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Watch for the hallmarks of 'pseudoaddiction'.

PALM SPRINGS, CALIF. -- Patients suffering severe, inadequately treated chronic pain can closely resemble drug addicts, posing diagnostic and management challenges for addiction and pain special-its, and primary care physicians.

John Femino, M.D., calls them "pseudoaddicts," a term developed in the past few years to characterize patients whose desperation to obtain relief may look a lot like an addict's drug-seeking behavior.

Like addicts, such patients may have a loss of control over their medication use. They may seek early renewals or report that their medication was "lost" or "stolen."

Sometimes, as in the case of a patient treated at his recovery center, the unresolved pain will lead to true addiction, said Dr. Femino, who practices addiction medicine in North Kingston, R.I.

This patient had previously unrecognized bone fragments left in his spine after unsuccessful surgery, causing excruciating pain. The patient's addiction and the source of his pain had to be treated in a collaborative, multidisciplinary fashion, Dr. Femino said at the annual meeting of the American Academy of Pain Medicine.

Several tip-offs can help to distinguish addiction from pseudoaddiction.

Importantly, a pseudoaddict is likely to keep appointments and to welcome non-pharmacologic adjuncts to medication.

"If I say, 'I've got a great physical therapist, 8% of our patients who go to him lower the dose of their pain medications,' the pseudoaddict will say, 'Great! Get me an appointment as soon as you can.'"

An addict is much more likely to dismiss the offer out of hand, saying it won't work, Dr. Femino said.

Addicts are also less compliant with psychological and other nondrug interventions and fail to report any pain relief whatsoever from them.

Chronic pain patients' biggest fear is becoming addicted. They may express concern about the possibility, rather than waiting for the physician to bring it up.

Another important element in sorting out addiction and pseudoaddiction is simply the family history, Dr. Femino stressed.

"I believe the single biggest determinant of addiction is genetic," he said.

Although the DSM-IV does not include a positive family history in the diagnosis of addiction, 100% of the patients in Dr. Femino's recovery center report a family history of alcoholism or drug abuse.

Patients with chronic pain who do have such a history merit special attention, such as more frequent counseling appointments, therapeutic drug monitoring, and stepped-up use of modalities such as physical therapy, he said.


Los Angeles Bureau
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Title Annotation:Addiction Psychiatry
Author:Bates, Betsy
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:Sep 1, 2005
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