
Against Against Pseudoaddiction - jerf
https://slatestarcodex.com/2019/09/16/against-against-pseudoaddiction/
======
paulsutter
"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
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
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

~~~
ozzmotik
that seems more appropriate for quasi but i could see how pseudo might be used
in such a manner

------
anm89
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.

~~~
CPLX
> never used them innapropriately

> I’d save them

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

~~~
obituary_latte
“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.

~~~
empath75
I got Vicodin after an appendectomy. I took 3 total I think. I threw away the
rest. I didn’t want them around the house.

The odds of you ‘needing’ spare opiates in the house are pretty small unless
you’re frequently doing impromptu field surgery.

------
l_t
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.

~~~
jnbiche
> 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...](https://annals.org/aim/fullarticle/2702061/chronic-pain-among-
suicide-decedents-2003-2014-findings-from-national)

~~~
munk-a
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.

~~~
jnbiche
> This is part of the cause of this epidemic, people were _entirely falsely_
> prescribed an ineffective medication that has heavy side effects.

It really depends. Opiates work for some people, with some conditions. People
should have the choice, just like with MJ. For me, one opiate worked, and
another didn't (and made things worse. it was Oxycontin, incidentally, haven't
taken it in many years).

Also, people with chronic pain take opiate breaks for the reasons of tolerance
you describe.

And yes, I've heard MJ works for many people (I've never tried it for my
conditions, since it's still not legal where I live. Also, I tried it a couple
of times in college and hated how it made me feel, no way I could work on MJ).
But I'm very happy it works for your spouse and that she's able to obtain it.
Chronic pain is brutal. If MJ is ever legalized where I live I might try it
just to see if it works.

~~~
fucking_tragedy
> _It really depends._

In the past, throwing opioids at chronic pain patients and calling it a day
was par for the course.

Now, there's a level of awareness that not only are opioids not very good for
managing chronic pain all of the time, they can even make pain sensitivity
worse in the long-run.

Criminalizing pain patients is disgusting, but I'm hoping we can reach an
equilibrium where those who have chronic pain are able to seek adequate
treatment and opioids aren't the first line of treatment or overprescribed.

As someone with family members suffering from chronic pain, I know several
people who have switched to MMJ or CBD supplements with great success. One of
them took pain killers for decades and hasn't needed them in years because of
CBD.

CBD won't affect you cognitively, if you have the time, money and your doctor
thinks it's a good idea, it wouldn't hurt to give it a go.

------
tempestn
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.)

~~~
simplecomplex
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.

~~~
jnbiche
> 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.

~~~
simplecomplex
> You know what's one thing that makes people very unhappy with their lives?
> Severe chronic pain.

That's my point. Having taken an opiate actually has little to do with whether
they form an addiction. So we shouldn't be focused on restricting supply to
treat and prevent addiction.

> Any flesh and blood human will become dependent on opiates after a few
> weeks.

Yes, if by dependency you're referring to withdrawal symptoms or tolerance.
Opioid addiction however varies wildly depending on the demographic, despite
all having consumed opioids. It's not the act of taking opioids that predicts
whether someone becomes addicted. Research points to addiction not being
caused by the drugs themselves. This isn't surprising when you consider that
humans get addicted to such a wide variety of totally unrelated chemical
combinations. When you think about it, isn't it a little suspicious that
almost any chemical that can be consumed is potentially addictive? That
strongly suggests that addiction is not about the drugs really, and research
is finally corroborating this.

Having said that, now think about the fact that all food is drugs (chemicals
that affect and manipulate your biology) and it becomes apparent that
addiction is a much much bigger issue than one might assume when only thinking
about things like Oxy and booze as drugs. If one qualifies harmful diet as
drug addiction it turns out the majority of our society is suffering from
addiction. But there's very little research going on in this area, despite
diet probably being the most prevalent and harmful form of drug addiction. You
can't unsee it. The similarity between someone talking about their struggles
with poor diet ("but that cheeseburger/cheetos/soda/etc. is all I have, can't
I have just one thing to look forward to?") and someone talking about
alcoholism or smoking is almost indistinguishable.

------
scrumper
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
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.

~~~
kelnos
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?

~~~
taneq
And a follow-up question: Would it help? Many of the examples given were for
non-addictive drugs, the deciding factor seems purely to be whether you’re
adamant that you need the drug. Especially awful are the examples involving
diabetics being denied insulin.

~~~
zamadatix
Both need to be solved but the problem spaces of "the doctor wants to you to
come for an appointment the next day" and "the doctor thinks you're addicted
so won't prescribe you anything" are completely unrelated and I don't really
see how the former ended up in this article.

Solving pain relief without being labeled an addict certainly shows value even
if you have to inconveniently schedule an appointment to be prescribed.

