BOSTON – Adolescents with undertreated chronic pain may develop pseudoaddiction to their pain medications, which would involve the demonstration of drug-seeking behaviors that are easy to confuse with true addiction.
“These symptoms can be very confusing,” Dr. John Knight said at the annual meeting of the American Academy of Pediatrics. “Virtually 100% of patients who get opioids for chronic pain will develop two signs of true drug dependence: physiologic tolerance and withdrawal symptoms if the drug is removed. But if you only have these two signs, that is not addiction.”
According to the Diagnostic and Statistical Manual IV, psychosocial symptoms must also be part of the clinical picture. These include the devotion of exorbitant amounts of time and energy to obtaining the drug; the relinquishment of important social, recreational, or occupational activities in favor of using the drug; and its continued use despite the understanding that it causes harmful effects. “Adolescents with pseudoaddiction are unlikely to engage in these sorts of behaviors,” said Dr. Knight, director of the Center for Adolescent Substance Abuse Research, Children's Hospital, Boston.
However, he said, the symptoms of pseudoaddiction can be alarming. Teens with pseudoaddiction will try to increase their drug supply to help better manage their pain. Behaviors commonly seen are hoarding of medication, requesting only specific drugs, increasing dosage without a physician consult, obtaining multiple prescriptions from different sources, and complaining about an increasing need for more drugs to obtain pain relief (J. Pain Symptom Manage. 1997;14:S27–35).
In cases of suspected pseudoaddiction, “I have a very low threshold for consultation. At a minimum, you need a pain management specialist and an addiction psychiatrist on your treatment team to help manage this,” he said. It's critical to maximize pain relief with supportive treatments. “Make sure you're providing adequate analgesia. You might need to add another narcotic, increase the dose, or switch to a longer-acting form or another medication.” Physical therapy can also play an important role in minimizing chronic pain, he added.
All chronic pain treatment plans require a monitoring component, he stressed. This includes parental pill counts and regular urine drug testing.
“These patients with insufficiently treated pain are going to try to ensure their supply of medication, but they are not usually going to engage in 'street behaviors' to get it,” Dr. Knight said.
“The street behaviors are much more suggestive of true drug dependence.” Patients with true addiction are more likely to sell their medication, steal medication or forge prescriptions, use illegal drugs or alcohol in combination with the prescribed drug, grind their pills for snorting or injecting, and obtain prescription drugs illegally.
Sometimes parents can unwittingly contribute to pseudoaddiction, he noted. Parents are understandably concerned when their child receives treatment with narcotic drugs and may limit the dosage to try to avoid addiction. When this happens, their children might have suboptimal pain relief and then display worrisome drug-seeking behaviors. Teens can also become resentful, feeling that the parent doesn't trust them to take medication appropriately and causes additional pain by withholding necessary medication. In cases like this, education is vital, Dr. Knight said.
“The parent needs to understand how important it is for the child to take the drug exactly as prescribed, and that although there is a risk of dependence, the risk is very low as long as we carefully monitor the amount of drug given.”
A written contract is a good way to help stress the importance of accurate dosing on both parents and patients, Dr. Knight suggested.
Patients with insufficiently treated pain usually won't engage in 'street behaviors.' DR. KNIGHT