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Against Against Pseudoaddiction

I.

“Pseudoaddiction” is one of the standard beats every article on the opioid crisis has to hit. Pharma companies (the story goes) invented a concept called “pseudoaddiction”, which looks exactly like addiction, except it means you just need to give the patient more drugs. Bizarrely gullible doctors went along with this and increased prescriptions for their addicted patients. For example, from a letter in the Wall Street Journal:

Parroting Big Pharma’s excuses about FDA oversight and black-box warnings only discounts how companies like Johnson & Johnson engaged in pervasive misinformation campaigns and even promoted a theory of “pseudoaddiction” to encourage doctors to prescribe even more opioids for patients who displayed signs of addiction.

Or from CBS:

But amid skyrocketing addiction rates and overdoses related to OxyContin, Panara claimed the company taught a sales tactic she now considers questionable, saying some patients might only appear to be addicted when in fact they’re just in pain. In training, she was taught a term for this: “pseudoaddiction.”
“So the cure for ‘pseudoaddiction,’ you were trained, is more opioids?” Dokoupil asked.

“A higher dose, yes,” Panara said.

“Did this concept of pseudoaddiction come with studies backing it up?”

“We had no studies. We actually — we did not have any studies. That’s the thing that was kind of disturbing, was that we didn’t have studies to present to the doctors,” Panara responded.

“You know how that sounds?” Dokoupil asked.

“I know. I was naïve,” Panara said.

Pseudoaddiction is among the few medical concepts that’s made it far enough to get denounced by US senators. From Senator Maggie Hassan’s website:

Senator Hassan then asked Jennifer Taubert, Executive Vice President of Janssen Pharmaceuticals, about the company’s promotion of the unproven and dubious concept of “pseudoaddiction,” an idea advanced by the pharmaceutical industry claiming that when certain patients present signs of addiction it is because they were prescribed insufficient doses of opioids, and that instead of providing addiction treatment, doctors should increase their opioid doses. Ms. Taubert claimed to be unware of the term.

“Janssen promoted this made-up concept of pseudoaddiction on a website it approved and funded was called ‘Let’s Talk Pain’” Senator Hassan said. “Since then, your company has repeatedly said that your actions quote ‘in the marketing and promotion of our opioid pain medicines was appropriate and responsible.’ So Ms. Taubert, how can you possibly claim that promoting the theory of pseudoaddiction – that doctors should prescribe more opioids to patients showing signs of addiction – was appropriate and responsible?”

Let me confess: I think pseudoaddiction is real. In fact, I think it’s obviously real. I think everyone should realize it’s real as soon as it’s explained properly to them. I think we should be terrified that any of our institutions – media, academia, whatever – think they could possibly get away with claiming pseudoaddiction isn’t real. I think people should be taking to the streets trying to overthrow a medical system that has the slightest doubt about whether pseudoaddiction is real. If you can think of more hyperbolic statements about pseudoaddiction, I probably believe those too.

Neuroscientists define addiction in terms of complicated brain changes, but ordinary doctors just go off behavior. The average doctor treats “addiction” and “drug-seeking behavior” as synonymous. This paper lists signs of drug-seeking behavior that doctors should watch out for, like:

– Aggressively complaining about a need for a drug
– Requesting to have the dose increased
– Asking for specific drugs by name
– Taking a few extra, unauthorised doses on occasion
– Frequently calling the clinic
– Unwilling to consider other drugs or non-drug treatments
– Frequent unauthorised dose escalations after being told that it is inappropriate
– Consistently disruptive behaviour when arriving at the clinic

You might notice that all of these are things people might do if they actually need the drug. Consider this classic case study of pseudoaddiction from Weissman & Haddox, summarized by Greene & Chambers:

The 1989 introduction of pseudoaddiction happened in the form a single case report of a 17-year-old man with acute leukemia, who was hospitalized with pneumonia and chest wall pain. The patient was initially given 5 mg of intravenous morphine every 4 to 6 h on an as-needed dosing schedule but received additional doses and analgesics over time. After a few days, the patient started engaging in behaviors that are frequently associated with opioid addiction, such as requesting medication prior to scheduled dosing, requesting specific opioids, and engaging in pain behaviors (e.g., moaning, crying, grimacing, and complaining about various aches and pains) to elicit drug delivery. The authors argued that this was not idiopathic opioid addiction but pseudoaddiction, which resulted from medical under-treatment (insufficient opioid dosing, utilization of opioids with inadequate potency, excessive dosing intervals) of the patient’s pain. In describing pseudoaddiction as an “iatrogenic” syndrome, Weissman and Haddox inverted the traditional usage of iatrogenic as harm caused by a medical intervention. In pseudoaddiction, iatrogenic harm was described as being caused by withholding treatment (opioids), not by providing it.

Greene & Chambers present this as some kind of exotic novel hypothesis, but think about this for a second like a normal human being. You have a kid with a very painful form of cancer. His doctor guesses at what the right dose of painkillers should be. After getting this dose of painkillers, the kid continues to “engage in pain behaviors ie moaning, crying, grimacing, and complaining about various aches and pains”, and begs for a higher dose of painkillers.

I maintain that the normal human thought process is “Since this kid is screaming in pain, looks like I guessed wrong about the right amount of painkillers for him, I should give him more.”

The official medical-system approved thought process, which Greene & Chambers are defending in this paper, is “Since he is displaying signs of drug-seeking behavior, he must be an addict trying to con you into giving him his next fix.” They never come out and say this. But they define pseudoaddiction as meaning not that, and end up saying “in conclusion, we find no empirical evidence yet exists to justify a clinical ‘diagnosis’ of pseudoaddiction.” More on this later.

The concept of “pseudoaddiction” was invented as a corrective to an all-too-common tendency for doctors to assume that anyone who seems too interested in getting more medications is necessarily an addict. It was invented not by pharma companies, but by doctors working with patients in pain, building upon a hundred-year-long history of other doctors and medical educators trying to explain the same point.

And in case you think this is a weird ivory tower debate that doesn’t influence real clinical practice, I offer you these cases from my own experience. Stories slightly changed or merged together to protect patient privacy:

Case 1: Mary is an elderly woman who undergoes a surgery known to have a painful recovery process. The surgeon prescribes a dose of painkillers once every six hours. The painkillers last four hours. From hours 4-6, Mary is in terrible pain. During one of these periods, she says that she wishes she was dead. The surgeon leaps into action by…calling the on-call psychiatrist and saying “Hey, there’s a suicidal person on my ward, you should do psychiatry to her or something.” I am the on call psychiatrist. After a brief evaluation, I tell the surgeon that Mary has no psychiatric illness but needs painkillers every four hours. The surgeon lectures me on how There Is An Opioid Crisis, Y’Know, and we can’t negotiate with addicts and drug-seekers. I am a consultant on the case and can’t overule the surgeon on his own ward, so I just hang out with Mary for a while and talk about things and distract her and listen to her scream during the worst part of the six-hour cycle. After a few days the surgery has healed to the point where Mary is only in excruciating pain rather than actively suicidal, and so we send her home.

Case 2: Juan is a middle-aged man with depression who is using Geodon for antidepressant augmentation. This is kind of a weird choice, and has theoretical potential to interact poorly with some of his other medications, but nothing else has worked for him and he’s done great for ten years. He switches psychiatrists. The new psychiatrist is really worried about the theoretical interaction, so he tells him that he can’t take Geodon anymore and switches him to something else. Juan falls into a deep depression. He asks to have Geodon back and the doctor says no. Juan yells at the psychiatrist and says he is ruining his life. The psychiatrist diagnoses him with a personality disorder and anger management problems, and tells him to attend therapy. Juan actually does this for a while, but eventually wises up and switches doctors to me. I put him back on Geodon and within a month he’s doing great again. Note that Juan displayed every sign of “drug-seeking behavior” even though Geodon is not addictive.

Case 3: This one courtesy of Zvi. Zvi’s friend is diabetic. He runs out of insulin and asks his doctor for more. The doctor wants to wait until his next free appointment in a few weeks before prescribing the insulin. Zvi’s friend points out that he will die unless he gets more insulin now. The doctor gets very angry about this and spends a long phone call haranguing Zvi’s friend about how inconvenient it is that he’s demanding the insulin now rather than at a more convenient time. Zvi’s friend has to threaten the doctor with a lawsuit before the doctor finally relents and gives him the insulin. I like this story because, again, insulin is not addictive, there is no way that the patient could possibly be doing anything wrong, but the patient still gets treated as a drug-seeker. The very act of wanting medication according to the logic of his own disease, rather than at the doctor’s convenience, is enough to make his request suspicious.

Case 4: John is a 70 year old man on opioids for 30 years due to a mining-related injury. He is doing very well. I am his outpatient psychiatrist but I only see him once every few months to renew meds. He gets some kind of infection, goes to the hospital, and due to normal hospital incompetence he doesn’t get his opioids. He demands his meds, and like many 70 year old ex-miners in terrible pain, he is not diligently polite the whole time. The hospital doctors are excited: they have caught an opioid addict! They tell his family and outpatient doctors he cannot have opioids from now on, then discharge him. He continues to be in terrible pain. At first he sneaks pills from an extra bottle of opioids he has at home, but eventually he uses all those up. After this, he is still in terrible pain with no reason to expect this to ever change, and so he shoots himself in the chest. This is the first point in this entire process at which anyone attempts to tell me any of this is going on, so I get a “HEY DID YOU KNOW YOUR PATIENT SHOT HIMSELF? DOESN’T SEEM LIKE YOU’RE DOING VERY GOOD PSYCHIATRIST-ING?” call. The patient miraculously survives, eventually finds a new pain doctor, and goes on to live a normal and happy life on the same dose of opioids he was using before.

Case 5: Evelyn is an elderly woman with dental pain. She goes to her dentist, who prescribes opioids. She is concerned – aren’t opioids addictive? “Don’t worry, you’ll be fine”, says the dentist. The dentist keeps her on them for eight months out of some kind of bizarre incompetence that is not her fault. Then that dentist retires and transfers her to another dentist in the same practice. Evelyn asks the new dentist to refill her opioid prescription, and he freaks out – why is this patient on opioids? He refuses to refill the prescription. She gets really scared because she is about to withdraw from opioids cold turkey, and asks for a week’s worth of pills so she can taper down. The dentist calls her an addict and refuses. She asks for some kind of help, any kind of help, getting off the opioids, and the dentist tells her to go to a drug rehab so she can get treated by people who understand her addiction. Finally in desperation she calls the psychiatrist who is treating her for an unrelated problem (me), and I prescribe the standard opioid withdrawal regimen and talk her through the process. I would like to say this story has a happy ending, but she’s currently in post-acute withdrawal syndrome, so @#$% everybody involved.

Case 6: Sandy is a middle-aged woman on benzodiazepines, a potentially addictive anti-anxiety medication. She has been stable for twenty years. She switches doctors. The new doctor has heard that Benzodiazepines Are Bad And Addictive, so he discontinues them over her objections. Sandy becomes a miserable wreck and has panic attacks basically all the time for a few months. Whenever she tries to mention this to the doctor, he accuses her of being an addict and trying to con him into giving her drugs. After a few months of this, she leaves that doctor and switches to me. I put her back on her previous dose of benzodiazepines, and within two days she feels perfectly normal and gets on with her life.

Case 7: Robert is a young man who is prescribed trazodone 50 mg nightly for sleep. This goes well for several years. Then he gets in a fight with his wife and they are considering divorce. He’s really worried and angry and can’t sleep, and so after going several nights without sleep and feeling completely miserable, one night at 4 AM he takes two trazodone – 100 mg – and gets to sleep right away. He mentions this to his doctor, who accuses him of “unauthorized dose escalation”, ie going up on your drug without telling your doctor. He refuses to prescribe trazodone further. Robert is now totally unable to sleep. He ends up with me, I put him back on trazodone, tell him that the maximum safe dose of trazodone is 400 mg but that if 50 mg works for him I want him to try to stick to that except in emergencies so that he doesn’t build tolerance, and he continues taking 50 mg on average nights and 100 mg once or twice a year if things are really bad.

Let’s look at those warning signs of addiction again:

– Aggressively complaining about a need for a drug
– Requesting to have the dose increased
– Asking for specific drugs by name
– Taking a few extra, unauthorised doses on occasion
– Frequently calling the clinic
– Unwilling to consider other drugs or non-drug treatments
– Frequent unauthorised dose escalations after being told that it is inappropriate
– Consistently disruptive behaviour when arriving at the clinic

In Case 1, Mary requested her dose of painkiller be increased (from once per six hours to once per four hours). In Case 2, Juan asked for a specific drug by name (Geodon), and was unwilling to consider other drugs. In Case 3, Zvi’s friend frequently called the clinic (to get them to refill his insulin). In Case 4, John showed consistently disruptive behavior in the hospital and took extra unauthorized doses. Etc.

All of these are drug-seeking behaviors. But I maintain that none of these patients were addicted. The correct action in all of these cases is to listen to the patient’s reasons for wanting the drug, realize that you (the doctor) screwed up, and give them the drug that they are asking for. Although the point that these behaviors can be signs of addiction is well-taken and important, it’s equally important to remember they can be signs of other things too.

Media portrayals of pseudoaddiction portray it as this bizarre contortion of logic: “A patient is displaying signs of addiction, so you should give them more of the drug! Haha, nice try, pharma companies!” But this is exactly what you should do! The real problem lies with anyone who conceptualizes pseudoaddiction as a novel hypothesis that requires proof, rather than as the obvious possibility you have to check for before accusing patients of addiction.

II.

At this point, any reasonable person will think I’m trying to bait-and-switch you. Surely the reasonable position I’m defending isn’t the same as the dreaded “pseudoaddiction” that everyone knows is a pharma company swindle? Surely I must be straw-manning the pseudoaddiction opponents somehow?

I don’t think that I am. I want to go over Greene & Chambers (2015), Pseudoaddiction: Fact Or Fiction, in Current Addiction Reports. This is the most important paper establishing the current consensus against pseudoaddiction as a concept. It’s been cited in debates before Congress on the opioid crisis, featured on CBS, and is the primary source for the current consensus that pseudoaddiction has been “debunked”. This is the best and most thorough anti-pseudoaddiction paper, and if there’s more to the story we’ll probably find it there.

G&C start with a review of the pseudoaddiction literature, beginning with the case study I quoted above. I’m going to quote it again, since I think it’s really important to establish that everyone agrees this is the kind of thing we’re talking about:

The 1989 introduction of pseudoaddiction happened in the form a single case report of a 17-year-old man with acute leukemia, who was hospitalized with pneumonia and chest wall pain. The patient was initially given 5 mg of intravenous morphine every 4 to 6 h on an as-needed dosing schedule but received additional doses and analgesics over time. After a few days, the patient started engaging in behaviors that are frequently associated with opioid addiction, such as requesting medication prior to scheduled dosing, requesting specific opioids, and engaging in pain behaviors (e.g., moaning, crying, grimacing, and complaining about various aches and pains) to elicit drug delivery. The authors argued that this was not idiopathic opioid addiction but pseudoaddiction, which resulted from medical under-treatment (insufficient opioid dosing, utilization of opioids with inadequate potency, excessive dosing intervals) of the patient’s pain. In describing pseudoaddiction as an “iatrogenic” syndrome, Weissman and Haddox inverted the traditional usage of iatrogenic as harm caused by a medical intervention. In pseudoaddiction, iatrogenic harm was described as being caused by withholding treatment (opioids), not by providing it.

Instead of concluding that okay, Weissman and Haddox have a point and someone should get this kid some pain relief, they note that case reports are a low level of medical evidence, and nobody has ever done any big studies or meta-analyses that provide empirical proof of pseudoaddiction. They don’t explain what this would mean, or how you turn “stop torturing children due to a misplaced desire to nab addicts” into a p-value of less than 0.05. They just conclude that this means pseudoaddiction has never been empirically proven to exist, then discuss how some of the case reports of pseudoaddiction (though not Weissman and Haddox’s original) were sponsored by Big Pharma.

Then they get more philosophical, arguing that pain can never be objectively proven to exist. Also, even if it were objectively proven that someone was in pain, that person could still be an addict, since addicts can feel pain too. Therefore, we can never prove that there is a person who is in pain but not an addict, and therefore we cannot empirically prove the existence of pseudoaddiction. Some quotes so you can judge whether I’m being unfair:

The existence of pseudoaddiction, and its distinction from true addiction, is understood by proponents as being based on the patient’s reported motivation for pain relief (e.g., if their behavior results from pain, then they have pseudoaddiction, not addiction). The reliability of this conceptualization seems to hinge on the assumption that addiction and pain do not co-occur (unless one can comprehend the possibility that a patient can have fake addiction and true addiction at the same time!). However, it is not the case that pain and addiction are mutually exclusive conditions, and no clear evidence exists that having pain protects against the genesis or expression of addiction.

A primary difficulty in measuring pain is its highly subjective nature that is influenced by many cultural, situational, and individual neuropsychological factors [62–64]. Given the large degree to which pseudoaddiction does not distinguish itself from addiction, except based on subjective reporting of pain, and the extent to which opioid addiction is associated with or may even cause subjective pain, it is unclear how the application of pseudoaddiction has further enhanced the clinical assessment and management of pain.

