There are many questions to be addressed when treating someone who has chronic pain and coexisting substance use disorders.  I start most of my Addiction-Free Pain Management™ trainings with three questions:

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 a while now.  I’ve worked with many patients who where labeled as prescription drug addicts when in fact it was pseudoaddiction.  One patient, Sharon is a great 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 and up until a few years ago she had never used any psychoactive prescription medications either.

About three years ago Sharon began having infrequent migraine headaches.  She went to her general practitioner and was given Vicodin to help her cope.  This worked for her at the time, but we now know that she would have been better off on migraine specific medication.  Although barbiturates and opioids are sometimes considered effective for short-term migraine relief, many doctors recommend against prescribing them for long-term use because of the potential for dependence and abuse and the very real danger of developing medication overuse headaches (this is sometimes called pain rebound).

Sharon’s migraines started coming more frequently and she eventually needed to take more and more to get any relief.  As the dose increased her family and then her doctor became concerned that she had become “addicted” to the Vicodin.  Her doctor told her he couldn’t help her anymore unless she went into an addiction treatment program.  Her family found a program that advertised treating pain and prescription drug addiction.  That’s when Sharon’s nightmare began.  As she was detoxing from the Vicodin, the treatment center made her stand up in front of groups and identify herself as a drug addict.  They wouldn’t even let her say she was a prescription drug addict, which was humiliating for this very conservative woman.  

Unfortunately her migraines kept coming back after she was off all her medications.  To add insult to injury, when she asked for help they said she was just “drug seeking” and needed to “turn it over” and work the steps.  Even though I’m a big advocate of 12-Step support for people with addictive disorders, it can be dangerous for support groups, or treatment programs based in the 12-Step program to either label or advise chronic pain patients. 

Sharon was discharged from this program and with a letter to her doctor stating she was an addict and shouldn’t be given opiates anymore.  She became extremely depressed and near suicidal.  That’s when her family entered her into the pain clinic I was consulting for.  I met with Sharon several times and assessed her case.  I discovered her diagnosis never was an addictive disorder; she suffered from pseudoaddiction.

Pseudoaddiction is a term which has been used to describe 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 in the patient’s efforts to obtain relief.  Pseudoaddiction can be distinguished from true addiction in that the behaviors will resolve when the pain is effectively treated.

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

Sharon responded well to Maxalt, but she also was put on preventative medication.  Ergotamine medications (used as vasoconstrictors for migraine prevention and are sometimes mixed with caffeine) such as DHE and Migranal; 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 being in the treatment program.

I want to add that it is crucial to conduct multidisciplinary assessments and keep an open mind to discover whether a patient is experiencing addiction or pseudoaddiction.  Going 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.  Sharon was experiencing pseudoaddiction—not addiction as everyone thought.  All of her addiction symptoms disappeared when she followed an appropriate and effective medication management plan, which enabled her to manage her migraines appropriately.

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