------
mindslight
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
> 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?

~~~
mindslight
[https://en.wikipedia.org/wiki/CIA_involvement_in_Contra_coca...](https://en.wikipedia.org/wiki/CIA_involvement_in_Contra_cocaine_trafficking)

------
cwkoss
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."

------
mnm1
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).

~~~
peteretep
> 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?

~~~
projektfu
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.

~~~
kunday
Glad to hear from an actual doctor. Is it common practice to get previous
medical history and notes if you are seeing someone for the first time who has
been under someone else's care? Or are there strange laws preventing you from
getting the continuity information from the other doc? In Australia once we
give consent, the other clinic/hospital would release notes electronically.
Sometimes it's also a quick check with state PBS registration to get
confirmation on dosage already being prescribed.

PS: based on my personal experience in Australia, not for opioids but for
other controlled substances like amphetamines or ritalin.

~~~
projektfu
I'm a veterinarian by the way.

Yes, you can get medical records. They're not as easy to get in an emergency
situation, which is how drug-seeking (and I assume pseudoaddiction) presents
itself. Sometimes the bizarre extremeness of the situation makes you skeptical
enough. For example, "The dog needs the meds for a trip tomorrow from Georgia
to a remote part of the Pacific Northwest and it will be in excruciating pain
and anxiety if you don't prescribe three months worth right now," and it's 6pm
on a Friday evening.

~~~
kunday
Gotcha, that’s super shady. My friend who used to be pharmacist said, he can
guess fraudulent prescriptions, because they were always the one just before
the pharmacy was about to shut doors and has a prescription that will lead him
to empty the full pill box behind the counter.

------
mrosett
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
_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.

------
dr_dshiv
>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”.

------
the_gipsy
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.

~~~
colechristensen
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.

~~~
prepend
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.

~~~
colechristensen
I meant something different.

The link between physical sensations of discomfort and pain and the conscious
experience of suffering is not constant across individuals or situation and is
correlated with cultural differences. I'm trying to create a distinction
between pain and suffering (perhaps there are better words).

Western cultures and Americans in particular have a generally much stronger
association of pain and suffering and expect that everyone else does too.

As an example, if you took me and a random life-long resident of the bay area
and dropped us, appropriately dressed, into a 5 degrees F day outside for an
hour, we would have very different experiences because I grew up in a cold
climate and I just like it. I don't think my nerves work any differently or
that any physical sensation I received would be different than anybody else's
-- but my attitude towards cold and my feelings about the sensations are very
much different than someone who spends most of their life in 65-90F.

Pain is information and your attitudes and experiences will change how you
perceive it. The sensation is universal but its interpretation is not. You
don't have to push nerve chemistry around with drugs to alleviate suffering.
It is certainly useful in some circumstances, necessary in others, but not all
circumstances and some cultures and some people put much to high a value on
eliminating the sensation as opposed to treating and improving the downstream
conscious and unconscious perception of it.

~~~
forgottenpass
5°? That's basically hoodie weather.

~~~
prepend
I went on a trip recently with some family and the weather was 5-10 but sunny.
Not bad at all. My partner kept remarking how freezing it was and miserable.
When mentioning this to locals we got conversations how it was midsummer and
beautiful weather.

------
jimbokun
"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."

~~~
jnbiche
> 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
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.

------
ianbicking
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](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.

------
bill_from_tampa
"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.

------
peterwwillis
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.

------
hinkley
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?

~~~
tachyonbeam
> 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
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.

------
rq1
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?

------
joe_the_user
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".

~~~
astine
" _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
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."

~~~
astine
Except that the pseudoaddiction isn't the misdiagnosis. The pseudoaddiction is
the collection of behaviors that have been misdiagnosed. Someone else in this
thread said 'underdosing,' and I think that gets at the idea better.

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

[https://www.mahf.com/](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?

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

------
dcolkitt
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](https://www.ncbi.nlm.nih.gov/pubmed/18489635)
[2]
[http://www.ncsl.org/portals/1/documents/health/APeeples0118_...](http://www.ncsl.org/portals/1/documents/health/APeeples0118_32103.pdf)
[3] [https://annals.org/aim/article-abstract/745518/opioid-
prescr...](https://annals.org/aim/article-abstract/745518/opioid-
prescriptions-chronic-pain-overdose-cohort-study) [4] [http://sci-
hub.tw/https://www.tandfonline.com/doi/abs/10.108...](http://sci-
hub.tw/https://www.tandfonline.com/doi/abs/10.1080/10550880903182986) [5]
[https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.html](https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.html)
[6]
[https://www.ehidc.org/sites/default/files/resources/files/Ch...](https://www.ehidc.org/sites/default/files/resources/files/Chronic%20Pain%20and%20Suicide.pdf)