In conclusion, we find no empirical evidence yet exists to justify a clinical “diagnosis” of pseudoaddiction. The renaming of pain with a term that essentially means “fake addiction” and serves to dismiss addiction as part of the clinical differential diagnosis is a construct that is conspicuously and uniquely attached to opioid therapies which are extremely addictive analgesics, among many other effective, evidence-based strategies for analgesia that are far less addictive. If pseudoaddiction is to remain an influential clinical construct that is taught in medical schools and textbooks, its usage and clinical acceptance need empirical support, with evidence-based disambiguation from addiction, and delineation of its treatment implications. However, to the extent that a diagnosis of pseudoaddiction relies on a self-report of pain (that is still essentially not objectively measurable) as the motivation for drug-seeking, it is not clear how rigorously it can ever be proven or disproven in human research.

It is hard to conclude from this review and the context of the current prescription opioid epidemic that pseudoaddiction is an objective, evidence-based diagnosis that has been clinically beneficial to patient lives. Instead, it may be most beneficial to retire the term and understand patients as simply having pain, opioid addiction, or very often both, and designing treatment strategies that best account for and balance the competing risk-benefit treatment concerns that these brain conditions imply.

Some of these quotes seem to suggest that it’s hard to define the border between addiction and pseudoaddiction. They don’t really make this argument clearly, but it could go something like – if addiction is an attempt to feel better than well, and pseudoaddiction is an attempt to feel better than some miserable baseline, and there’s no clear bright line between “so miserable you deserve drugs” and “so well that you don’t”, how can we wall of “pseudoaddiction” as a separate concept? I agree this is difficult, but it’s the same kind of difficulty you get in having any concept at all, so you should probably deal with it.

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.

Others seem to argue that pseudoaddiction doesn’t rise to the level of a medical diagnosis, with the faux-objectivity that implies. But nobody was previously trying to turn it into one – if you look at the paper that coined the term pseudoaddiction, it’s very clear that it’s just making a new word for a common-sense concept that everyone has known about for a long time.

Also, one of the G&C authors, Chambers, goes on to write a nearly identical paper which also attacks the concept of “self-medication”, Have Pseudoaddiction And Self-Medication Led Us Astray? It argues:

‘Self-medication’, a concept originating when psychiatrists noticed frequent tobacco, alcohol, and other drug use in the deinstitutionalized mentally ill, has been around for many decades, but was also formally elaborated on in the 1980’s. It has subsequently been endorsed and widely embraced in primary research and review papers and educational sources spanning the field of psychiatry, as the standard explanation for why persons with mental illnesses use substances. ‘Self-medication’ has become so widely and dogmatically accepted as the key explanation for substance use in mental illness, that it has become nearly synonymous with ‘dual diagnoses’. In both ‘pseudoaddiction’ and ‘self-medication’, drug use is explained as a choice to seek and use drugs for benefit—to gain symptom relief from pain or psychiatric symptoms. Whereas in addiction, the behavior is explained as compulsive, not a voluntary choice, that persists despite negative consequences, not because of benefits. As suggested in Table 1, the construct similarities between ‘pseudoaddiction’ and ‘self-medication’ are quite comprehensive, including how they consistently contradict the disease model of addiction.

Nobody is claiming that self-medication is an official medical diagnosis, so I conclude that is not the meat of G&C’s objection.

If we want to be super-charitable to them, we can focus on a paragraph from the self-medication paper which is more self-aware than anything I see in the pseudoaddiction paper:

Of course, untreated pain does exist. People do self-medicate (e.g. taking an antibiotic for pneumonia). And sometimes, taking addictive drugs (usually short term) can be very therapeutic. But it may be time to ask: 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?

Here Chambers seems to be saying that maybe “pseudoaddiction” and “self-medication” describe real things, but that the pendulum has swung so far towards treating drug use as legitimate, and so far from being willing to call people “addicts”, that we need to excise ideas like pseudoaddiction and self-medication from the lexicon so that doctors will have no choice but to recognize addiction in their patients when they see it.

I disagree with this, but it’s at least a coherent position. But if you want to have this argument, say “pseudoaddiction is rarer than people think”. Don’t say “pseudoaddiction doesn’t exist”. If you say it doesn’t exist, then our first argument has to be over whether it exists, and as far as I can tell it obviously does.

I worry that G&C are vacillating among a bunch of different claims, making their argument hard to address. Sometimes they argue that no double-blind empirical study has proven pseudoaddiction. I think this is a category error, like wanting a double-blind empirical study to prove the existence of ennui. Sometimes they argue that pseudoaddiction cannot be proven to exist. I think this is true only in the very philosophical sense where pain cannot be proven to exist, and once we start using common sense, it clearly exists. Other times they argue that there’s no clear bright line between addiction and pseudoaddiction. I agree, but think there is no bright line between any concept and any other concept, so we better get used to this and not stop prescribing clinically indicated drugs on that basis. Other times they argue that pseudoaddiction should not be a reified diagnosis-like concept. I don’t think it is supposed to be, so they are attacking a straw man. Other times they argue that doctors are too likely to coddle addicts. I think this is a potentially fruitful thing to argue about, but they need to start this argument by saying the thing they actually believe, not an unrelated claim that “pseudoaddiction doesn’t exist”. Overall the argument seems muddled, and unworthy of the consensus in favor of its claims that it has produced.

III.

If pseudoaddiction is such a common-sense idea, how did we reach this point where people are deriding medicine for ever having believed in it?

As far as I can tell, the concept started off well-intentioned. But painkiller companies realized that the debate over when to diagnose addiction vs. pseudoaddiction was relevant to their bottom line, and started funding the pseudoaddiction side of it.

I’m not sure how substantial an effort this was. G&C note that of 224 papers mentioning pseudoaddiction, 22 were sponsored by pharma (but that means 202 weren’t). Of a stricter category of 12 papers that focused on arguing for the concept, 4 were sponsored by pharma (but 8 were not). Taking their numbers at face value, the majority of discussion of pseudoaddiction had no pharma company sponsorship. But the image of an expert getting up in front of a medical conference and telling doctors that the solution to opioid addiction was more opioids – something that certainly did happen, I’m not sure how often – was so lurid that it burned itself into the popular consciousness. The media exaggerated this from “basically good idea gets misused” to “doctors invent vicious lies to addict your loved ones” to get more clicks. Experts didn’t want to be the guy saying “well actually” in the middle of an Opioid Crisis, so they kept their mouths shut. Reporters copied each others’ denunciations of ‘pseudoaddiction’ without checking what the term really meant.

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”. This happens again and again on any issue people care about, and I want to reiterate for the nth time that you should treat reporting on medical, scientific, and social scientific topics as having almost zero credibility.

Second, you should stay cautious about bias arguments. Yes, some people pushed pseudoaddiction because they were shills of the opioid companies. But other people pushed pseudoaddiction because it was true. Just because you can generate the hypothesis “maybe people are just shills of the opioid companies” doesn’t mean you’ve disproven pseudoaddiction. And if you focus too hard on the opioid companies’ obvious financial bias, then you’ll miss less obvious but possibly more important biases like those of the drug warriors. Your best bet would have been to just stop worrying about biases and try to figure out what was actually true.

The opioid crisis is really bad. I nevertheless think pseudoaddiction is the most obviously true medical concept this side of Hippocrates. The denial of its existence is a failure of national epistemics that deserves more scrutiny than it’s getting.

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231 Responses to Against Against Pseudoaddiction

  1. colomon says:

    Holy crap, wonder if this explains a very weird medical experience I had last year.

    I’ve got type 2 diabetes, which so far I have controlled nicely with Metaformin. However. monitoring showed that my blood sugar was gradually worsening again, and after discussion with my doctor, we concluded that if it kept on doing that I should switch from 1000mg a day to 1500mg a day.

    Eventually I did switch over to the higher dose, and as an obvious result, I ran out early because I was taking 50% than the prescription said. Called to get my refill, and Rite Aid won’t refill it without talking to the doctor’s office. Called them, and they started reading me the riot act for taking more pills than I was supposed to, and obviously they couldn’t possibly refill it.

    Normally I work hard to control my temper, but this made me furious. I’m using this medicine to control my blood sugar. The doctor has emphasized to me that letting my blood sugar stay up will cause irreparable damage to my body. And they’re planning to deny me the medicine for a month or two because they cannot be bothered to check the e-mail correspondence between me and the doctor to see that I’m following the instructions he gave me.

    Eventually they insisted that I drop everything and drive the 30 minutes to their office to sort everything out. And when I got there, the doctor is all apologetic and says that it was confusion because they thought I was saying I was taking the 3 pills at three different times in the day, and that was bad. Notice that, even if it is true that you shouldn’t take three separate doses a day, the appropriate response would have been to re-prescribe and tell me that. (In fact, I was taking 2 pills in morning and 1 in evening.)

    But hey, now I see that I clearly satisfied the first four things on that checklist of addiction behavior back there. That might explain a lot…

    • Scott Alexander says:

      I don’t think things have gotten so bad that anyone thinks you were addicted to metformin. I think it’s more likely that procedures set up to catch addicts in general were applied thoughtlessly and you got stuck in the crossfire.

      But you can probably imagine how much trouble someone on a potentially addictive medication has in the same situation.

      • armorsmith42 says:

        The point I take away from Colomon’s post is that “addict desperately seeking the substance they are addicted to” is very similar to “person focused on getting the medical care which they already know they need.”

        For example, my dad doesn’t have a thyroid. I think it someone stole his thyroxine and his doctor mysteriously refused to renew his prescription, he would exhibit:

        – Aggressively complaining about a need for a drug
        – Requesting to have the dose increased (from zero)
        – Asking for specific drugs by name
        – Frequently calling the clinic
        – Unwilling to consider other drugs or non-drug treatments
        – Upper-middle-class style disruptive/aggressive behaviour when arriving at the clinic

      • mwigdahl says:

        I think you’re exactly right, Scott. My father in law was one of those. Had increasing abdominal pain, no cause could be found, was put on opioid pain medication. When the pain worsened, his doctor of 30 years decided he must be a drug-seeking addict, cut the opioids, referred him to drug rehab, and put him on risperidone for good measure.

        His real condition was Stage 4 pancreatic cancer. When he went to Mayo and they figured that out, he finally (after months of increasing suffering) got the medication he needed to properly control his pain, for the 3 months he had remaining until he died.

        How does a doctor who has known his patient for literally decades decide that this guy, who had been completely stoic and low-maintenance up to that point, has suddenly at age 72 become a lying drug addict faking months of pain to get a fix? Do these doctors even see their patients as real people any more?

    • Jack V says:

      And presumably even if you’re the king idiot of all idiots and really were taking the pills really unsafely, making you go cold turkey on diabetic medication world still have been bad!?

      • cuke says:

        Key point here. Amazing to me that there are doctors still willing to cut people off cold turkey from drugs that are well known to cause serious discontinuation health risks. The lack of guidance/support for patients to taper safely is amazing to me (I say this as both patient and psychotherapist who hears a lot about my patients’ medicare care).

      • BladeDoc says:

        Cold turkey is not a concept that makes much sense when talking about medications that do not have habituation potential. If you stop taking metformin your blood glucose goes up, this is not a withdrawal syndrome. For example if you stop metformin but start insulin which has a completely different mechanism your blood glucose may actually improve. This is unlike if you are on chronic narcotics, wherein if you cure the underlying pain the patient will still undergo withdrawal symptoms (including the cold sweats and goosebumps that lead to the term “cold turkey”) if you acutely stop the narcotic.

    • denis says:

      Hey colomon: I really hope Scott doesn’t frown on me posting this – it boils down to one person’s experience with insulin resistance, but I think it’s too important to not share.

      In 2013, I got diagnosed with insulin resistance after my blood glucose and insulin showed up very high on a blood test. This was after years of symptoms where I was thirsty too much, and desperately had to pee too much, which I should have taken seriously and didn’t.

      I was diagnosed with pre-diabetes and put on Metformin, but I didn’t desire a future like that. Instead I searched and found that consistent, strenuous aerobic exercise may reverse insulin resistance. I therefore embarked on a rigorous routine of 45 minutes, and later 30 minutes, of high intensity aerobic exercise on an elliptical trainer every day. I also reduced my high intake of artificial sweeteners since studies show they alter the gut flora in a way associated with diabetes.

      Within a matter of 6-8 weeks, the situation was resolved. My symptoms of polyuria disappeared. I had my blood glucose and insulin tested several times later, and it was OK each time since then.

      You don’t have to keep exercising at same intensity forever. Over the following years, I dialed the exercise back to more convenient levels, and still haven’t had the symptoms re-occur.

      The doctor said I’m a unique case, that this hardly ever happens. I don’t know if people are just so set in their lifestyle that they prefer diabetes to daily rigorous exercise, or if it’s a lack of trust that exercise really will help. My experience is that it really helps. It reversed my pre-diabetes in weeks.

  2. RohanV says:

    I kind of feel that this entire problem would disappear if the medical establishment had called it “insufficient dosage” instead of being clever and calling it “pseudoaddiction”.

    • Scott Alexander says:

      I’m focusing on dosage here, but here are a few other situations:

      – A patient is found to be stockpiling their medication. This is sometimes a sign of addiction, but can also be a sign of being afraid of running out and going into withdrawal, especially since the medical system is really bad at getting patients their pills consistently.

      – A patient is overly specific, eg they come to a new doctor and instead of saying “I have anxiety” they say “I need Xanax 1 mg three times a day”. This is sometimes a sign of addiction, but can also mean the patient has a lot of experience and knows what does and doesn’t work for them.

      – A patient doesn’t want to be taken off their meds. This could be a sign of addiction, but could also be a sign that the meds are working very well.

      • Jack V says:

        That’s true, but I still wish there’d been some medical sounding jargon meaning “patient not being treated sufficiently, needs more treatment” instead of “sort of like addiction but not”. Maybe that wouldn’t have attacked the problem enough

      • DeservingPorcupine says:

        Absolutely did this with Addy in the past when the DEA was causing a huge shortage. One time it took me a month to find a pharmacy near Chicago to refill it.

      • Maxander says:

        “Nonpathological drug-seeking behavior”? “Treatment-aligned affective presentation”? There has to be some term someone could come up with that captures the various aspects of of this without sounding nefarious.

        I wonder if the reason that this common sense issue presents trouble for medical practice is that medical ontology generally considers “patients” as purely passive beings moved about by various conditions- physical symptoms, mental disturbances, addictive compulsions, doctor’s orders, etc. “A patient using normal human agency for some particular end” is difficult to fit in a framework that has been tuned for hundreds of years to talk carefully about things that happen to people.

        • keaswaran says:

          I’m not sure if you’re intentionally referring to the etymology or not, but the pair of words “agent” and “patient” actually come from the same verbs that “active” and “passive” come from. The former verb means to do something, and the latter means to “suffer” it (obviously there’s been some change in meaning from “suffering”, into general receptivity, especially when you consider the pair “action” and “passion” – when you’re in passion you’re not necessarily sitting there suffering, but you are sitting there experiencing something rather than really doing it). And of course, the duality between “agency” and “patience” shows how doctors want you to behave.

      • PedroS says:

        The first offense was commited by whoever started to expand the meaning of “addiction” to mean “symptoms found in addicts”.
        it is unsurprising that choosing “pseudoaddiction” instead of a neutral expression to refer to “behavior often, but not exclusively, found in addicts, when observed in non-addicts” would lead to the mess you see, since all the emotional affect of the word “addiction” inevitably got carried to the unrelated phenomenon “pseudoaddiction”. I would expect to see the same transfer of connotation and ensuing confusion if, for example, “dining” started to be referred as “low-grade binging” or “studying hard for an exam” were called “pseudo-obsessive-compulsive reading”

        • March says:

          ‘Pseudoaddiction’ as a term really suffers from ‘two wrongs don’t make a right’ syndrome, although in this case it’s ‘two bads don’t make a good.’ Addiction = obviously bad. Pseudo often means fake, which = usually bad.

          I LOVE your other confusing examples.

          • eyeballfrog says:

            I think another issue is that people often conflate “pseudo-” (false) with “quasi-” (similar to). Just calling it false addiction would probably work better, as it better emphasizes that the phenomenon is not addiction.

          • keaswaran says:

            And even worse, “pseudo-” and “quasi-” get confused with “crypto-” (secret). A pseudofascist is someone who looks like a fascist but isn’t one. A cryptofascist is someone who doesn’t look like a fascist but is one. Even when you know the meanings, it’s very easy to get those switched around.

      • DragonMilk says:

        I nominate, “false flags”…oh wait

      • methylethyl says:

        Well, crap. My mom’s diabetic, and we live in a hurricane zone– we occasionally have to evacuate on short notice. She totally stockpiles medication, because it is a huge pain in the arse to get your insulin rx filled in another state, when your prescribing doc has also evacuated and/or the entire phone system back home is down (true story: happened last year) and your doc cannot be contacted. ER won’t see you until it’s an actual emergency, so you basically have to wait till you run out, then show up at the hospital with dangerously high glucose levels, to get more insulin.

        But hey, stockpiling… obviously she’s an addict. Probably selling some on the street, too.

      • Can we just call this “normal usage of critical prescription drugs,” “asking for necessary medication,” and “requiring pharmacological treatment”? That seems to capture everything needed without referring to addiction at all.

