Pseudoaddiction is a drug reality: the nursing home medication problem you may not know you have.

Pseudoaddiction is a delicate issue, especially when you consider the potential for survey and legal problems. Although the term was first introduced in 1989, many healthcare professionals have never heard it used. But you probably have residents with this condition in your facility, and most of them have diagnoses of chronic, painful, or progressive diseases.

Residents with pseudoaddiction are your "clockwatchers." The prefix pseudo means "a false image," or "something that resembles the original subject," which in this case is addiction.

Pseudoaddiction is a syndrome, not a diagnosis, and residents with pseudoaddiction typically have pain that is partially but not adequately relieved by their current pain management regimen. This is often due to one or more of the following reasons:

* The drugs given provide inadequate relief

* The dosage is too low

* The interval between doses is too long

Pseudoaddiction is a condition that is created by healthcare providers through the following:

* Inadequate, inconsistent, and irregular pain assessment

* Lack of understanding of pain management and methods of assessing pain, such as using the various pain rating scales

* Our own fears and misunderstanding of pain, pain treatment, and addiction

Identifying the pseudoaddicted resident

The resident with pseudoaddiction often has great distrust of staff, and drug use is often a source of conflict between the resident and caregiver.

The resident views the pain regimen as inadequate, whereas staff consider the pain medications excessive. There is seldom a middle ground. The resident may become isolated and labeled a behavior problem because of clockwatching and acting out in frustration. Some residents are dramatic and will moan, hold their extremities in rigid positions, and display body language suggesting pain.

As the conflict escalates, nurses sometimes ask the physician to order a placebo. But consider two principles in this situation:

1. Pain is whatever the resident says it is, and staff should accept and respect his or her word, even in the absence of physical signs and symptoms of pain.

2. Placebos are never appropriate unless a fully informed consent is obtained, such as in a research situation. The American Geriatrics Society and American Medical Directors Association both state that their use is unethical and has no place in clinical practice. In addition, once the resident surmises that a placebo is being used, this compounds the problem.

Tolerance and dependence

Drug tolerance is a state in which a larger dose of analgesic medication is needed to control pain or maintain the original drug effect. In this condition, the pain exceeds the ability of the prescribed drug to control it. You correct it by increasing the dosage of the drug. Some clinicians believe in reducing the dosage to eliminate tolerance, but this is ineffective much of the time.

Drug tolerance is an unavoidable phenomenon in people who take narcotic analgesics over a prolonged period. Physical dependence is the development of physical withdrawal symptoms when opioids are abruptly discontinued. Tolerance and dependence are both normal responses to narcotic analgesic use. These are expected after two to four weeks of regular drug use, although it may take longer in some individuals.

Healthcare personnel do not usually consider the potential for tolerance and dependence at the time the drug is ordered or discontinued. Tapering the drug off gradually by decreasing the dosage or frequency usually eliminates intolerable side effects related to dependence.

Resident improvement

Occasionally, residents' pain will improve on its own through surgery or other interventions, such as injection of a long-term steroid. When the pain is less severe, people with pseudoaddiction usually request the painkilling drugs less often. However, the need to decrease the drug is much less common than the need to increase it.

Residents with pseudoaddiction are usually alert and unafraid to complain to surveyors. Inadequate pain relief may result in a nursing home receiving deficiencies for decreased quality of life, inability to maintain the maximum level of physical and psychosocial function, and whatever other complaints an angry resident can conjure up in retaliation for inadequate pain management.

Resident treatment

Pseudoaddiction should be ruled out any time there is a suggestion of addiction due to a change or escalation of pain behaviors. Do this by performing a complete pain assessment and reviewing the history of analgesic administration.

You should have a variety of pain rating scales available for residents, and each resident should select the one he or she wants to use. The pain rating scale is nothing more than a tool for communication that keeps residents, nurses, and physician on the same page regarding the level and intensity of each resident's pain.

The "cure" for pseudoaddiction is to adjust the pain management regimen so the resident is regularly medicated with an appropriate drug dosage at an appropriate frequency. The World Health Organization's (WHO) pain ladder is an excellent tool for planning a pain management regimen. Although originally developed for the treatment of cancer pain, the WHO ladder is accepted for treatment of all types of acute and chronic pain. For additional information, go to www.who.int/ cancer/palliative/painladder/en.

Do not be afraid of administering opioid (i.e., narcotic) analgesics. Many facilities fear that they cause respiratory depression in elderly persons. Reactions of this nature are rare, particularly when the dosage is started low and increased gradually. However, certain drugs, such as meperidine, methadone, propoxyphene, and tramadol, are not recommended for elderly persons.

Another consideration is to medicate the resident before the pain is out of control. Some residents do much better on a four- to six-hour scheduled regimen instead of receiving the analgesic drugs on an as-needed basis. Some residents also do well if a narcotic analgesic is alternated with an anti-inflammatory, such as ibuprofen. This may mean medicating the resident as often as every two to four hours with one drug or the other, but for a resident with uncontrolled pain, it can make a huge difference in quality of life and satisfaction with care.

The need for pain management education

If you see yourself or your nursing staff withholding or strategizing to withhold pain medications, consider taking a continuing education class on pain management. You may be surprised and pleased by what you learn.

Erroneous and inadequate pain management education is shockingly common among physicians and nurses. Sadly, some textbooks and teaching materials being used for pain management education are inaccurate. Being uninformed or misinformed, nursing home staff often experience great anxiety when deciding when and how to administer narcotic analgesics.

Improvements in professional education would contribute to an improved understanding of the differences between drug abuse and the legitimate use of narcotic medications for pain. Meanwhile, always consider pain as a factor if residents (whether alert and confused) are acting up.

Consider unrelieved pain as the reason for your "clockwatchers" and modify dosage and schedules as appropriate. Residents will benefit from your improved understanding of pain assessment and management.

RELATED ARTICLE: Are my residents drug addicts?

Many residents with pseudoaddiction have been labeled drug addicts. In fact, many nurses believe that signs and symptoms of pseudoaddiction provide conclusive proof that a resident is addicted to pain medication.

Because of this, nurses sometimes go to extraordinary measures to withhold or delay scheduled drug administration. If an opioid and a milder analgesic such as ibuprofen or acetaminophen are ordered, nurses frequently elect to give the lesser drug.

A pseudoaddicted resident may be a thorn in your side, but he or she is not a drug addict--even though the residents condition may mimic addiction at times. According to the American Geriatrics Society's Panel on Persistent Pain in Older Persons, addiction rarely occurs in people who are, under the care of a physician, taking narcotic analgesic drugs for valid medical conditions, including persistent or chronic pain.

Withholding pain medications exposes the facility to survey scrutiny and potential deficiencies, as well as lawsuits for providing inadequate pain medication to residents with painful chronic or terminal conditions. A handful of multimillion-dollar judgments have been awarded in similar lawsuits against long-term care facilities nationwide.--Sarbara Acello, RN, MSN 

BY BARBARA ACELLO, RN, MSN

Barbara Acello, RN, MSN, is an independent nurse consultant and educator in Denton, TX. She is a member of the Texas Nurses' Association and the American College of Healthcare Acello has worked as a long-term care facility consultant and educator in eight states and has written many textbooks, journal articles, and other materials related to long-term care and nursing assistant education. She may be contacted at [e-mail].