Iatraddiction: A Diagnostic Term In Lieu Of Pseudoaddiction
When David Weissman coined the notion of pseudoaddiction to explain addictive-like behaviors in non-addicts, he underscored how important it is to closely consider a patient’s life situation and motivators before we assigned a psychiatric diagnosis to those behaviors.
Current diagnostic protocols are too often limited to just the ticking of items from a menu of observations. These are tallied up and the score produces a diagnosis. Too little attention is paid to the motivation for a behavior. This is especially so in cases of possible or suspected substance abuse disorders.
Axis IV Mitigators
Mitigators are used in the legal system to explain behaviors. The DSM-IV-TR offers the Axis IV sphere to capture important mitigations, but too often Axis IV information is either not adequately provided or it is not given the weight of the other Axes. Modifying the attributes of an event with Axis IV information can drastically alter how and why a perceived behavior is formed, articulated and interpreted. Although any one of the nine Axis IV categories may apply to a particular patient, the most common ones related to iatraddiction are economic problems (e.g., inadequate finances to get medical care), problems with access to health care services (e.g., problems with available facilities or insurance), or other psychosocial and environmental problems (e.g., a difference of clinical opinions with caregivers.)
Pseudoaddiction could be an accepted Axis IV diagnosis because it provides the seat on which to explain why other behaviors occur. Axis IV information unites the real life dimensions of human behavior to the diagnostic work-up — it tells us about the world in which the patient lives. It is, therefore, the place to note iatrogenic disorders. Pseudoaddiction is one such disorder.
The Federation of State Medical Boards of the United States, Inc. Model Policy for the use of Controlled Substances for the Treatment of Pain, addressed this iatrogenic concept. In May 1998 they defined pseudoaddiction as “The iatrogenic syndrome resulting from misinterpretation of relief-seeking behavior as though they are drug-seeking behaviors that are commonly seen with addiction. The relief-seeking behaviors resolve upon institution of effective analgesic therapy.” In May 2004 the definition was modified to this: “Pattern of drug-seeking behavior of pain patients who are receiving inadequate pain management that can be mistaken for addiction.”
Pseudoaddiction never became an official diagnosis. It stands as a mixture of multi-axis concepts. Medical and legal problems often result from pseudoaddiction. It may appear complex, yet it can be easily understood and treated. Essentially, the pseudoaddict wants medication (in particular pain medications) sooner than the prescription allows. Inevitably, the patient uses the medication more rapidly than prescribed, usually because the therapeutic effect of the medication isn’t lasting long enough or it is too weak. The patient complains and asks for an earlier medication refill or different dose. If the primary doctor refuses to approve the refill or change, then the patient — now acting as a ‘pseudoaddict’ — seeks out medications from other sources. These sources can be other medical providers, sympathetic friends or family, illegal drug sellers, or internet pharmacies. The goal, however, is not to feed an addiction. The goal is to get symptom relief.
The sine qua non of pseudoaddiction is that once the physician matches the treatment dose to the patient’s real needs, there is no further need for medications from other sources. The aberrant behaviors associated with getting extra medications are the direct result of an insufficient primary treatment. This condition is iatrogenic. The author would propose that this behavior be called “iatraddiction” instead of “pseudoaddiction.”
Separating Addiction from Iatraddiction
Typical addictions are not readily treated — the tendency to relapse is very high. Treatment is lengthy, costly, and demands a solid set of clinical skills and commitments. Iatraddiction, however, is easily treated, and relapse is virtually nil as long as the proper treatment plan remains in place.
The reason is simple. Addicts use the medications to escape from life. Iatraddicts, by comparison, use the same medications to re-join life.
Until the physician understands the patient’s motivations for surreptitiously getting medications from another source, any suspicion of an addiction can be given no credence because it might surely be a possible false-positive diagnosis.
Popper’s Falsifiability and Hypothesis Testing
Weaver and Schnoll offer a simple test for what they call pseudoaddiction: “…giving the patient appropriate pain medication and observing the pattern of behavior to determine which is causing the drug seeking behavior.” If the drug-seeking behavior ends, the condition is a pseudoaddiction, not an addiction. This reaches a diagnostic syllogism in the style of Karl Popper. Popper insists that any hypothesis be tested not only to see if is true, but also to see if it is false. This is the notion of falsifiability. This brief test by the Weaver scenario shows how a theory of an addiction is proven to be false.
Falsifiability requires that before a theory can be considered true, it has to be tested to show where it might be false. In medicine this should be central to every diagnostic process.
When a pain patient displays behaviors consistent with an addiction, the physician is obligated to try to prove that a possible diagnosis of an addiction is wrong. In other words, the physician has to reframe the hypothesis and challenge it to a test to see if he is correct, and one way to do this is to explore the motivations for the patient’s behaviors. In an ideal world, testing the motivations would occur if the patient is allowed unfettered access to pain medications. If only the amount needed to control the pain is used despite the ready availability of additional medications, and the drug seeking behaviors characteristic of a conventional addiction disappear, then the addiction hypothesis is wrong. Of course this is not a realistic test — patients can not initially be given unlimited access to medications. But there must be the development of a doctor-patient rapport and trust such that both doctor and patient feel comfortable discussing it. Then the doctor should systemically increase the strength of any inadequate treatment tool — including medication doses — until the iatrogenic problem resolves. This testing and diagnostic approach also applies to other clinical situations in which a patient clandestinely seeks to supplement an inadequate principal treatment.