      • nameless1 says:

        But why is the answer to addiction “fuck you, you won’t get any more, just suck it up” instead of working out the plan of treating the addiction while still giving the opioid? Last time I checked addiction was itself considered and illness to treat. This is biologically questionable, but it is a very useful social construct because it allows things like treatment and insurance paying for it and reduces stigma and whatnot. And yet, it sounds like it is treated like a moral issue that the patient has to be punished for by denying the substance.

        If addiction is officially an illness, showing the very same symptoms as reacting to pain simply implies different treatment.

    • kgp says:

      Agree. I’m not familiar with the term pseudoaddiction but the concept makes perfect sense. Seems to me one of the big problems is that people are treating the “warning signs of addiction” as absolute incontrovertible proof of addiction rather than as a flag to make the prescriber at least consider addiction as a possibility.

      • keaswaran says:

        It’s sort of a problem that the medical establishment bought into enough positivist ideology that the syndrome (i.e., collection of symptoms) is the thing that gets described. If addiction is defined as a syndrome involving certain behaviors, then it’s easy to diagnose, but it’s hard to determine whether it’s caused by the bad thing (real addiction) or the good thing (pseudoaddiction).

    • Immortal Lurker says:

      If we are playing with names, I have a suggestion: “Acceptable Addiction”. I think it fits. The reason we care about addiction, the reason there is a category around that sort of thing at all, is that we noticed a joint in reality where sometimes people

      – Really want a particular substance/behavior
      – Are willing to do almost anything to keep getting it
      – start having physiological/psychological problems if denied their substance/behavior
      – Sometimes they keep needing more and more of their substance/behavior for the same results, or problems start happening anyway.
      – Frequently, the substance will have negative side effects.

      Addiction is frowned upon because sometimes these things spiral out of control. Usually, its driven by the need for more combined with negative side effects and the willingness to do anything to get more. If you get hooked on heroin, you will might doing more until you run out of money and have to do unspeakable things to get more money for more heroin, or until an OD kills you, or until your life becomes about nothing besides heroin.

      But all downsides exist on a scale. Reasonable people should be able to say “yes, this is an addiction, but the benefits are worth the costs. Yes, if you run out or are in danger of running out, you will be willing to do bad things to get more. We will treat this risk by making sure you never run out.”

    • milith says:

      That’s also the feeling I got from reading the article. From the outside this looks like a failure of communication, at least partly due to poor naming.

  3. renato says:

    Scott, most of the case you used to describe the occurrence of pseudo-addiction are triggered by changing doctors.
    Is it a good rule of thumb to drop the new doctor if they do not accept to continue the previous treatment/medication or does it depends on other stuff?
    I’m asking it because you wrote a simple guide of how to find a therapist, but I don’t remember it mentioning anything related to it.

    • Scott Alexander says:

      I think it always depends on other stuff. There are cases where the previous doctor was genuinely wrong and the new doctor is correct to want to change things. There are cases where the two doctors have a genuine disagreement and both have some pretty good points.

      I think a good rule of thumb is that your new doctor should be able to explain what they’re doing to you, and shouldn’t get angry if you are curious or concerned about changes to your medication.

  4. TheApiary says:

    The version of the pseudoaddiction argument that I have in my head sounds much more nefarious to me. I’d heard that the drug companies were saying this about things that are specifically opioid withdrawal symptoms, like doctors were saying “My patient used to be fine on x mg, and now starts to have nausea, sweating, anxiety, etc a few hours before it’s supposed to be time for her next dose, I think she’s getting more and more addicted, what do I do?” And drug companies would say “Oh that’s not real addiction, that’s pseudoaddiction, she just needs more opiates.”

    The reasonable answer for that patient might be, “yes she is addicted to opiates and that is fine because it’s much better than her being in horrible pain all the time and she’s doing fine.” But those withdrawal symptoms are the symptoms of actual addiction, not the symptoms of untreated pain, and that seems like a meaningful distinction.

    Did I make up a steelman, or is that actually what happened and this post is unfair, or am I missing something else?

    • Scott Alexander says:

      People can use the same term for lots of different things, so I recommend you read the paper that coined the term, http://sci-hub.tw/10.1016/0304-3959(89)90097-3

      Also, you seem to be talking about tolerance and physical dependence, which are importantly different from addiction. You can have tolerance without addiction and addiction without tolerance. I think the debate around pseudoaddiction is mostly about how it differs from addiction, not from tolerance.

      • TheApiary says:

        You seem to be totally correct about what it means in the original paper that coined the term, and the other ones you quote.

        But that sounds like a genetic fallacy to me– I’m much more interested in how drug companies described it to doctors at conferences, for example. I would be unsurprised if some Purdue reps took a paper that said “Sometimes people in pain act like people who just want more opiates because they’re addicted” and spun it to mean “You shouldn’t worry about increased tolerance and should just give people more and more Oxy.”

        I think that a lot of people (maybe most people?), including doctors who aren’t specifically addiction specialists, basically define addiction as “Either taking the drug is causing major problems in your life or when you stop taking it you have major problems that you wouldn’t have without having taken it in the first place” so I think it would sound normal to most people to talk about symptoms of physical dependence as addiction.

        I just did two minutes of Google research, and at least this one well-written New Yorker article tells basically that story. Purdue had a really successful marketing campaign about how Oxycontin is so effective and controlled that you only need to take it every 12 hours. So people were prescribing it every 12 hours, and then eventually getting withdrawal symptoms after 8 hours, and Purdue’s response was that it’s just pseudo-addiction. It was easy for them to fuzz that, because it was probably also true that the people having withdrawal symptoms also had pain that needed treatment after 8 hours, but it nonetheless sounds like obfuscation to say that that’s entirely pseudo-addiction. The honest response would have been “Yes some patients have more pain or build tolerance and need Oxycontin more than every 12 hours, afterwards you’ll have to help them get off opiates.” https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain

        • Scott Alexander says:

          My training (not sure if this is universal) distinguishes pretty heavily between “tolerance” and “addiction” (remember, you can develop tolerance to anything, including eg insulin). It sounds like the Purdue patients were getting tolerance but (unless more is going on that you’re not describing, I haven’t read the New Yorker article) were not getting addicted, and so it’s correct to describe their requests for more medication (to treat the extra pain they have as a result of tolerance) as pseudoaddiction rather than addiction.

          I agree that other issues arise like “but given that they’re already getting tolerance to opiates, opiates might not be a good choice for their pain anymore”, but I don’t think the pseudoaddiction claim is the problem here.

          • opioidresearcher says:

            Patients in extreme pain requested more pills, doctors turned to Purdue for advice, and Purdue insisted that the patients were lying or wrong because Oxy definitely lasted 12 hours.

            Purdue fought to keep Oxy out of the hands of desperate patients. There is a long list of legal records showing this. The overprescription story is literally the exact opposite of what happened.

          • opioidresearcher says:

            Also, opioids like buprenorphine have consistently been shown to be the best cure for addiction. Either this is an AMAZING MYSTERY, like using cigarettes to cure cancer, or opioid addiction is just what happens when people don’t have enough opioids. Either because they’re in pain or dependent, which is hugely different from addiction.

          • pdbarnlsey says:

            @opiodresearcher, these are really significant points if they’re accurate – but it sounds like you’re verging on claiming there’s never really been an opiate epidemic at all.

            I think I’ve seen someone else here argue that in the past – that there’s a lot of pain, we medicate it, and sometimes the medication hurts people but not much more than you’d expect – but I’ve also seen people argue “it’s actually all due to Medicaid expansions, which did all the fentanyl, thanks Obama!”

            So I guess some links would be nice.

          • opioidresearcher says:

            @ pdbarnlsey

            There has been a major opioid crisis. Hundreds of thousands have died.

            There is an extraordinary lack of evidence that any of this is due to addiction. Instead, “addicts” seem to consists of three groups.

            1. People in pain.

            2. People dependent (not addicted) on opioids. These are people who need opioids to substitute for a lack of natural production.

            3. People who like getting high.

            All three groups have a rational demand for opioids which is driven into the black market. Deaths arise due to black market use. There is literally no evidence at all that using corporate drugs in a safe, legal environment leads to people suddenly dropping dead.

            Heroin use is bad for you, like cigarettes. Like cigarettes, you shouldn’t drop dead on the street from their use.

          • cuke says:

            opioidresearcher,

            Do you know, is there data on what portion of the current overdoses is due to cutting heroin with fentanyl and carfentanil?

            People are pointing at multiple things when they say “opioid crisis.” They often point to rising overdose deaths, so that deaths are seen as the crisis. Hugely expanding access to methadone and the like, of regulated quality, would seem to address a lot of that? Or am I wrong in thinking that?

            Other people when they say “crisis” mean the growing volume and new demographics of people using opioids who are in life-threatening situations as a result of unregulated black market, but maybe also who are not functioning well as people now that they have to get access to opioids. Maybe we think of this as the “substance use” part of the crisis rather than the “overdose” part of the crisis.

            What about the “use” part of the crisis is new? Is it more people “self-medicating” for emotional pain and stress? Is it people self-medicating in new ways? My understanding is it’s not new ways because then we’d see declines in alcohol or other drug use, right?

            Anyway, “crisis” like “addiction” seems to be a word importing a lot of baggage and it would be helpful to unpack it as we talk about it. I’m not pointing at anyone as I say that; I’m just pondering how to have a coherent conversation that entails frequent use of terms that are not so coherent.

          • cuke says:

            “Heroin use is bad for you, like cigarettes. Like cigarettes, you shouldn’t drop dead on the street from their use.”

            That’s a thought-provoking sentence.

          • opioidresearcher says:

            Hi Cuke,

            Fentanyl deaths shot up in 2012, coincidentally the same year that the legal prescription rate finally started to fall. Death statistics happen to be extremely unreliable—they are meant to be part of the legal process, not the medical one. Most states instruct the doctor to simply take a guess as to the cause of death. As long as there isn’t a murder or signs of the bubonic plague, it obviously doesn’t matter too much from the local county’s perspective exactly what caused the death.

            I would confidently guess that fentanyl would be extremely less deadly if it were no more difficult to acquire than cigarettes. People die of overdosing. Overdosing would be much rarer in a legal marketplace. (You can die of alcohol overdose. It does not happen very much. And opioids do not have a culture of “Inject more! Inject more!” the way that a rowdy bar scene does.)

            Regarding substance use, it is unclear why regular opioid use should be inconsistent with a functioning normal life. See the long history of poppy tea, for example. The experience of Chinese opium pre-and-post British prohibition strongly suggests that many of the social problems we associate with opium use are really the result of illegality. Just like having a drink before work may not be ideal but still consistent with a productive day, why shouldn’t an opium smoke during your lunch break be just fine?

            We correctly see opioid use as heavily associated with anti-social behavior. However, restrictions on legal access are the primary source of this association.

            Hard to say why more people are using opioids. The data is bad and the theories are weak.

          • cuke says:

            “The data is bad and the theories are weak” seems like a useful phrase for much of behavioral science. I’ll keep it handy.

            I’m amazed watching BBC crime procedurals set in the 50s and 60s (which we know are accurate depictions of history) and legal dramas of any decade the volume of straight whiskey being consumed by professionals all day long. Clearly a lot of people through history regularly functioned with a lot of intoxicants on board. I guess we could split hairs over “regularly.”

          • teageegeepea says:

            People don’t suddenly drop dead from cigarettes, but they do sometimes drink themselves to death. It actually causes a large portion of deaths among men in Russia today. Among some human cultures, alcohol has been around for a long time and they are less likely to have problems with it. Among others, typically from outside what we call the “Old World”. Many of these opiates have not been around long enough for anyone’s genetic heritage to be adapted to them. Years ago I would have thought legalization would solve the problems we have with illicit drugs, but in the wake of the recent opiate disaster I am much less optimistic. People were having problems with legal Oxycontin as soon as they figured out how to beat the anti-abuse formulation.

          • BladeDoc says:

            This is absolutely a fundamental problem. Most physicians that can and do prescribe opioids have minimal to no training in the difference between addiction and tolerance and tend to conflate them.

  5. broblawsky says:

    Can there be a grey zone between addicted and non-addicted? In some of the cases described here (especially #5, Evelyn) it sounds like some of these people are dependent on these drugs without, as addiction is commonly defined, having “an intense focus on using a certain substance(s), such as alcohol or drugs, to the point that it takes over their life” (from the APA’s website). Maybe some people have a maximum on their susceptibility to addiction, such that the can become dependent on something without it becoming the center of their existence.

    • Scott Alexander says:

      It sounds like you’re talking about physical dependence (ie you’ll withdraw if you go off it). I agree this is a grey zone which is not technically addiction but has some similar properties. A good example of this is Effexor, which is not at all addictive but which people can have really bad withdrawals coming off.

      • broblawsky says:

        Thanks. I guess a better way of stating my question is whether people can develop physical dependence to an addictive substance (e.g. an opioid) without developing psychological addiction? Also, how well correlated are tolerance and dependence/addiction? The conventional picture is that all three (psychological addiction, physical dependence, and eventual tolerance) are well correlated, but is that true?

        • Scott Alexander says:

          I think people can definitely develop physical without psychological dependence to any substance, even substances that sometimes do produce psychological dependence in other cases.

          These are correlated only because if you’ve taken enough of an addictive drug to develop physical dependence on it, you’re more likely to have taken enough to get psychological dependence on it, but some people (eg people with genes that make them more resistant to psychological dependence) won’t.

          All of this is complicated by post-acute withdrawal syndromes (these aren’t universally agreed to exist, but I think they do), where in some people, their bodies will take a long time to adjust to the pre-drug baseline. So for example, alcoholics might use so much alcohol that their body naturally shifts to a higher-activation baseline (to compensate for alcohol’s inhibitory properties), and then for a few months (years?) after they withdraw they will be anxious and twitchy, which (among other things) will make them want more alcohol. I think of this as a different thing from addiction, but I can’t blame people who think this is too fine a distinction to care about.

          • broblawsky says:

            Thank you for explaining that to me. It seems that part of the problem is the common conception of addiction as being both binary (people believe that you’re either an addict or not) and universal across all forms of addiction (people believe that alcoholism, opioid addiction, and even gambling addiction are all fundamentally the same). The medical establishment’s decision to fold all of these conditions together and treat all cases identically seems to make your job, and those of my friends in the medical professions, a lot harder.

        • opioidresearcher says:

          Physical dependence is very common. Think of it like this. Imagine you had the ability to grow apples inside yourself, and your body ate those apples for nourishment. Pretend that’s how our species eats food: we just grow apples inside ourselves.

          One day you get into an accident. To recover, you’re given a drug that artificially produces apples inside you. Because of that, your body produces fewer apples naturally.

          Your prescription runs out. You stop taking the drug. But your body’s natural apple production takes time to recover. You’re not growing enough apples inside yourself, and you’re starving.

          You go to the doctor begging for pills to make the apples grow artificially inside you. He tells you that you have an addiction.

          You starve and die. Everyone laments this senseless tragedy, but takes solace that the doctor didn’t make the problem worse by prescribing more of those pills you were addicted to.

          • BladeDoc says:

            A good metaphor except for one problem. The data on chronic opioids for pain generally indicate that reported pain level return to pre-treatment values over time. Even people that report their pain as “controlled” on chronic doses of narcotics are essentially merely treating their dependence. So the metaphor would have to be more like the apple growing drug helps the body grow poor apples that don’t actually give good nutrition and the patient slowly starves over time as long as the drug is continued.

        • notpeerreviewed says:

          Addiction and tolerance / dependence are much less correlated than people seem to think. Examples going each way: Someone can be an problematic binge drinker without ever developing high enough tolerance that they suffer withdrawal symptoms. Likewise, someone can take develop physical tolerance to prescription opioids without having a problematic psychological relationship with them.

          • AnthonyC says:

            To support your last poit: an ex of mine was once prescribed Percocet for kidney stones. She, like her father, brother, and half brother, had a naturally extremely high tolerance for painkillers. Normal doses had almost no effect. Doctors were really worried the tolerance was due to prior addiction/abuse.

      • Alsadius says:

        Yeah, this seems like my experience with methylphenidate(Ritalin, in layman’s terms). I’m on a decently high dose for ADD, and if I forget to take my pills daily I’m a bit of a zombie. It’s definitely physical withdrawal, because I wasn’t nearly this bad before I started taking ADD meds. Because I work a super-intellectual job with super-intellectual hobbies, brain fog really scares me, and hearing that it’d take something like a month to taper down(plus probably a few more weeks to taper up any replacement drug) worries me. So I intend that if I ever feel the need to change drugs, it’ll be while I still have pills on hand to adjust my tapering if I need to, and I’m resistant to trying new drugs that I might otherwise want to try (because they might treat me better and/or with fewer side effects).

        I don’t think this is psychological addiction – I don’t have any particular fixation on the drug(as evidenced by the fact that I routinely forget to take doses), I’ve turned down offers to increase doses before, and I’d be perfectly happy to stop it if my symptoms could be dealt with some other way. But I’m definitely physically addicted, and if my supply of pills was ever threatened, I’d totally do things that might scan to a doctor as drug-seeking behaviour(and would, in the literal sense, be drug-seeking). I already do stash pills like a squirrel stashes nuts, for fear that I might not have some on hand when I need a dose.

