Differentiating Between Addiction and Pseudoaddiction

Posted on Friday, February the 19th at 9:31pm

Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

No one undergoing chronic pain management starts out with the goal of becoming addicted to their pain medication; nevertheless it happens at least 10% of the time. If someone has a family or personal history of addiction or mental health conditions, they have a higher risk of racing through the progression of addiction. 

People at risk for addiction react differently from the very first experience of taking pain medication. With ongoing exposure they experience the “seeking reaching” stage, at which time doctor shopping can begin. There are many questions to be addressed when treating someone who has chronic pain and coexisting substance use disorders. The three most important ones I talk about at my Addiction-Free Pain Management® trainings are these:

1.    Are we managing pain but fueling the addiction?
2.    Are we treating the addiction but sabotaging the pain management?
3.    Is it addiction or pseudoaddiction?

The term pseudoaddiction is fairly new to the addiction treatment field but has been used in pain management for quite some time now. What is important to remember is that even though pseudoaddiction looks like addiction, it is actually caused by an undertreated or mistreated chronic pain condition. However, the treatment plan for pseudoaddiction and addiction is identical. The major danger of pseudoaddiction is that if it is not adequately addressed, it will turn into full blown addiction—sometimes quickly, sometimes slowly.

In 2004 the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine collaborated on defining pseudoaddiction: Behaviors that may occur when pain is undertreated.  Patients with unrelieved pain may become focused on obtaining medications, may "clock watch," and may otherwise seem inappropriately "drug seeking."  Even behaviors such as illicit drug use and deception can occur in the patient's efforts to obtain relief.

I have worked with many patients over the years who were labeled prescription drug addicts when the correct diagnosis was pseudoaddiction. One patient, Sharon, is an example of how damaging a misdiagnosis can be. Sharon was in her early forties and came from a fairly normal and religious upbringing. She had never used alcohol or any other drugs, including nicotine, and up until a few years ago had never used psychoactive prescription medications either.

A few years before I started working with Sharon she began having infrequent migraine headaches.  She went to her general practitioner and was given Vicodin to help with the pain which worked for a time. Sharon later discovered she would have been better off using migraine specific medication.  Although barbiturates and opioids are sometimes considered effective for short-term migraine relief, many doctors are now recommending against prescribing this type of medication for long-term use.  The risks for potential dependence and abuse are too high and there is a real danger of developing medication overuse headaches (sometimes called pain rebound or transformed migraines).

Because transformed migraines are difficult to diagnose, many people are not being treated appropriately. Treatment is further complicated by the chronic nature of migraine headaches. People with transformed migraines may overuse pain relievers, both prescription and over-the-counter, on a daily basis with or without having a headache. This puts them at risk for building a tolerance to the drugs. Additionally, taking too many pain relievers containing caffeine can also lead to rebound headaches.

Sharon’s migraines became more frequent and she had to take more and more medication to get any relief. As the dose increased, her family and then her doctor became concerned that she had become “addicted” to the Vicodin. Sharon’s doctor told her he couldn’t help her anymore unless she went into an addiction treatment program. Her family found a one that said they treated pain and prescription drug addiction. This is when Sharon’s nightmare began. While detoxing from the Vicodin, Sharon was forced to stand up in front of groups and identify herself as a drug addict. She was not even allowed to say she was a prescription drug addict, which was humiliating for this very conservative woman. 

After Sharon was off all her medications, the migraines kept coming back. To add insult to injury, when she asked for help with the migraines the program said she was “drug seeking” and all she needed to do was “turn it over” and work the steps. Even though I’m a big advocate of a 12-Step approach for people with addictive disorders, it can be dangerous to label or advise chronic pain patients in this way. 

Sharon was discharged from that program with a letter to her doctor stating she was an addict and should not be given opiates anymore. When she became depressed and near suicidal her family got Sharon into the pain clinic I was consulting for. I met with Sharon several times, assessed her case and discovered her diagnosis was not addiction; but pseudoaddiction.

As mentioned above, Pseudoaddiction describes patient behaviors that may occur when pain is under-treated. Patients with unrelieved pain may become focused on obtaining medications, clock watch, or otherwise seem to be inappropriately drug seeking. Even such behaviors as illicit drug use and deception can occur if the patient's efforts to obtain relief are unsuccessful. Pseudoaddiction can be distinguished from true addiction in that the behaviors disappear once the pain is effectively treated.

This was the case for Sharon. The pain clinic decided to use migraine specific medications since opiates are contra indicated for ongoing migraine treatment. There are seven triptans (Imitrex, Maxalt, Zomig, Amerge, Axert, Frova, and Relpax) that were developed as migraine abortive (management) medications and approved by the FDA. These medications work to stop the migrainous process in the brain and stop an attack with its associated symptoms. 

Sharon responded well to Maxalt, but she also was put on a preventative medication. Ergotamine medications such as DHE and Migranal, are used as vasoconstrictors for migraine prevention and sometimes mixed with caffeine. They are also FDA approved for migraine treatment as is Midrin (a combination of acetaminophen, dichloralphenazone, and isometheptene). Sharon was also prescribed Migranal. Because of these two medications, her migraines were now being effectively managed.

Sharon was also prescribed an SSRI antidepressant as I implemented a cognitive behavioral therapy plan for the depression and pain-focused psychotherapy for pain management. Today Sharon is once again experiencing a great quality of life, but still has nightmares about her time at the treatment center. Getting back to my original three questions; Sharon’s general practitioner was at risk of fueling addiction and the addiction treatment program definitely sabotaged her pain management. 

When working with patients who have chronic pain and coexisting addictive disorders it is important to conduct multidisciplinary assessments and be open to discovering whether a patient is experiencing addiction or pseudoaddiction. Sharon experienced pseudoaddiction—not addiction—as everyone thought. Once Sharon was placed on an appropriate migraine medication management plan, along with cognitive behavioral therapy to address the psychological pain symptoms, her quality of life improved dramatically and her migraine episodes lessened both in frequency and intensity.