Slate Star Codex

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.