    • Clutzy says:

      Such a state is obvious to people who know “alcoholics”, as defined by medical establishment rules. People who drink to excess, every day, to their own detriment. But these are also known by normal people as “functional alcoholics” (in some cases). These people can quit without having significant withdrawal in the normal windows and do whatever is demanded of them, and then go back to drinking a lot because it is their preference. The problems that result manifest not from the addiction, but from side effects like obesity. I know such people, and that so few medical professionals have experience with this result is mindblowing to me. I’m talking about people who slam 12 beers 7 days a week. Yet the medical profession is totally naive to this subpopulation.

      Sure, they die at ages like coal miners, but no one accuses coal miners of being addicted to coal dust.

    • DinoNerd says:

      I’m currently displaying pseudo-addicitve behaviour myself. Due to as cascade of incompetence, medicine I’ve been told by my doctor was “life threatening to quit cold turkey” was automatically refilled just before my house was tented for termites, and the pills brought into the house before the tent went up. The wonderful(sic) person I called at the health insurer’s mail order pharmacy the day I discovered this first didn’t understand the implications (= pills contaminated; do not use); when explicitly told “these pills need to be replaced” said they’d do so – but nothing happened for 2 weeks. The pseudo-email I sent yesterday through their “secure system” – was extremely nasty, and stressed the incompetence and poor English comprehension of the person answering the phone 2 weeks ago. My expectation is that they won’t even read the email promptly – because they had no category for “I need my meds ASAP” – and everything’s barricaded against commonsense or system overrides. I’m really wishing I’d lied to them and said the pills had not arrived at all – they have a category for that, though the “solution” offered is “look harder for where they may have been left by the carrier”.

      Next step is to call my doctor, and get her to send another prescription – probably to my handy dandy “Canadian” pharmacy – because the next step in the dance will be insurance requiring me to pay full price for the replacements – but only telling me at the last minute when it’s too late for mail order. (FWIW, I have history with this insurance company screwing with my meds. The eventual resolution of the last battle left me on a different, more expensive drug for the same condition. I believe they are capable of semi-intentionally arranging for insured people to die [= increasing the insured’s risks of death, not literally attempting murder] when they become “too expensive” for the insurer. They are just that bad.)

  6. honoredb says:

    If I remember correctly, a story like this is part of House’s backstory: as a patient, he was in pain from a blood clot, and Demonstrated Drug-Seeking Behavior to address the pain, which caused the hospital to misdiagnose him as just an addict and not treat the underlying issue until it was too late to avoid permanent damage.

    But I didn’t connect the angry tweets about “pseudoaddiction” to that show until now; it’s fascinating and horrifying to think of this as a widespread problem.

  7. Jiro says:

    I was skeptical of case 3 at the time it was posted on lesswrong. Based on the facts described there, the patient was told that he could make an appointment to see the doctor the next day, which would have been enough time for him to get the insulin without any break in coverage. He refused to come the next day, claiming that he “does not have the time”. In other words, he would suffer bad consequences (having to forego other things he wanted to do during that time) but these consequences would not be death, and it’s dishonest to claim that the doctor had to do what he asked or he would die. Furthermore, the post said that he waited seven months to see his doctor when the doctor wanted three–in other words, if it wasn’t for his own procrastination, he wouldn’t have had to worry even about those consequences.

    I wonder how many of the other cases above have similar unmentioned details.

    • mrr says:

      Thanks for the context.

      • Alsadius says:

        Amusingly, my doctor (in Canada) is way more up-front about this than American doctors seem to be from that thread. He straight-up told me the first time I called in for a refill that the government only pays him for in-person visits, so it’s $20 for phone refills (though he waived the charge the first time). The last time I was in the waiting room, I even saw a poster advertising their no-extra-fees package – $79/year gets you freebies on things like phone refills, doctor’s notes when ill, medical records being mailed to people, and so on. It also listed off the prices they charge for all those things a la carte. It was impressively transparent for an industry which is so famously tight-lipped about the financial side of things. And again, this was in Canada, where “medical care is free” is our default mindset.

    • caryatis says:

      A person shouldn’t have to visit a doctor exactly as often as the doctor wants to have access to lifesaving medication. Especially something nonaddictive like insulin.

      • cuke says:

        Given how prevalent and regular the need for insulin is, I wonder why it’s not an over-the-counter drug?

        Tylenol causes several hundred deaths a year due to acute liver failure, and we seem okay with that.

        • John Schilling says:

          Given how prevalent and regular the need for insulin is, I wonder why it’s not an over-the-counter drug?

          Because it’s only a lifesaving medication if you use it correctly, otherwise it can be a life-threatening poison, and the rule has traditionally been “drugs that can kill you if you use them wrong(*), need a doctor’s prescription so that a doctor can teach you how to use them right”.

          Certainly with old-school injected insulin, there would have been a non-trivial number of people who would have self-diagnosed with (or been told once by a doctor) probable diabetes, reason that they can afford $10/month for insulin but can’t afford/don’t have time for/really hate going to the doctor and, hey, the first few times they self-medicated it seemed to work fine. Until it didn’t, because they e.g. didn’t know that they didn’t know the difference between subcutaneous and intravenous.

          As a libertarian, I’m willing to let them take that risk for the sake of not making Zvi’s friend face a different risk, but the US stopped being libertarian-ish well before insulin made it to market.

          * Excluding trivial cases like really massive overdoses

          • Douglas Knight says:

            No, that is not the rule. I’m not sure that has ever been the rule. The rule is that nothing is over the counter until the manufacturer asks for it. The FDA can refuse, but it almost never does. This isn’t a nanny state, but an extortion scheme.

            Insulin is available over the counter. Fancy new insulin is not available over the counter for the sole reason that the manufacturers have not asked the FDA to make it so. It is available over the counter in, eg, Canada.

    • AnthonyC says:

      Furthermore, the post said that he waited seven months to see his doctor when the doctor wanted three–in other words, if it wasn’t for his own procrastination, he wouldn’t have had to worry even about those consequences.

      I get what you’re saying, but without knowing more, I’m hesitant to pin this on the patient, because I’ve been there, too.

      I see a specialist. He says “Come back in 4 months.” I head to the front desk to check out, and make my next appointment. Next opening is in 6 months. 5 months later, work says I need to travel to visit a client the week I have the appointment scheduled. Call the doctor to reschedule. Oh, no appointments for another 4 months, will that work?

      Luckily in that case I wasn’t in dire need of any prescription refills. But it isn’t terribly unlikely that a 7 month gap between appointments may have nothing to do with procrastination.

  8. mrr says:

    Based on the examples you gave, physicians seem to have a disappointingly unsophisticated response to the word “addiction” or to any signs that point in the direction of it. My understanding is that 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 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.

    • Alsadius says:

      How much of this is due to pressure from on high? I can’t speak to their accuracy or frequency, but I’ve heard tales of doctors who are too liberal about giving out pain meds having their licenses threatened by regulators because they’re enabling addicts. If that’s the incentive structure you face, it’s no surprise that you’d be anal about finding addicts, and slow to help people who look like addicts.

  9. Le Maistre Chat says:

    Holy crap.
    I don’t know what to say, except “The cognitive biases of people ~2 standard deviations above average can systemically hurt people.”

  10. HMSWaffles says:

    Theoretically, could addiction be defined in terms of a specific set of subjective states a person experiences? And could it potentially be detected by some very advanced EEG + AI system, or differentiated from undertreated physical pain by measuring electrical activity in the right nerves?

    • opioidresearcher says:

      Probably not. Addiction doesn’t have a clear definition. Either it’s a set of problematic behaviors, or it’s scientists watching brain scans of smokers looking at pictures of cigarettes, pointing to a lighted-up section, and going “that must be the addiction right there.”

    • sclmlw says:

      I think this kind of thinking is a large part of what Scott is arguing against. In this case, addiction as a neuroscientific concept is conflated with a related set of behaviors, but pseudoaddiction requires some objective standard. The problem isn’t that we haven’t found a good way to measure it. The problem is that we have a drug to treat a real but subjective condition, and our enlightenment toolkit is only equipped to measure objective evidence.

      This not only impacts how we approach problems, but also how we think of them. We should be looking at pain and saying, “We’re trying to treat a condition that is inherently subjective by asking doctors to make objective judgement calls. That’s guaranteed to fail in some meaningful way.” Instead, because we’ve been trained to only see objectively-derived evidence as legitimate, we lose the ability to ask whether we even have the tools to answer the problem. The 2015 paper Scott cites is a perfect example of this when it starts claiming the burden of proof should be laid on the person suffering pain, not on the physician denying relief. Why? Because they need to provide objective evidence of their subjective experience. But just because something is subjective doesn’t mean it’s not real. That just means we can’t use the same tools of empiricism to investigate it.

      I saw this play out with my dad’s lower back pain. He was having difficulty sleeping nights, and we could all tell when the pain was getting too bad because it affected his mood adversely. He couldn’t walk down the block because he’d have to stop and rest. He went to dozens of doctors (fearful each time they might prescribe him an opiate that could be addictive) and each one treated him like he was drug seeking. Even the specialists who could clearly see the spinal injuries that were causing the pain and told him to stop taking NSAIDS all the time because chronic use was bad for him had no great alternatives. Finally, after I convinced him I’ve seen plenty of patients with chronic pain like his do fine on low-level doses of opiates to deal with their pain he got over the stigma. Even so, it took him about a dozen more doctor’s visits (and a half-dozen treatment strategies that didn’t work) before one finally prescribed him the lowest-level mild opiate he’s on now.

      He’s doing much better, and since the pain doesn’t keep him from walking down the sidewalk he can now do more. That has strengthened his lower-back muscles, and he reports less pain even when not using the opiates. All this is entirely subjective, but it’s also all the difference in the world. Indeed, it’s the only reason he was engaging with the medical community in the first place. Until he found a doctor willing to engage seriously with his subjective pain, he found no relief.

      • Frederic Mari says:

        I don’t like to feel obtuse but how “[he]e’s doing much better, and since the pain doesn’t keep him from walking down the sidewalk he can now do more. That has strengthened his lower-back muscles, and he reports less pain even when not using the opiates” can possibly be described as “[a]ll this is entirely subjective”?

        It doesn’t sound subjective to me at all. Your father seems very objectively to be doing better….

        • sclmlw says:

          Sure, but how do you objectively measure, “I don’t need to stop and rest due to the excruciating pain”? The only way to know that pain is the reason he’s stopping every fifty feet is that he’s reporting he can’t go on from the pain and is grimacing.

          Anyone could fake that. “Sure, but why would they?” Plenty of docs have witnessed patients doing exactly that in order to get a fix. And I’ve known people who do exactly that in the clinic. A physician can’t tell the difference, just because it manifests externally. They might be convinced by following the patient around all day, because who would fake that long? But that’s still a subjective judgement, not an objective measure.

          Even so, most guideline committees would prefer a surrogate biomarker they can track to gauge what’s happening, over the actual reason the patient came into the clinic because you can’t tell the difference between a faking patient and real need.

          • Frederic Mari says:

            Sure. I’m not saying it’s easy to distinguish from the outside but your father knows the truth. That’s very objective, whether it can be easily proven to a third party.

          • keaswaran says:

            Frederic Mari – I think you’re using a different concept of “objective” than sclmlw is. Pain counts as objective to you and subjective to sclmlw (and the medical establishment).

    • notpeerreviewed says:

      No. Addiction is a pattern of behaviors. It might be theoretically possible to measure certain aspects of it, like cravings, but that won’t tell you whether or not the cravings in question are f*cking up someone’s life.

  11. John Schilling says:

    I’m with RohanV on this one: “Pseudoaddiction” is such an atrociously bad term for this common-sense behavior that I find myself wondering whether it was coined by a stealth drug warrior trying to preemptively discredit the idea that sometimes drugs are good, mmkay? OK, Hanlon’s razor, but I’m worried that the last, best hope for common sense is for the whole concept to be discredited, abandoned, and then reinvented under another name in twenty years and I have to hope that I personally don’t suffer from anything that results in severe chronic pain (or a need for any other potentially-addictive medication) before then. Sucks to be one of this generation’s severe pain patients, and I don’t have an answer for them.

    And, yeah, in hindsight I do suspect I may have been on the wrong end of this myself earlier this year, but fortunately only through a case of acute pyleonephritis that lasted only a few days.

    • sclmlw says:

      The problem is that this knee-jerk reaction of assuming a patient is drug-seeking is itself harmful. My wife experienced this when we went into the hospital to report severe abdominal pain, and all the HCPs treated her like she was drug seeking and tried to send her home without doing anything.

      I deal very closely with HCPs, so I know how to advocate for myself (or in this case my wife). Still, it wasn’t until after we plowed through significant resistance that they finally took us seriously – and sent her in for an ultrasound to determine if she had kidney stones. She did, and in fact she ended up having to get them surgically removed. The urologist later said there was no way even the small one would have passed on its own.

      The point is that we were dismissed out of hand because they thought my wife was drug seeking. She didn’t go into the hospital looking for a fix, she went in looking for someone to help fix what was legitimately wrong with her. But because the opiate scare has everyone everywhere focused on the moral panic of the day, we couldn’t get care for a legitimate and unrelated problem! I hope it doesn’t take 20 years for this cause du jour to pass, because it’s not just about chronic pain. It’s about needing any help from a profession that used to be able to walk and chew gum at the same time, but that for too many is only able to focus on one thing – and that’s no longer the patients.

      • Corey says:

        I’ve read that the assumption at ERs is that anyone presenting with pain and no glaringly obvious trauma is always a drug seeker. Their experience probably bears this out.

        • FormerRanger says:

          How does their experience bear it out unless they do a thorough background check of the ER patient, or contact his/her doctor before concluding “drug seeker”? My guess is their experience is “don’t give the patient drugs and send them away,” which obviously works unless the patient comes back to the ER with some sort of proof of pain.

        • albatross11 says:

          It’s sort of like some witch hunter who knows he’s always right, because every woman he accuses of being a witch denies it and screams insults and curses at him as she’s being burned at the stake, just like you’d expect a witch to do.

  12. lordlicorice says:

    I know this isn’t 100% on topic but it’s bothering me that case #5 (with opioids) ends with you weaning the patient off of them while case #6 (with benzodiazepines) ends with you restoring the original dose. Without even a sentence of explanation, as if it should be obvious that the latter case is sustainable and healthy while the former is dangerous.

    This is a major grievance of mine against psychiatrists: very few of them seem to appreciate the power and danger of benzodiazepines. It feels like we’re still in the early 20th century and people are taking heroin as a cough suppressant. To me, that’s how insane it feels that psychiatrists prescribe a daily dose of benzos for generalized anxiety.

    I took Ambien (a drug related to benzos) for the better part of a decade and ended up tapering off over several months, bringing my dose down one excruciating milligram at a time. I had indescribable anxiety, panic attacks, tremors, and one seizure. I was one of the lucky ones because my symptoms abated after half a year. I have also gone through withdrawal from fairly heavy use of IV opioids a few times. I would go through the opioid withdrawal ten times – a hundred times – before going through the Ambien withdrawal again once. You psychiatrists don’t realize what you’re playing with. If you’re giving partially-fictionalized illustrative examples, the benzo one should end in tapering off, not the opioid one.

    • Scott Alexander says:

      I’ll write a post on this eventually, but for now see eg https://sci-hub.tw/10.1176/appi.ps.54.7.1006

      Your experience was pretty atypical – I’m not saying fake, a small percent of people do have the experience you described – but overall I think psychiatrists should be using benzos more, not less. I also wonder if your taper was poorly managed and some of your suffering could have been prevented with better tapering.

      • lordlicorice says:

        Just to clarify, my experience with Ambien was especially bad because I was taking over 100mg zolpidem per night (and extra during the day to stave off interdose withdrawal). I don’t think it’s likely to be that bad at ordinary therapeutic doses (e.g. the equivalent of ~10mg of diazepam). However, it is absolutely the expected, normal experience when coming down from high doses, particularly of shorter-acting benzos, and it is disturbingly common for people in this situation to have post-acute withdrawal for years.

        I will say that the paper you shared about dose escalation doesn’t really square with my anecdotal experience from when I moved in illicit drug use circles. The only way I can make sense of it is to question their methodology of aggregating data from prescription records. People don’t usually keep their doctors in the loop when escalating. Asking your doctor for an increase of any habit-forming drug risks getting your prescription cut, not increased. The way this usually works is that dose escalation is facilitated by drawing from leftover pills that went unused over the years, and then ultimately (by necessity at that point) by obtaining more pills illicitly. In my case I even used illicit pills to taper, so from the prescription records it looks like I just had a flat dose that never escalated.

        I’m looking forward to your future post – this is an issue that’s obviously near to my heart.

        • Scott Alexander says:

          Thanks for being open about that. I agree that’s a much more expected experience when coming off 100 mg, which is 10x the normal recommended dose. I think at the normal recommended dose, you won’t have those kinds of problems unless you are genetically very unlucky (eg being ten times more sensitive than usual).

          I don’t think your experience necessarily contradicts the paper – illicit drug use and prescribed use are two different indications and populations, and I wouldn’t expect findings from one to carry over to the other.

          This is the same with amphetamines – there are lots of meth addicts, there are lots of Adderall users, and they just seem like two totally different populations with really different experiences, way beyond the ability of the relatively small differences between amphetamine and methamphetamine to explain. As the old saying goes, “the dose makes the poison” (and the route of administration, timing, etc).

