] http://sci-hub.tw/https://www.tandfonline.com/doi/abs/10.108... [5] https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.html [6] https://www.ehidc.org/sites/default/files/resources/files/Ch...

dr_dshiv• 7 years ago

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”.

bill_from_tampa• 7 years ago

"Pseudo-addiction" is a very bad term and should never have been concocted. A more correct term would be "inadequately treated". Calling a person suffering from pain who reasonably desires relief from pain a "pseudoaddict" shifts the 'blame' and actual problem from the source of the problem (the doctor who is not adequately treating the pain) onto the patient -- like there is something wrong with the patient rather than something wrong with the doctor (inadequate skill in managing pain).

I'm a retired physician who prescribed opiates for decades and have seen how persons with inadequately controlled pain behave. This problem is created by (1) not having adequate treatment facilities and funding for such treatment for actual addicts, and (2) draconian drug laws that encourage addicts to visit physicians and pretend to have pain so they can get a high-quality safer supply of the desire of their addiction.

The problem is not 'pseudoaddiction', but rather 'pseudopain' behaviors that addicts have been trained to display. It is a glass half full vs half empty sort of problem, but using a term (pseudoaddiction) to describe a failure of medical treatment just seems perverse to me.

Against Against Pseudoaddiction

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