          • lordlicorice says:

            You’re right, of course, that it’s difficult to draw conclusions about the general population from observations of the population of illicit drug users. However, the two worlds of illicit use and prescribed use aren’t as neatly distinct as you might think or hope. I wasn’t an illicit drug user until I was already heavily dependent on legal pills. Pretty much any patient is a potential addict if you give them a potent enough drug, and I think that psychiatrists generally underestimate how potent this class of drug is. Giving someone with no tolerance 10mg of Ambien confers all of the disinhibitive effects of getting wildly black-out drunk, with an intoxicating feeling of coziness and well-being, and no hangover the next day. Xanax and other shorter-acting benzos are similar, with less whimsy and more melty warm drowsiness. Having that kind of experience on a daily basis is a ticking time bomb for abuse, especially for people with anxiety who need to take it to feel normal and for whom (I can tell you firsthand) the relief is divine. The other side of that coin is a dark place indeed – if you don’t take it, or if you take a constant dose for too long without increasing it, you experience rebound anxiety and insomnia worse than when you started, and a grimy sandpaper-like feeling in your nerves that you can’t shake. Refer to the experience stories on Erowid for first-hand accounts of the depths of horror that await if you want to stop entirely. Stories like this are a dime-a-dozen in any online harm-reduction chat.

            Some 6% of the adult population already can’t control their drinking, which produces qualitatively similar but less intense effects and includes a bunch of nasty side-effects. I cannot believe that the incidence of dose escalation to a high dose is only 1.6%. Why would anyone heavily abuse alcohol if they have access to benzos? It doesn’t make sense.

            The British National Formulary has some sensible advice:

            Benzodiazepines are indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling or subjecting the individual to unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic or psychotic illness.The use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate and unsuitable. Benzodiazepines should be used to treat insomnia only when it is severe, disabling, or subjecting the individual to extreme distress.

          • caryatis says:

            @lordlicorice

            Re why people abuse alcohol when they have access to benzos—I’ve used both many times, and alcohol is just a lot more fun. Benzos are relaxing but not euphoria-inducing. Plus alcohol is often socially encouraged.

      • cuke says:

        I really look forward to your post about benzos and hearing more on this comment that “overall I think psychiatrists should be using benzos more, not less.”

        Among all the people I’ve known who have been prescribed benzos, I’ve not once seen dose escalation. I have seen people who are already abusing other drugs (heroin, oxy) also abuse benzos they were prescribed and/or bought illegally — it wasn’t dose escalation; they were just blowing through all at once whatever they’d gotten ahold of. Those same folks had a history of other illegal behavior. It seems like one distinguishing factor has to do with impulse control. I’d be interested in whether benzos are a risk-factor/cause of suicide in any significant numbers?

        Taken at low doses, benzos seem to have a much lower side-effect profile than SSRIs, which is what doctors push for instead of benzos. My non-scientific impression is that for anxiety rather than depression, that benzos and other treatments (theanine, lavender pills, CBD, etc) are as effective as SSRIs with lower side-effect profile. Do you have an impression that way or a read on the current evidence?

        My own experience for the anecdote mill: I was prescribed 1 mg clonazepam when the Zoloft I’d been started on made me extremely anxious (delayed onset post-partum depression, years ago). At the time, I wasn’t yet working in the mental health field and had no idea what benzos were, only that my doctor was pressuring me hard not to go off the Zoloft and she seemed confident 1 mg clonazepam would get me over the hump of adjustment to the Zoloft.

        I couldn’t tolerate the side-effects of the Zoloft and cycled through four more SSRIs (and related — Lexapro, Effexor, Wellbutrin) over the following year, all of which made me more anxious than I was, and all of which the benzo helped me tolerate. I finally got off the last one (Wellbutrin) after experiencing serotonin syndrome from switching to a generic version that was metabolized differently (my liver enzymes are weird). The only thing I stayed on was the benzo, because it still really helped and I was not taking any more of it nor having any side effects from it.

        More than a decade later, alas, and I’m still on a (very) low dose of clonazepam (1/8-1/4 mg/day). Doctors laugh at the “sub-clinical” dose I take, but if I go down in dosage I don’t sleep at all. On the other side, if I go up in dosage at all — as little as 1/8 of a mg, I get therapeutic benefit during periods of elevated stress or hormone-induced insomnia.

        One psychiatrist wanted to get me entirely off the low dose because of studies that it may be a risk factor for dementia (a study now countered by a subsequent one I believe). In that effort, she prescribed me Gabapentin to “support” my tapering off. Gabapentin had no effect, but if I tried to come off it, I would get crippling abdominal pain. So now I am more hooked on the Gabapentin than the clonazepam, while it has no beneficial effect for me at all. Another doctor prescribed me trazodone to “support” my tapering off, a prescription I decided not to fill.

        I have yet to find a doctor who will say “I’m fine with you staying on 1/8-1/4 mg of clonazepam for the rest of your life if you want to, I don’t care. And if once or twice a year you need a whole 1/2 mg for unusual anxiety or stress or insomnia, have at it.” I feel if I were a doctor, that’s what I’d say to me.

        Among other things, the choice of benzo vs. SSRI for many people is the difference between having a sex life and having no sex life. It seems like patients should get to weigh these factors. For a patient of mine, their having a benzo prescription vs SSRI is the difference between being able to buy their own groceries or not — no amount of SSRI or behavioral intervention enables them to grocery shop independently, while 1/2 mg of benzo does the trick every time. Seems like this is a larger conversation worth having.

  13. drethelin says:

    We should burn the DEA to the ground and legalize all drugs over the counter at Walgreens.

  14. Scchm says:

    Scott,

    What is up with your and the current psychiatric profession understanding of Geodon?

    I do know examples of Geodon being surprisingly effective for depression after augmentation with other atypical antipsychotics failed. But what is weird about that? Unlike other atypical antipsychotics, Geodon is a potent 5HT1b antagonist. Its 5HT1b antagonism is even more potent than its D2 antagonism (D2 receptors are the main target of antipsychotics). Many 5HT1b receptors are auto-receptors, which are responsible for the dampening of serotonin transmission. Inhibiting 5HT1b receptors increases serotonin transmission, and 5HT1b knockout mice have an anti-depressive phenotype. So, using Geodon for anti-depressant augmentation is a logical choice, not something “weird”.

    Secondly, what “theoretical potential to interact poorly with some of his other medications” are you talking about? Geodon is metabolized by a poorly studied enzyme aldehyde oxidase. It may have unexpected interactions with some medications that are aldehyde oxidase inhibitors. But I am sure not many people are aware of these potential interactions. So what are you referring to? What is this theoretical potential?

    • Scott Alexander says:

      I’m mostly against antipsychotic augmentation because of side effect risk, most people would say other receptors like 5HT-2A, 5HT-2C, and 5-HT7 matter more, and Geodon is one of the less studied atypicals for depression. Like I said, it’s not a terrible choice, just something I see less often than other strategies.

      The other doctor was concerned that Geodon + trazodone = QT prolongation, but I don’t take QT issues very seriously in otherwise healthy patients.

      • Scchm says:

        Geodon is a logical choice, after other atypical antipsychotics and anti-depressants failed (as I said). Depression, particularly treatment-resistant one, is a heterogeneous condition, so maybe for some people 5HT2a are important, for some – 5HT7, for some – 5HT1b, for some – GRIN2B, for some 5HT3, etc. Besides, Geodon is a very potent 5HT2a inhibitor as well, potent 5HT2C inhibitor (equipotent with its D2 inhibition), slightly less potent 5HT7 inhibitor – so it presses all the other buttons you mentioned.

        5HT2c receptor inhibitors’ popularity is due to the pharma promotion of agomelatine and other antidepressants for which 5HT2c is a target. In my opinion, 5HT2c inhibition is, generally a downside, as it is strongly associated with weight gain.

        You are right to be less concerned about QTc prolongation. The main reason for the over-emphasis on QTc is that some people at FDA made a nice life-long career out of it. In the doses used for the augmentation (up to 80 mg) QTc prolongation with Geodon is negligible.

        My main concern with the use of Geodon is that 5HT1b inhibition in addition to being anti-depressive also increases impulsivity. So sometimes in the literature you see weird suicides on Geodon, for example, by drowning. But if, for example, aripiprazole and risperidone did not work/were not tolerated, Geodon is the next logical choice.

      • Garrett says:

        > I don’t take QT issues very seriously in otherwise healthy patients

        Any reason why? One of my local ERs won’t give out Zofran until they’ve done a 12-lead to rule out long QT syndrome.

  15. User_Riottt says:

    I broke my elbow a few years ago and it was ridiculous the dance I had to do to convince them that I needed a higher dose and wasn’t a junkie.

  16. Scchm says:

    There are three things that astonished me in this post:

    1. I have never heard the term pseudo-addiction before. That is an astonishingly poor term that a drug warrior would pay to someone to come up with. Why not just say, in most cases drug-seeking behavior does not mean addiction?

    2. There are some astonishingly stupid doctors. These patients in Scott’s examples did right to drop them and are lucky to get Scott.

    3. What century do these poor patients in some of Scott’s examples live in? What about internet and globalization? Why go through all that suffering? Why not just order the replacement medications trazodone and ziprasidone from an Indian pharmacy?

    • pilfered-words says:

      Why not just order the replacement medications trazodone and ziprasidone from an Indian pharmacy?

      1. Insurance won’t pay for it.
      2. It’s illegal.

      • Scchm says:

        1. Insurance won’t pay for it.

        That is true, but consider the costs of copay for the prescription and the doctor’s appointment. Buying most drugs from India is not much more expensive. Also in the life-and-death situations Scott described, the cost is a minor issue.

        2. It’s illegal.

        That is not so. There is an FDA rule allowing importation of up to 90 days’ supply of medications for personal use. That is what people who travel to Canada or Mexico for cheaper medications do. I simply suggest skip traveling and order medications by mail.

    • liate says:

      Why not just order the replacement medications trazodone and ziprasidone from an Indian pharmacy?

      1) Lots of people don’t know it’s an available option.
      2) Getting things from Indian pharmacies may technically be legal, but it’s a dark enough grey market for it to look possibly illegal. This excacerbates reason 1, because people are less likely to publicize a thing that seems possibly illegal.
      3) Buying cheap drugs from overseas seems like it would be rather risky. It might be safe, but there’s less assurance than with decidedly legal drugs, and I’d bet that that anything that level of grey market is going to be harder to, say, sue if they sell you fake or contaminated medicine.

  17. onyomi says:

    I clearly remember receiving a surprising answer from an older psychiatrist once in response to my concern that transitioning from taking benzos on occasion for bad panic attacks to taking benzos every day on a regular dosing schedule to treat my then-daily panic attacks could cause me to become addicted, since previous psychiatrists had warned me that benzos are very addictive and we very much want to try you on all these other things rather than having you take benzos every day.

    She said, “no, I’m not worried you’ll get addicted because you don’t have an addictive personality.”

    She was right. I don’t really get addicted to things (as an example, I think I find quitting refined sugar harder than I found it to taper off daily klonopin). I can get into a habit of using things, like having a drink every evening or a caffeinated beverage every morning, but I also can stop doing those things whenever I feel like it and it seems, at worst, a mild nuisance. I can also feel symptoms of physical withdrawal like “today I feel edgier because I lowered my dose of klonopin,” or “today I feel sleepy because I didn’t have any caffeine,” but again, it just doesn’t strike me as anything like the behavior of e.g. anecdotes I’ve heard about friends who get prescribed a month’s worth of benzos by their doctor and they’re all gone in five days.

    All of this probably sounds very judgmental. As if I’m saying “if these stupid addicts could just exercise a little self control like me they’d be fine.” But I mostly don’t really think that. It seems pretty clear to me that something very different is going on in their brains than in mine in response to such substances and I know some really, really smart, thoughtful people who are also obviously easily addicted to a variety of substances.

    Anyway, it sounds overly simplistic, and I don’t know if “addictive personality” is a legit concept real psychiatrists use nowadays, but the above-described strikes me very much as an attempt to apply a one-size-fits-all standard to patients with very different (but probably hard to figure out based on e.g. a short interview or any sort of diagnostic) psycho-physiological profiles.

    • alwhite says:

      I would say the concept of “addictive personality” is way too simplified. Classifying and describing addiction is pretty hard, but there’s way more to it than just personality. There are real brain changes when you’re exposed to a substance for a long period of time. Those changes can influence your desires and behaviors. Undoing that influence then requires another brain change, and that can take a lot of time.

      Trauma is also heavily implicated. People with abusive and traumatic pasts have higher rates of addiction than those without. Is addiction really about the brain craving a substance or about the person trying to avoid psychological pain? It’s hard to separate.

      I don’t think your psychiatrist did the right thing by saying you don’t have an addictive personality. However, they could have picked up on this trauma aspect and recognized your risk factor for addiction was lower. And addiction doesn’t happen over night. If you’re paying attention, willing to work with your doctor and tell them everything, it’s not that hard to recognize you might be getting closer to addiction and taper off before too much damage is done.

      (quitting refined sugar is a thing that some training facilities will tell people to do so they can experience what life is like for an addict)

      Here’s the Surgeon General’s Report on the topic.
      https://addiction.surgeongeneral.gov/

      • onyomi says:

        Regarding the “doesn’t happen overnight” aspect, I know I took benzos daily for several months at least, maybe more, before tapering off of them, whereas I also have heard personal anecdotes of people who, soon after their first dose, were running through a month’s supply in days.

        I am not ruling out that there could be non-genotypic factors like trauma that make one more susceptible to having the latter reaction rather than the former, but I also wouldn’t rule out that trauma could alter a person’s “personality” at least to some degree (nor do I have a precise definition for “personality”–I am just reporting what a psychiatrist said to me).

        • alwhite says:

          The definition of addiction is really frustrating. A person is not addicted to heroin after their first hit, yet they may want it a whole lot afterward, say to help with the withdrawal and make the hangover go away. Harmful behavior can absolutely happen (I haven’t eaten pickles in years and I got a new jar recently and realized I couldn’t stop eating them until the jar was empty) but harmful behavior alone doesn’t qualify as addiction.

          I assume there’s an implication that these anecdotes were “caused by an addiction” or “addictive personality”, but we have no idea what the cause is. All we can say is that harmful behavior happened. Jumping to the addiction label seems premature and wrong.

          • onyomi says:

            It seems to me that the danger of taking such an agnostic stance wrt to the causes of behaviors you seem to want to focus on here and below is that it may create a false impression that the road to addiction and/or recovery is a lot “wider” than it really is.

            For example, it may be the case that there are some individuals who can, whether for reasons of genetics, upbringing, or whatever combination, drink quite frequently and/or heavily without it ever having a destructive effect on their lives or presenting much difficulty should they chose not to drink. At the same time there definitely seem to be people for whom, whether for reasons of genetics, childhood trauma, or some combination of other factors, drinking in a non-self destructive manner presents so much difficulty they’d probably be better off not drinking at all (indeed, that is AA’s stance, if I understand: once an alcoholic, always an alcoholic, even if you haven’t had a drink in decades).

            It seems equally inappropriate to say to the former sort of person, “every drink you have you’re risking becoming an alcoholic” as it does to say to the latter sort of person, “look, it’s not that hard just to have one glass of wine with dinner and call it good.”

            That said, I’m definitely not committed to describing such predispositions as part of a person’s “personality” or “moral fibre” or what have you; indeed, I would think it odd to describe “predisposition to alcoholism” as a personality trait per se. I’m just saying that was how one older psychiatrist described it to me, probably based on long experience she had of differentiating among patients likely to have a problem on e.g. benzos and those less likely.

          • Error says:

            I haven’t eaten pickles in years and I got a new jar recently and realized I couldn’t stop eating them until the jar was empty

            Not that it’s relevant, but I have this experience with cereal. I can’t keep it in the apartment, but I don’t have a screaming need for it when it’s not there. I don’t think I’ve ever run into someone with a similar problem.

          • Alsadius says:

            Not that it’s relevant, but I have this experience with cereal. I can’t keep it in the apartment, but I don’t have a screaming need for it when it’s not there. I don’t think I’ve ever run into someone with a similar problem.

            I’m the same with some snack foods – jellybeans, for example. Self-control is far easier for me at the store than after I’ve already bought the food and made plans to consume it at some point. It seems fairly common, anecdotally.

          • Frederic Mari says:

            Error – regarding cereal – I’ve got the same issue but with most food, especially when I’m dieting… 🙂

            Basically, I’m trying to do intermittent fasting (to see if it works for me) and, some years ago, I had successfully been dieting (carb and calorie reduction)…

            In general, it is (and was) fine. I dont/didn’t feel overly hungry and was/am pretty impressed by how long I can go without food/with less food than I thought I need.

            The hard parts are : Resisting tasty food when I see it. Not having hungry feelings triggered when I smell food, especially grilled food but frankly any nice food smell will do.

            It’s plain weird to see my feelings of hunger be so visual/olfactory stimulus-related.

          • onyomi says:

            @Frederic Mari,

            I think intermittent fasting has become so popular because many, myself included, find not eating anything for periods of time easier than eating regularly but always in moderation. Maybe this is a side effect of so many foods being hyperpalatable now.

            For many, myself included, the choices seem to be: a. include regular, semi-extended periods of eating nothing at all, b. don’t eat your favorite foods at all or only rarely, or c. eat your favorite foods but only in small quantities. I find c to be harder than b and b to be harder than a.

          • Frederic Mari says:

            onyomi – that’s certainly part of it.

            I didn’t have too much trouble with the smaller portions 3x a day but then food smells would really set me off.

            If I take one fairly big lunch/dinner, I’ll be stuffed enough that the next 12-16 hours, I don’t want to see/smell or hear food. The last few hours can be a bit more ‘dangerous’ i.e. I’ll start reacting if I smell food.

            But in a controlled environment (workplace) that’s not a factor and so, yeah, I think I can make this intermittent fasting thing works in my present circumstances.

            I’m just wondering how effective it really is. For weight loss. Longevity and health span extension, obviously, I won’t know before 20 years…

    • cuke says:

      onyomi,

      I agree with what you say here. I think impulse control is a big part of the distinction — and as far as we know that’s a personality trait that like others is a mix of genes and environment.

      There are other factors of course, like what current stressors and supports a person has. People with good impulse control in the face of multiple setbacks will show poorer impulse control. People with better social supports will ride out stressors with impulse control more intact.

      I don’t hear what you wrote as judgmental, but just that you’re raising an interesting question based on your own experience.

  18. alwhite says:

    In situations like this, I try to abandon identity type words and resort to behavior type words. Instead of saying a person “is addicted” say something like “is taking too high a dose of X”. A person taking meth doesn’t have to be addicted and I will still tell them to not take meth. That behavior is not good for them. In the case of this pseudoaddiction, the identity type label just seems to be getting in the way. I don’t know how to have a reasonable discussion with that word there.

    We have behaviors: patients are seeking more medication for pain. We also have other facts, high dosages of opioids cause problematic effects on the brain. A person wouldn’t have to be addicted for me to be concerned about giving them a higher dosage. Are there guidelines along this train of thought? Abandon the thinking of “higher dosage is addictive behavior” and replace with “these levels of medication are destructive in the long term. Even if you are in pain, the long term issues are important to consider here”.

    This seems like an important step in resolving the conundrum.

  19. opioidresearcher says:

    Happy to weigh in with a few observations.

    Everyone should read the dramatic story of Purdue Pharma’s crimes—specifically, how they fought tooth and nail to stop doctors from prescribing opioids. Purdue was intent on their 12-hour formula; when patients objected that it wasn’t lasting that long, Purdue battled to keep additional dosages of Oxycontin out of their hands.

    Everyone should know that the death rate from opioids shoots up dramatically precisely when the prescription rate starts to plummet.

    Opioids are the best cure for addiction. Why? Because addiction is a word for “acting crazy because he doesn’t have enough opioids.” Whether that’s due to extreme pain or a lack of natural opiate production, even if due to previous opioid use, the resulting drive to acquire opioids for consumption is rational and easily dealt with simply by providing opioids.

    Great book on the history of another false opioid narrative.

  20. Furslid says:

    This looks like another instance of a problem I’ve noticed everywhere. People don’t understand that there is a tradeoff between type one and type two errors, and every reasonable test will have mistakes.

    The only way to never prescribe opiates to addicts would be to never prescribe opiates to anyone.

    The only way to never deny someone in pain an opiate prescription would be to prescribe opiates to everyone who said they were in pain.

    The question will always be “What tradeoff between prescribing to addicts vs. denying people needed treatment is best?” This type of question seems to have become taboo in our society. Even admitting that there is a tradeoff is enough to get various positions rejected.

    • Steve Sailer says:

      I’ve noticed quite a few similar situations where the media doesn’t understand the Type I vs. Type II Error trade-off: e.g., the Moral Panic of the last 15 months over “Barbecue Becky.”

      One reform might be to get rid of the terms Type I and Type II, which are completely non-mnemonic. More people might talk about False Positives and False Negatives if they didn’t feel embarrassed that they couldn’t remember which is Type I and which is Type II.

      • teageegeepea says:

        I’ve found Type I vs Type II a helpful framework, particularly as it’s been used as a common example of how a Bayesian should incorporate the base rate when making something like a diagnosis in response to a medical test. However, Andrew Gelman, the person I’d trust most on statistics, is dead set except for specific circumstances. I’d like to be able to think about things in a way approaching his standards, but I only ever took one probability course rather than any statistics.

      • Furslid says:

        Sadly true. I always end up googling to remember which is which.

        The BBQ Becky incident brings to mind another example of an interesting and related phenomenon. People get attacked for using reasonable standards, when they are wrong.

        It might be reasonable to suspect that someone trying to jimmy open a car door with a coat hanger is a thief. Wrong. How dare you call the police on an unfortunate person who locked their keys in their car.

        People don’t ask, “Should the police be called whenever someone is apparently breaking into a car.” Instead they ask “Was this particular instance attempted grand theft auto.”

    • Viliam says:

      If you go to one extreme, you hurt one group of people. If you go to other extreme, you hurt another group of people. If you propose to choose the optimal tradeoff, you admit you are trying to hurt both groups of people.

      People are bad at quantitative thinking, so they will not notice that the third option would hurt fewest people. But some people are sympathetic to one group, some people are sympathetic to the other group, and both will yell at you for trying to hurt both groups.

      Behold the human thinking at its usual.

      • Steve Sailer says:

        Good point. People naturally ask: Who are the Good Guys? Who are the Bad Guys? They like simple answers to those questions about who to root for.

        It would be interesting to do a survey with the following questions:

        1. A woman feels that a man is acting suspiciously. Fearful, the woman calls the police on the man. Is this the right thing to do?

        2. A white feels that a black is acting suspiciously. Fearful, the white calls the police on the black. Is this the right thing to do?

        3. A white woman feels that a black man is acting suspiciously. Fearful, the white woman calls the police on the black man. Is this the right thing to do?

        • Furslid says:

          Some people ask if the man was doing something wrong. That is not information that the woman had access to, so cannot be the right approach. Instead, we have to examine the woman’s perceptions when she made the choice. Sometimes the man may be doing nothing wrong and the woman may right to call the police. Sometimes the man may be doing something wrong and the woman may be wrong to call the police.

  21. Steve Sailer says:

    I had cancer in 1997 so I took an interest in reading articles in the news weeklies about pain treatments. The standard article at the time said that Science Now Knows that American doctors don’t prescribe enough pain medication. Fortunately, there are new non-addictive synthetic opioids that will lessen the pain from dying of cancer. Real Soon Now, everybody will realize this and then the rules will be changed to allow a reasonable amount of these totally non-addictive pain pills to be prescribed.

    That was reassuring to me at the time.

    Now, I presume that was malign Sackler propaganda.

    Still, it strikes me that they did have something of a point: that people dying in agony should get more pain relief medicine.

    How you keep the increase in pain pills from leaking out to people who aren’t in danger of dying (except from pain pills) is a different question.

    I’m guessing that Sackler used the Dying Cancer Patient argument to crack open the much larger Bad Back market.

    • teageegeepea says:

      I recommend Sam Quinones’ Dreamland, which I reviewed here, on the history. You’re right that the push for prescribing more opiates began with dying cancer patients. Since they’re dying, there’s really no downside to them getting “addicted”. Later doctors started generalizing from them to conclude that there wasn’t any risk of addiction. And the “contin” formulation was designed to delay the release of the opiate, preventing the highs and lows experienced by addicts and instead giving relief over a long period of time so people don’t have to repeatedly take pills all day. Unfortunately, recreational users figured out how to get around that formula and a huge pool of users sprung up. Then, when the formula got changed again and effectively prevented abuse, these new users switched to riskier drugs like street heroin and started dying at much higher rates.

      • Steve Sailer says:

        So, this really did turn out to be a Slippery Slope situation …

      • Furslid says:

        This seems to be a weird pattern we see with illegal drugs and drugs trying to outrun legalization. Over time users switch to more and more dangerous forms of the drugs, and this is a scary side effect of trying to avoid drug use and addiction.

        It’s much harder to accidentally overdose by smoking opium than by injecting fentanyl. But addicts are driven to more potent drugs (smaller volumes means easier smuggling and concealment) and more efficient delivery mechanisms (injecting the same amount gets people higher than smoking or eating.)

        Synthetic cannabis-like drugs are riskier than natural ones. And as some synthetics get banned, more dangerous ones are put on the market.

        During prohibition, people moved from drinking beer and wine to drinking hard liquor.

        • Anthony says:

          The prohibition angle shows that the tendency to more concentrated drugs is mostly a function of legal restrictions on the supply. Though I suspect for some users, there’s a genuine preference for the stronger stuff, just as there are drinkers and alcoholics who prefer 80-proof to beer and wine for their own reasons.

  22. len says:

    You may wish to clarify that the first quoted paragraph is from a letter to the WSJ rather than attributing it to the WSJ.

  23. ECD says:

    For a relatively lengthy discussion of why people might take everything the pharmaceutical companies have to say on this topic with a grain of salt, the Oklahoma State Court judgment (publically available here: https://www.oscn.net/dockets/GetCaseInformation.aspx?db=cleveland&number=CJ-2017-816&cmid=2266216, scroll down to August 26, 2019) has a lengthy discussion of the history of the sales tactics, studies funded and ‘addictive, what’s addictive?’ (not a quote) position of J&J.

    Now, based on the definition given, I generally agree that psuedoaddiction (good God is that a terrible name, as others have noted) is clearly a real thing. It might also be called being an informed patient. However, this tells us nothing about the relative rates of drug seeking vs treatment seeking (to shift terminology) patients.

    Now, as I am not a drug warrior, I don’t actually care that much about proportions, legalize, inform, regulate and tax and I’ll be fine with it, but if you’re looking to convince any of the many, many people who are deeply concerned about addiction that mistakes are going to be made and it’s better to overprescribe than let people suffer, I think they’re going to need (1) confidence that the system isn’t being rigged (because oh, boy, will people absolutely cut off their nose to spite their face if they think they’re being screwed) and (2) some idea of relative costs.

  24. statsman says:

    > Just because you can generate the hypothesis “maybe people are just shills of the opioid companies” doesn’t mean you’ve disproven pseudoaddiction.

    theory as evidence

    You see this all the time – people counting their theory as evidence, without regard for whether there is any evidence for the theory.

    • eyeballfrog says:

      I think the issue is that people see that their theory fits the facts and conclude their theory must be true, rather than consider that other theories may fit the same facts.

  25. yoyo says:

    I think a lot of this is just doctors not wanting authority questioned…Not necessarily from a power trip, but it is viewed with suspicion if you ‘know too much’, even just knowing the name of the drug you take.
    I had a rapid remission from depression on a mail-ordered MAOI after half a dozen combinations of various SSRIs and 2nd gen antipsychotics all failed strongly. MAOI worked great. It was very hard to find a pdoc who would continue me on this drug.

    There also seems to be this weird gulf where opioids are readily handed out, and then discontinued without any taper. I wonder if part of the problem is a difference in responsibility between ‘first line’ providers who start someone on opioids, and the idea that only ‘pain docs’ write continuing prescriptions. But it really seems like if you start someone on oxy for something, the default should be similar to the ‘steroid taper’ (prednisone).

    • Error says:

      it is viewed with suspicion if you ‘know too much’, even just knowing the name of the drug you take.

      There might be some justice in this. I used to work at a small computer repair shop, and some of the most aggravating customers were the ones that thought they knew what they were talking about. They usually didn’t. I do my medical homework, but I’m sometimes reluctant to show it with doctors I don’t know well, because I don’t want to come across as That Guy.

      I’m not sure how significant that problem is in medicine, but I’d be interested in knowing. The shop had adverse selection to account for. In tech, people who actually know what they’re doing probably don’t go to repair shops anymore. Unless you’re literally a doctor, that’s not an option for drugs.

      • Scchm says:

        In tech, people who actually know what they’re doing probably don’t go to repair shops anymore. Unless you’re literally a doctor, that’s not an option for drugs.

        Actually, it is an option, especially, if you got a jerk doctor who refuses to refill a prescription. See Internet, globalization. You can simply order your prescription from an Indian pharmacy.

    • Scott Alexander says:

      OOC, which MAOI did you use?

      • yoyo says:

        Tranylcypromine. I would have preferred phenelzine, since I also had/have social anxiety. The depression was basically gone after a week, and it did little for the anxiety (to be fair, nothing has ever helped the anxiety, other than getting older.)

        • Scchm says:

          In the eyes of drug warriors tranylcypromine is an addictive medication because amphetamine is its major metabolite. You may have better luck with Emsam (selegiline patch), which has very similar pharmacology, but have been “blessed” by recent pharma promotion. Emsam has the advantage of lesser chance of “cheese reactions” and, unlike other MAO-Is, may not require major dietary restrictions.

          For Scott. There is an old Australian doctor, Ken Gilman, who published a lot on MAOIs; he has a website with a detailed description of how to administer MAOIs (other than Emsam) in practice: MAOI diets, how to titrate MAOIs, etc https://psychotropical.com/maois/

  26. TheRadicalModerate says:

    As a lay person, I have to say that “pseudoaddiction” sounds like a pretty skeevy concept. However, “undertreated pain” sounds like a perfectly reasonable thing. Sometimes it matters what you name things.

  27. J says:

    Friend of a friend was like case 6 but without the happy ending. Doc had her on benzos for years. I forget why she had to go off, had nightly horrible nightmares, killed herself a few months later.

  28. summerstay says:

    My wife had a test procedure that involved injecting fluid into her spine go badly, and was in a lot of pain. She got a little opioids and it helped, but all over the counter painkillers did nothing. Everyone– the doctors, the nurses, the pharmacy, acted like our efforts to obtain more opioids were suspicious and put up barriers, when really she had just had a major shock to her spinal cord and just needed powerful painkillers for a few days to help her get through it.

  29. Viper23 says:

    The core problem here seems to be with having this ambiguous judgment laden term addiction in the first place.

    We consider it our prerogative to “help” people stop using substances which they tell us help them overcome the pain of existence itself even when they are not asking for such help.

    It would appear to me that the first requirement for qualifying someone as an addict should be “wants to stop using substance X and can’t do so on their own”.

    Someone who thinks that life is dumb and boring and wants to burn health making it more interesting by consuming heroic quantities of cocaine should not be treated for anything so long as they don’t perceive themselves as having a problem. They also should not be coddled if the use of that cocaine causes real life breakages for them.

    The catch seems to be that too many friends and family of people who choose chemistry as a solution find it easier to blame the chemistry for issues rather than blame the user.

    • Scott Alexander says:

      It does become a tiny bit of a problem if they expect a doctor to prescribe them the substance and insurance to pay for it, though.

      • Viper23 says:

        It should be available for purchase with an acknowledgment of known risks by the buyer rather than through a prescription. As for insurance, they should only be on the hook for things that a doctor prescribed as a needed medication.

    • cuke says:

      I agree with parts of this, but what do you do when said substance user is an only parent? Do we just take their child away without any attempt to offer solutions/treatment options?

      Yes, if a person repeatedly refuses treatment, there’s not much anyone can do. Same with a person determined to kill themselves. But there’s a lot of territory between abusing substances and committing suicide, and what is worth offering by way of help in the meantime?

      Very often the people we call “addicts” want other things in addition to using their substance and up to that point they’ve been able to have multiple things — their heroin and their job; their alcohol and their children, etc.

      It seems to me the issue isn’t about blame at all; it’s about what workable solutions exist. Most everyone is trying to solve multiple problems at once with a limited armory of options.

      • Viper23 says:

        It does not matter why someone is being bad for their kid, they should be informed of the behavior that society wants them to change and then be given the opportunity to make that change. Offering them help with accomplishing that change is a net good.

        I imagine that somewhere out there, there is someone who is able to handle a job, heroic levels of heroin and raising 3 kids. I’m also sure that one of the added difficulties that person is having to manage on top of all of those other things is hiding their drug use. That person should not have to hide what they’re doing but at the same time, accept that if that drug use leads them to be a terrible person then they will be judged based on their terribleness.

        What the world doesn’t need is for society to make the lives of people who seek chemical augmentation even harder and more complicated than what it would be from simply living their lives with chemical augmentation.

        I wonder how many more heroin addicts would seek help when they needed it if it was as simple as telling your doctor that you’ve got strep throat… and how many more people would lead enhanced lives if they had ready, informed and quality access to such chemistries.

  30. Hackworth says:

    In case 5, you write that you prescribe the standard opioid withdrawal regimen. Does withdrawal not imply addiction? Going by the wiki article on PAWS, it sounds like a serious issue. If she shows enough signs of withdrawal to warrant treatment, then why is it not fair to say she was addicted?

    • Enkidum says:

      There was a lot of talk in the 80’s and 90’s about how “physical addiction” was the thing to worry about, which basically boiled down to “your body begins to require the drug to function normally, and you have nasty withdrawal symptoms if you stop”. Things like heroin, alcohol, and cocaine, and to a lesser extent caffeine and nicotine, have serious withdrawal symptoms.

      The trouble is that people’s drug-seeking behaviours have little to do with the strength of said withdrawal symptoms, people seem to exhibit all the problematic signs of addiction for behaviours that cannot have any withdrawal symptoms at all (notably gambling), and the brain circuitry involved in those behaviours is very similar to that involved in seeking heroin.

      A short statement which I think most addiction researchers would agree with: (many) addicts are not addicted to being high, addicts are addicted to getting high. It’s the journey, not the destination.

      So the short answer to your first question is “no”. Having withdrawal symptoms just means you’ve been using a lot of opium and need to manage your return to not using it, or you will be puking, etc. It does not mean that said opium was a problem for you, that you are unable to control your use, or that you will find a compulsion to return. That’s an entirely different problem.

      • Hackworth says:

        I am not sure I’m following completely. You say there is addiction without withdrawal, such as gambling. Makes sense to me, no objection there.

        What I’m asking is, how can there be withdrawal without addiction? Do you have an example of that as well? Maybe we are not on the same level as to what “withdrawal” means. Your example of someone who stops using opium and starts puking because of it sounds no different from a heroin addict’s withdrawal symptoms.

        Or are you saying that e.g. a diabetic is considered to be in withdrawal if they don’t use their Insulin when needed, though clearly you wouldn’t consider a diabetic an Insulin addict?

        • Enkidum says:

          If I, say, take a bunch of opium for severe pain relief and then stop (I dunno, let’s say I have cancer that is successfully treated), but I never take it for any reason other than the pain, I feel no compulsion to take it as soon as the pain goes away, and I don’t ever try to get any again, in what meaningful sense of the word am I an addict? Whether I get withdrawal symptoms is entirely irrelevant to the question of whether I am an addict. What matters is my behaviours and thoughts in regard to the drug.

          • Hackworth says:

            and I don’t ever try to get any again

            That’s not what I was asking about. Originally, I referred to Scott’s case 5, where the patient did seek more of the drug after the new doctor refused. Scott did not unambiguously state it, but I got the strong impression that Evelyn did have withdrawal symptoms, since he prescribed anti-withdrawal treatment.

            but I never take it for any reason other than the pain

            This is not the circumstance I was asking about. I was asking about a person who has withdrawal symptoms, such as puking, like you mentioned in your previous reply. The reason to continue using the drug would then be to not have to puke. I think it’s reasonable to not want to puke, just as reasonable as not wanting to be in pain from cancer treatment.

            The difference between taking drugs against cancer treatment pain and taking drugs against puking caused by not taking drugs is, of course, that in the latter case drugs are the both the problem and the solution. Just stopping to use the drug is the long-term correct answer, because you don’t need the drug to survive like a diabetic needs insulin, but obviously, it’s not always the easiest solution if there would be withdrawal symptoms.

            So again, my question: Assume I was using a drug for some reason; maybe it’s cancer treatment, maybe I want a mental escape from my shitty life. Stopping to use it would cause me withdrawal symptoms that are survivable but that I find less bearable than the alternative of quitting. Therefore I continue seeking and using that drug. What is the most meaningful distinction between me and an addict of that drug?

          • Enkidum says:

            Assume I was using a drug for some reason; maybe it’s cancer treatment, maybe I want a mental escape from my shitty life. Stopping to use it would cause me withdrawal symptoms that are survivable but that I find less bearable than the alternative of quitting. Therefore I continue seeking and using that drug. What is the most meaningful distinction between me and an addict of that drug?

            If you continue seeking and using it over a long period of time, in a self-destructive manner, then yes you’re an addict.

            If you have exactly the same withdrawal symptoms, but you just stop cold turkey, you’re not an addict. Ergo the withdrawal symptoms are not what makes you an addict.

            If you experience the same withdrawal symptoms, take a gradually-reduced dose to ameliorate them, and once that is finished you don’t seek them out any more, you’re also not an addict.

            Again, the pattern of behaviour and thoughts is what matters.

        • notpeerreviewed says:

          Some people use the phrase “physical addiction” to describe tolerance and dependence, but more commonly “addiction” refers to something like “substance abuse disorder”, which means substance use that’s causing major life problems. And it’s easily possible for someone to be physically dependent on a substance without having it screw up their life; it happens all the time with medical opioids.

        • DarkTigger says:

          What I’m asking is, how can there be withdrawal without addiction?

          Hangover is considered an withdrawal symptom isn’t it?

          Beliefe me I suffered from some quite nasty hangovers, and while I would agree that I abuse alcohol from time to time, I’m surley not addicted.

          • notpeerreviewed says:

            Believe it or not, we actually don’t know exactly how hangovers work. The symptoms do overlap with alcohol withdrawal to some extent, but full-fledged withdrawal is a much different beast than a hangover.

          • Nornagest says:

            Hangovers are pretty complex: they probably have something to do with alcohol metabolites, and something to do with impurities in the alcohol, and something else to do with dehydration. But they don’t have much to do with withdrawal — habitual alcohol users might even get less severe hangovers for a given quantity of liquor, the opposite of what we’d expect from withdrawal symptoms.

            Alcohol does have withdrawal symptoms, though, especially for serious alcoholics. Delerium tremens is one.

        • Protagoras says:

          The standard example is antidepressants. Effexor is particularly notorious (and I have personal experience with that one; it was awful, and I understand it can get much worse than it was for me). In such cases it is usually called “discontinuation syndrome” rather than “withdrawal,” but the different terminology doesn’t seem to involve any meaningful difference. But antidepressant use generally doesn’t resemble what we usually call addiction in really any other respect apart from the withdrawal, and antidepressant users are not considered addicts. Do you think they should be?

          • cuke says:

            It’s my sense as well that there’s no difference between discontinuation syndrome and withdrawal except that the first one sounds more fig-leafy for doctors who often don’t adequately oversee a long, slow taper off a drug like Effexor. Two of the hardest months of my life were spent “discontinuing” Effexor. Heroin users have reported to me that getting off Effexor was harder for them than getting off heroin just in terms of the physical withdrawal effects.

      • J. Mensch says:

        The trouble is that people’s drug-seeking behaviours have little to do with the strength of said withdrawal symptoms, people seem to exhibit all the problematic signs of addiction for behaviours that cannot have any withdrawal symptoms at all (notably gambling), and the brain circuitry involved in those behaviours is very similar to that involved in seeking heroin.

        Is it possible to become physically addicted to whatever is causing the thrill of gambling? (as in dopamine or whatever it happens to be)

        • Enkidum says:

          Is it possible to become physically addicted to whatever is causing the thrill of gambling? (as in dopamine or whatever it happens to be)

          In the way that most people use the term “physically addicted”, I don’t believe so (I am not a medical doctor or addiction specialist, so someone please correct me if I’m wrong.) You are unlikely to become extremely nauseous or suffer from crazy headaches, and you definitely won’t suffer catastrophic organ failure (which you might if you were a serious alcoholic).

          That being said, there will likely be consequences, and those are physical, because, you know, dopamine is physical. It’s just they tend to manifest themselves in what we think of as psychological space.

    • Scott Alexander says:

      See discussion earlier on this thread on physical dependence vs. addiction.

    • Grek says:

      I went through withdrawal symptoms after abruptly discontinuing Celexa. Does this indicate that I was addicted to Celexa?

      • cuke says:

        I do think this is a terminology problem. Doctors would call what you experienced “discontinuation syndrome” and no professional I know would call that “addiction.” Your body’s chemistry adjusted in various ways to the medication — that’s not addiction.

        Addiction is poorly defined and loosely used, but it would generally be understood to include behavioral changes that interfere with your daily functioning — whether due to impairment or substance-seeking.

        Withdrawal symptoms do get listed as a criteria for substance use disorders, but they are neither necessary nor sufficient to make the diagnosis.

      • notpeerreviewed says:

        Unfortunately people use the phrase “physical addiction” sometimes, which is a misnomer. “Addiction” more properly refers to disordered substance use – use that is difficult to stop despite the problems it’s causing for someone’s life.

  31. Lancelot Gobbo says:

    Beware of all behaviours that make one feel virtuous. Until you’ve been there, you can’t imagine the self-righteous glow that some docs feel when they can say no to someone using an addictive substance in a way they disapprove of. On the other hand, discovering that people will use a pin to traumatise their urethra so that even an observed urine sample shows haematuria and ‘prove’ their renal colic symptoms really deserve opiates, and seeing it happen over and again jades one’s willingness to give the benefit of the doubt. Add to this the very close tracking and supervision of opiate prescribing in most jurisdictions and you create docs terrified of prescribing them even to people who clearly require them. I took over a rural practice in which the previous doc had some odd habits. Having created a culture in which people could complain of a migraine and report to the ER and get a telephone order for Demerol and Gravol IM, it got to the point where there was a line up before a Saturday night dance for this form of party pre-medication. He had some awareness of the hole he had dug, and would sometimes order a sterile water injection instead, which I understand burned similarly to the real thing. It took years to clean up the mess, and involved confronting patients with records I had laboriously gone through showing they had attended several hundred times for Demerol injections. Eventually, it was stopped and I spent thirty years after that dealing with the oral benzos, barbiturates(!) and narcotics he had been generous with. I had the mixed luck of help from a doctor who I took on who was in a recovery programme for impaired physicians (alcohol and benzos) – he was extremely strict and righteous about denying addictive drugs; if he could quit then you bloody well can too. I say ‘mixed’ as a dry drunk isn’t always easy to work with and he eventually jumped ship saying it was too busy, which left me with the entire workload.
    But the fact remains, doctors feel they have lost to an addict who gets a script from them, and they win by catching them out. It’s the wrong way to think of the transaction, which is better characterised as trying to understand what will be the best help for the patient, and, harder, getting them on board. There is certainly a place for opiates in chronic non-cancer pain, even though they are no wonder drugs, they are sometimes all we have to offer and they can be used safely with appropriate safeguards such as a contract.
    As an aside, I am leary of ‘convenient’ papers that happen to support an agenda. I noticed the wave of papers showing nebulised bronchodilators to be far superior to inhaler delivery that came out in the late 70’s were all contradicted by another flurry of studies 15 years later when budgets were tight and nobody wanted to pay for nebulisers any more. You see it happen time and again that medical researchers follow the zeitgeist and publish what wants to be heard. So on contentious issues like the opiate crisis I expect to see a whole lot of such stuff. Maybe one day we will look back and laugh at ourselves. I’m out of it now, so not my worry!

  32. rahien.din says:

    It seems like a major hurdle for many people is distinguishing physical dependence from addiction.

    Physical dependence is : using a substance because of a physiological need, even if that need is avoiding withdrawal symptoms. You can become physically dependent on corticosteroids (and corticosteroids can even make you feel really good). No one in their right mind would describe corticosteroids as addictive.

    Addiction is : compulsively using a substance, out of proportion to physiological need, and despite adverse consequences. No one needs to take cocaine, and taking cocaine leads to many adverse consequences. Some people still feel compelled to take cocaine.

    When I prescribe medications to prevent seizures, some of my patients will say “But you have to wean off of those or you’ll go into withdrawal, so aren’t they addictive? I don’t want to get addicted!” You’re not addicted to levetiracetam, because A. you had epilepsy before you started taking levetiracetam, and B. once you wean off of levetiracetam, you won’t compulsively start taking it again.

    The tricky part comes when using medications that have genuine medical utility, but also the potential for addiction.

    By Campbell’s law, addicted patients will give you the same signals as merely-dependent patients (either deliberately, or, by simple evolution of behaviors), and your likelihood ratios will degrade. Meanwhile, even properly-prescribed opiates can create addicts – a physician may effectively give their patient a permanent and highly consequential disease. Furthermore, physicians have been sued for malpractice when their patients became addicted to opiates, and have lost.

    The “undertreating” and “overtreating” dose ranges seem to overlap! And they overlap unpredictably.

    A doctor prescribes a medicine. Then, to their own peril, the patient manipulates the doctor into giving more medicine. Then, when their life is ruined, they attack the doctor for responding to those manipulations.

    This is basically entrapment. A certain defense against this kind of entrapment is to become arbitrary – you’re just following your own orders. But being arbitrary means some people are going to fall on the wrong side of your inflexible rule. Seems like that’s what happened with some of these cases – physicians feel blackmailed and entrapped, and are solving the problem with the tool available to them.

    It’s extremely good that these patients came to you. But if we are going to fashion a different tool that solves this problem more effectively, we have to begin with compassion for these undertreating/overtreating physicians.

    • captbackslap says:

      I was explicitly taught, as part of my school system’s multi-year Drug Awareness and Curiosity Promotion Program, that physical dependence was literally synonymous with addiction. Anything else was mere “psychological dependence,” which the program clearly regarded as a lesser issue. They took this so far as to state that snorting cocaine was merely “dependency-forming,” although crack was addictive. I recall other informational literature at the time (the early 90’s) taking the same view.

      The 90’s were wild.

    • Gerry Quinn says:

      The thing is, surely, that if you have some element of psychological dependence, the physical dependence is going to be an additional barrier in stopping: “I’ll just have a few beers to cure this hangover and go home early, and tomorrow I’ll stop…” [Spoiler: subject did not go home early; also did not stop on the morrow.]

  33. Alex M says:

    A large part of the reason that we have an opioid crisis is because a lot of these hospitals don’t do good post-care after surgery. They will literally have a pharmacy hand people a container full of opioids and say “Take these for the next week, then take only when you’re in extreme pain.” Let me rephrase that so that we can all turn it over and ponder how stupid it is. They expect people in EXTREME PAIN – who are taking MEDICAL GRADE OPIOIDS for the FIRST TIME IN THEIR LIVES – to SELF-MANAGE a withdrawal plan. This expectation is total insanity.

    To me, it would make more sense for a short-term opioid prescription to automatically come with a withdrawal plan. For example, maybe the first week, you get the full strength opioids. When you go back to the pharmacist to refill your prescription next week, the new opioids are half strength, and the rest of the pill is placebo. If you go back to get your prescription refilled one more time, the new opioids are 25% the strength, and the pharmacy automatically notifies your doctor that you may have an addiction problem, because a normal person would have stopped taking the opioids after week 1 or week 2. The fact that you are still getting refills into week 3 means that you fall into the unfortunate tail end of the bell curve of people who have addictive personalities and require extra care.

    This isn’t rocket science. This is basic common sense shit. Unfortunately, I feel like our medical establishments – like a lot of other public institutions – refuse to listen to common sense unless they are incentivized to do so. And while this may be “uncharitable,” it needs to be said (because this is an indisputable FACT) that sometimes, the best incentive for institutions to change is for a bunch of really smart and ruthless people to get a really sharp and painful stick, and then start using it to poke the people at the very top of those institutions until they finally wake up from their oblivious lives of privilege and decide to use their power and position to do the right thing – for the sake of the public, of course. 😉

    • aphyer says:

      If you see a problem and your proposed solution is ‘let’s cause a bunch of pain and damage in order to coerce people I don’t like into fixing it’, not only do I not want you in charge of fixing the problem, I start to wonder if the problem might somehow have been your fault to begin with (as part of a similar plan to ‘fix’ some other problem).

  34. Don_Flamingo says:

    The doctors involved in the casestudies 1 to 7 seem to show a remarkable lack of judgement. (author excluded)
    If this happens so often, should we not assume that this is pathological?
    I have heard that in the United States, an aspiring doctor goes thru something called a “residency program” in which they have to do badly paid work for at least three years and up to five years, but with so much overtime and stress that they barely get any sleep. This is considered completely normal.
    Should it not be assumed that a considerable proportion of practicing US doctors is thus left partially braindamaged from the experience?
    If I was trying to be a snark, I’d point out that one would have to be, to even consider such a career path, but I’m not, I’m trying to raise a serious point here.
    Sleep deprivation for several years does not seem safe and not something that you’d expect everyone to “just walk off”. I would strongly expect this to have long-term deleterious effects on intelligence.
    Has anyone ever compared IQ-scores before and after a residence program?

    The human brain is quite a resilient machine, there are Zen monks in Japan who sleep only two hours a day and spent most of their hours doing a walking meditation to various shrines. And do that for decades.
    And they may do all that with a smile on their face, but it does not seem prudent to entrust any of them with heavy machinery, much less with the responsobility to save lifes.

  35. Leonard says:

    Question for Scott as Dr. Alexander:

    In addition to patients that are pretty clearly in pain and mishandled (“pseudoaddicted”), as paraphrased in this post, I assume that you also have patients who are pretty clearly trying to get more drugs but not for pain (that is, “addicted”). And also probably a lot of patients who are not clearly in either category (“maybe pseudoaddicted”?).

    What do you estimate are the proportions of each of these three types of patients?

    • Scott Alexander says:

      I don’t prescribe opiates and only interact with them when something has gone wrong, so I can’t tell you about that.

      I do sometimes prescribe benzos and amphetamines, which have some similar dynamics. I’ve only had one or two patients who struck me as clearly just drug-seeking, maybe because I have a long waiting list (which discourages addicts) and a private insurance based practice (which means people have to be holding down a job). I’ve had a few patients come to me with admitted addictions that we’ve worked on getting rid of, and a few patients who needed the drug but it retriggered an old addiction and we had to stop it, but actual drug-seeking has been pretty rare.

      Or I’m just really gullible, one or the other.

  36. OriginalSeeing says:

    Case 5: Evelyn is an elderly woman with dental pain. She goes to her dentist, who prescribes opioids. She is concerned – aren’t opioids addictive? “Don’t worry, you’ll be fine”, says the dentist. The dentist keeps her on them for eight months out of some kind of bizarre incompetence that is not her fault.

    This is really sad and something I observed myself years ago. When I got my wisdom teeth pulled my dentist gave me a month’s prescription for opioids with 3 refills. I only needed them for about 2-3 weeks. Obtaining 4 months worth of a highly addictive drug when I needed a bit less than 1 really blew me away. I wasn’t surprised to later find out that the US has an opioid crisis.

    Conversely, a friend of mine was recently prescribed only 1 week’s worth of the same opiod after a serious surgery. One week later, her husband had to fight hard with the doctor to get a 1 extra week’s worth because she was still in extreme pain. It was so painful that she wasn’t able to be fighting with the doctor herself about it.

    The pendulum swings far and wide.

    • Scott Alexander says:

      When did you get your wisdom teeth pulled?

    • Senjiu says:

      I got mine pulled about 15 years ago. Only two, not four. And not in the US, it was in Germany.

      I got local anesthetics for the procedure and I think that was it. It was in the afternoon and their effect ceased during the evening. It was a bit painful but I managed to fall asleep and the next day, so long as I didn’t put pressure on the area where they’d have been, it didn’t hurt. Not putting pressure meant I couldn’t chew either, but we were told that in advance and I just ate soup for two days.
      After that I didn’t have any problems with it any more.

      I think generally the stance towards painkillers is different over here. If you say the pain is bearable (and most people try to answer questions about that truthfully) they send you home without any and tell you to phone in if it changes. I’m not sure but from what I’ve heard they’re quicker in the US with prescribing painkillers. But I’ve never been so ill that I really needed painkillers for more than a day or two and I’ve never been ill in the US so I can’t compare it myself, it’s mostly hearsay.

      • notpeerreviewed says:

        Fifteen years ago was very far end of the pendulum swinging the other way, so it may have more to do with time period than location.

        • DarkTigger says:

          No, I asked an dentist who is friends with my parents, standard procedure is still local anesthetics, and a couple of high dose Iboprofen pills for the day, maybe a prescription for more if the pain is still inbearable the next day.
          After my root treatment 3 years ago I was send home with out anything after I assured I had 600mg Iboprofen pills at home.
          Opoids are considered a thing you give for serious chronic illnes (like tumor’s), the first few days after big surgeries, or people on their death beds.

          • Furslid says:

            I’ve never understood the reason for prescriptions of 800 mg ibuprofen. Why not take 4x 200 mg OTC ibuprofen. I already have a big bottle of ibuprofen at home. I can count to four, and can use the rest of the bottle for lower dose pain relief afterwards.

          • Exa says:

            (in response to furslid above)
            After I had my wisdom teeth removed (all four, just last year, in Texas) I was put on 4×200 mg ibuprofen (over the counter) and 1x500mg tylenol (also over the counter) every 6 hours for three days. So at least some doctors will trust the patient to count to four and just use the over-the-counter stuff.

            Relatedly, it turns out that a combination of ibuprofen and tylenol is really exceptionally effective for pain relief.

          • Enkidum says:

            But neither ibuprofen nor Tylenol are opiates (unless it’s Tylenol 3). EDIT – you did not imply they were, I was misreading the thread.

            Related and extremely-sad-but-pathetically-funny story (trigger warning for suicide attempt) I had a friend who tried to kill himself using over-the-counter Tylenol. Which could only work through very slow liver damage, or possibly choking to death if you cram enough in at once. He’s still around two decades later. Poor kid (at the time).

        • Aapje says:

          @notpeerreviewed

          I got one half-emerged wisdom teeth pulled in The Netherlands late last year. I also got a local anesthetic with the instruction not to eat with that side for a while.

          I was told the teeth had to come out during a yearly checkup and opted to get it over with right away; even though I left for a foreign conference the day after. This proved to be no problem, as there was very little pain. The wound closed up so quickly that I could eat with that side two days after the pull.

          Supposedly, the pain depends a lot on how the teeth are located and how strong the root is.

    • faoiseam says:

      I had a sinus infection a few weeks ago, and I got antibiotics for it from my GP. I stupidly climbed under my house to try to fix a dryer vent, which aggravated my sinuses, and that night could not sleep, so I went to the local emergency room. The attending asked me if I wanted something for the pain, and I told them that I doubted they had anything that would work, and said I didn’t really want anything. He gave me some steroids, and a prescription for 30 percocet. I did not get it filled, as honestly, I hate opioids. I think that doctors have a tendency to push drugs on people who don’t want them. Reverse psychology works best on two year olds and professionals.

      In contrast, my daughter just had her wisdom teeth out, and was prescribed tylenol with codeine, and told to not take it if at all possible, and given instructions on how to dispose of it. My older children had a similar experience, but without the excessive warnings and signing of documents explaining how I understood that it was more than likely that my child would now be an addict for ever because she took some codeine.

  37. Murphy says:

    Obviously Scott is part of the conspiracy.

    And probably an Insulin Dealer.

    https://www.youtube.com/watch?v=Es2f5MsEWmg

  38. Lambert says:

    Sounds to me like the cart’s before the horse.
    Addiction is pseudo-needing-drugs-for-a-medical-reason.

    • aphyer says:

      I support the push to rename this post ‘Against Against Pseudo-Pseudo-Needing-Drugs-For-A-Medical-Reason’.

    • Lambert says:

      I’ve worked out where this train of thought was going.

      Addiction is the pseudo one in the sense that addics are, to an extent, trying to imitate the ‘pseudoaddicts’. They’re actively obfuscating the distinction.

      This makes the problem anti-inductive in a way the medical system isn’t designed to deal with. Addicts will try to game any method to differentiate them from pseudoaddicts.

  39. Kyle Rowland says:

    Labeling people who act unpleasantly — “…Consistently disruptive behaviour when arriving at the clinic, aggressively complaining…” — as ‘addicts’ serves as an excuse to perform ersatz disciplinary actions. You need a way to manage patient misbehavior. I think the only way to make this humane is to allow people to freely disassociate with people who are behaving unacceptably. In the medical case, this would mean no duty of care, you can just decide you don’t like a patient and send them off.

    If people are hard to disassociate with, then you need to be able to hurt them to manage their behavior. If this can’t happen straightforwardly, it will happen in twisted and opaque ways. In my ideal world, patients who yell at doctors or staff would get yelled at louder, and if they didn’t stop it would escalate to them being removed physically. People who behave unacceptably get their behavior corrected, right then and there.

    If this is not allowed, then you need to be able to frame your disciplinary action as medical necessity. If you can’t disassociate from a patient then the degree to which you need control of them massively increases, and that means your ability to punitively hurt them must rise proportionally.

    It seems like the practical individual take-away is to try to be low-friction. When you need something you may have to push hard to get it, but push in ways that make it hard to see you as histrionic or a troublemaker.

  40. caryatis says:

    So if I’m ever in serious pain, what can I do to increase the odds that it’ll be effectively treated?

    “Be privileged” is the first thing that comes to mind, along with “be male.” “Don’t mention specific drug brands?”

    Edit: don’t admit any past substance abuse. As far as I’m concerned, no doctor needs to know I ever had a drink or a cigarette, let alone a joint.

  41. albatross11 says:

    How much of this behavior comes down to doctors being scared of lawsuits or criminal prosecution if they’re insufficiently on board with the current war on opiods? I know laws in our state have changed recently to impose all kinds of restrictions on what doctors may prescribe, in full moral panic mode. It seems very unlikely that state legislators can do a reasonable job of making this kind of decision from their armchair and overriding the doctors actually treating patients, but that’s never stopped them before.

    I’m asthmatic. Back when I was younger and my asthma was a common problem for me, I hoarded rescue inhalers. This was largely due to having had the experience of having an asthma attack, no rescue inhaler with doses left, and nobody willing to fill it till I can see the doctor on Monday, so I end up in the ER. I’m certain this would have fit the normal definition of addictive behavior, and yet I don’t think anyone gets addicted to albuterol.

    One advantage of getting older is that I’ve seen several previous moral panics, so I can recognize this one for what it is right away, and could have predicted more-or-less the reaction we’ve seen. I liked this quote from Scott’s original piece: Experts didn’t want to be the guy saying “well actually” in the middle of an Opioid Crisis, so they kept their mouths shut. This is exactly the dynamic of a moral panic.

    One thing that would ease some of this dynamic would be to eliminate the prescription requirement for most medicines–especially stuff that has low abuse potential and isn’t particularly dangerous. Birth control drugs, asthma control drugs, statins, antidepressants, insulin, etc., would be natural candidates. But it’s almost impossible to imagine this being done in today’s climate, where we’re even in a moral panic about flavored vape solutions (the answer to some homebrew vape solutions making users sick is apparently to bad widely-used off the shelf vaping solutions–nobody could possibly forsee what will likely happen next).

  42. yossarian says:

    One thing that non-addicts don’t understand, is how is it to be an addict. For example, non-alcoholics don’t understand that without medical help, one needs about 0.7 liters of vodka in order to quit drinking… (properly dosed, of course), otherwise – seizures, psychosis, etc…

    • notpeerreviewed says:

      Oddly, popular culture takes opioid withdrawal seriously, and based on what I’ve heard, tends to exaggerate how bad it is. And yet somehow most people don’t realize how awful alcohol withdrawal is.

      • Protagoras says:

        Indeed. Opioid withdrawal is supposed to be miserable, but as I understand it there’s very little chance of it actually killing you. For alcohol withdrawal, the chance of it actually killing you is substantial (not like it will probably happen if you don’t taper substantial, but when the issue is risk of death, anything higher than a small fraction of a percent is a Big Deal, and the risk from alcohol withdrawal for a long term heavy user, at least without treatment, seems to be closer to a few percent).

  43. SCPantera says:

    re: signs of drug seeking behavior

    Have a bit in the pharmacy piece I’m working on like that too where for virtually every common red flag we’re advised to look for has an extremely plausible explanation. Ton of parallels to what we’re having to deal with at the pharmacy too.

  44. dlr says:

    The real problem is that people are required to get prescriptions from doctors to buy medicine. That’s maybe a good idea for people who are under age, but hardly for an adult. Basic respect for the individual requires that they be allowed to make decisions for themselves. Information, and education, and recommendations are one thing, force is something else.

    That will get you more heroin addicts, but that is THEIR DECISION. They are the ones experiencing the consequences of their own actions, they should be the ones to make the decisions. It’s not like being a heroin addict is so dangerous to the rest of society that the rest of us have to intervene to keep ourselves safe from their behavior. All we would really need to do would pass a law saying you can’t drive a car or operate heavy equipment while drugged up, just like you can’t drive a car or operate heavy equipment while drunk. Keeping people from doing that is a legitimate public interest. The rest of it is just more meddling busy-body-ism, the real crisis of our times.

  45. echidna says:

    ‘Pseudoaddiction’ seems like a particularly unfortunate term. It sounds like something complicated, and forces you to argue that something isn’t really addiction. But if I understand correctly, what we are really talking about is failure to prescribe the drugs someone needs. This is a simple enough idea, and makes it clear that the onus of proof should be reversed: a necessary condition for diagnosing addiction should be establishing that the drug isn’t actually medically useful.

  46. thomasbrinsmead says:

    It’s well known that most racists deny being racist. Some of them say things like “I am the least racist person I know”. If you want to know whether someone is racist, simply accuse them of being a racist. Racists will almost always deny it. They will say things like “What have I ever done or said that makes you think I am racist?”, or “What do you mean by ‘racist’ ?” And if you are foolish enough to explain what a racist is, they will try to argue against it, or make excuses why your explanation doesn’t apply to them. This is a sure-fire way to identify racists. The best treatment for racists is to make them confess their racist ways, apologise, and promise not to be racist any more.

    Occasionally, however, this approach doesn’t work very well. Sometimes the accused will present as racist, complete with the denials and questioning over definitions. But for these people, the best treatment is paradoxically, to apologise to THEM and say “I must have misread you, I’m sorry that I accused you of being racist.” These people are pseudo-racists. They look and behave exactly like racists, but they belong to an entirely different category altogether.

    Some of my friends are absolute experts at spotting racists. And most of the people they accuse act in exactly the way that the model racist behaves in the textbook. “I’m not racist”, they say. “What do you mean?”, they challenge. Sometimes they become hostile and offensive, which is exactly what you’d expect from a racist.

    What do you think – is “pseudo-racism” really a thing? My expert racist-spotting friends are very skeptical.

    There is a similar dynamic involved with impenitent criminals who continue to maintain innocence, despite being convicted. Some of the very worst of them manage to get a retrial and an overturned conviction based on incontrovertible evidence that they couldn’t have committed the crime they were originally convicted of. In the legal system, these people are called “innocent”, but if the justice system were as infallible as the medical profession, they’d possibly be known as “pseudo-impenitent”. Since prosecutors actually are infallible, the term they use is “pseudo-guilty”.

    That reminds me, many black slaves used to suffer from a mental illness called Drapetomania. Less well-known is the condition of pseudo-drapetomania which should be treated, not by the removal of the big toes, nor by whipping the devil out of the sufferer, but by taking away their shackles. Differential diagnosis is challenging, but possible. True drapetomania sufferers have very dark skin. If your patient is white, it’s probably only pseudo-drapetomania.

  47. Nietzsche says:

    TL:DR. There’s a test for whether a patient is an addict. This test can give false positives. The false positives turn up when the patient really needs the drug, or needs more of it. That’s pseudoaddiction (= false, not-real addiction).

    • Enkidum says:

      That seems pretty heavy on the “DR”.

    • thomasbrinsmead says:

      It’s worse than that. There is a test for treatment dosage being incorrect. If the dosage should be decreased, we call this condition “overtreatment”. If the dosage should be increased we don’t call this condition “insufficient treatment”, but bizarrely, “false overtreatment”. The test for treatment dosage being incorrect gives essentially identical results whether the treatment dosage should be increased or decreased, but we don’t call the it a test for “wrong dosage”, we still call it a test for “overtreatment” which sometimes mistakenly classifies “false overtreatment” as “overtreatment”. To emphasise the asymmetry, consider that we don’t call it a test for “false insufficient treatment” which sometimes mistakenly classifies actual “insufficient treatment” as “false insufficient treatment”. 

      If my lawnmower won’t start on a cold day because I have run out of petrol, it would lead to a very strange way of looking at it to describe the problem as “false engine flooding”, even if the flooding the engine is more common than running out of fuel. If the test I’m using can’t diagnose the difference between too much fuel, and not enough fuel, the test is not a test for engine flooding, its just a test that indicates that “something is wrong”. The correct interpretation is “There’s probably too much fuel in the engine… or maybe there isn’t enough fuel in the engine” and no-one but a Bayesian statistician would consider the test a particularly useful guide to providing insight into the cause.

  48. AMT says:

    I think pseudoaddiction is just a bad, misleading term that should not be used. Replace it with “legitimate need” and it should become a lot more obvious. Yes, it’s common sense that some people are in pain and others may just be pretending to get a drug and possibly hard to tell, but only a robot could believe that no person could ever have a legitimate need for pain medication.

  49. Cptn.Penguin says:

    This post (like SSC posts so often do) showed me how wrong I was about something that in retrospect seems so obviously true.
    The first time I heard about pseudoaddiction was on Last Week Tonight or the Daily Show or something like that. And I have to admit, what I took away from it was “They advocate for treating addicts with more drugs? I can’t believe pharma companies are so -almost cartoonishly!- evil, to try and get away with this kind of bullshit!”
    And here I am reading the arguments of someone who actually thought about it for a second or maybe even two and feel like a complete idiot.
    Of course the show “explained” the term in an as ridiculous sounding manner as possible to fit into their “funny bit about the evil pharma companies” narrative. But that doesn’t excuse my own gullibility, especially since (I thought?) I already had a pretty low prior on “these-kind-of-shows-actually-getting-things-right”.
    I also feel like this whole issue is exacerbated by the english language using the word “drug” both for medicine and, say heroin. If it was called “medicine-seeking behavior” maybe we wouldn’t be having this problem, since it would be plainly obvious that people sometimes “seek meds” because they need meds for their condition/disease.

    • cuke says:

      I support using the word “drug” for both medication and illegal drugs — they’re both substances we take to effect some change in how our mind or body is functioning. The boundary between legal and illegal, between “drug” and “medicine” moves over time. Using different words to my mind creates a false distinction that distracts from the science of a substance producing change in a body over time such that the body has trouble adjusting to not having the substance. In both cases, a person going through withdrawal needs more treatment or support than they’re getting to reach to the other side of the experience safely.

  50. Peter Gerdes says:

    I don’t understand the focus on denying drug seekers medication. The problems that caused opiate crisis were doctors giving perfectly genuine patients opiate scripts they didn’t need that got them addicted.

    Given that we treat opiate addiction with actual opiate prescriptions if a committed drug seeker gets a script..shrug. Once your sure the patient either really needs the meds or is a committed active drug seeker the risk of harm from prescribing is minimal.

    It’s the scripts written when the person isn’t saying they absolutely need this to avoid anguish that are the danger yet that’s where least scrutiny is applied.

  51. jhertzlinger says:

    This article reads slightly differently when taking pseudoaddiction into account.

  52. jbslattery says:

    I’ve been reading Fentanyl Inc. (link below), and I’d love to hear your take on the surge in synthetic opioids/cannabinoids/cathinonines coming from research chemical companies as someone with a strong background in the science around it. It seems like there are several concurrent “drug epidemics,” and politicians/the media are all treating them as the same thing.

  53. arctan says:

    The examples mentioned are what made me afraid to ask for pain meds when I broke my ankle, and I suspect the opioid crisis is what led to my not being offered meds in the first place.

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