Pain, Palliative Care

Opioid Pseudoaddiction revisited.

I see little wrong with the term “pseudoaddiction.”

The term, and the paper from which it was derived, has recently been the subject of some criticism.  But really there is not much wrong with the paper (yes, a single case report of which there are many in the medical literature).  It was published in Pain, the international peer reviewed journal of the International Association for the Study of Pain (IASP). Most young physician would be ecstatic to have a Pain publication.

So let’s revisit the clinical story that was reported, some 23 years ago….(Pain; 1989 Mar; 36(3):363-6)

“A 17-year-old man with acute leukemia and no prior history of drug or alcohol abuse was hospitalized with fevers and treatment-related bone-marrow aplasia. Several days into his hospital course he began complaining of continuous chest-wall pain directly over a new pulmonary infiltrate associated with a pulmonary friction rub. Initially he was given 5 mg of intravenous morphine every 4-6 h p.r.n. pain. Over the next several days he made repeated requests for pain medication prior to the 4-6 h dosing schedule. This prompted discussions between nurses and physicians resulting in repeated one-time orders for additional intravenous morphine or meperidine. During this time he was also receiving 50 mg of intravenous meperidine p.r.n. to control shaking chills during amphotericin administration. After 1 week of continued chest pain he began requesting meperidine for relief of chills unrelated to fever, amphotericin or blood product administration. complain of a variety of aches and pains for which he requested additional pain medication. The medical and nursing staff were not convinced that his pains were due to objective pathology and suggested (in written chart notes) that he was becoming addicted to meperidine and morphine. The housestaff consulted the cancer pain management team for advice as to how to manage the patient’s opioid ‘addiction.’

After reviewing the details of the case and interviewing the patient, a therapeutic intervention was made by holding a meeting with the involved nurses and medical staff. The purpose of the meeting was to: (1) help staff realize that the patient had a very real cause for pain (pneumonia, pleural rub), (2) point out that the current p.r.n. regimen of analgesics was inadequate (both in potency and frequency of administration) to control the patient’s pain, and (3) provide a role-play-demonstration where the staff was asked to imagine their own behavioral response to being given an inadequate supply of pain medication with no other resources available for analgesia. Concrete suggestions for management included: (1) instructing the team to go to the patient and openly discuss the past difficulties in pain control and give the patient reassurance that they believed his pain was both real and of sufficient severity to warrant strong medication, (2) prescribing a potent oral opioid on a time-contingent basis, with additional medication ordered for breakthrough pain, and (3) reevaluating pain control every 8 h with dose adjustments to be made as needed. Within 24 h of institution of these measures the patient’s pain was well controlled. Within several days his requirement for analgesia markedly reduced as the pneumonia resolved.

(1) inadequate prescription of analgesics to meet the primary pain stimulus,
(2) escalation of analgesic demands by the patient associated with behavioral changes to convince others of the pain’s severity, and
(3) a crisis of mistrust between the patient and the health care team.

Let me translate this for you. A young man (maybe of minority race with predominately white clinical caregivers) comes into the hospital after a bone marrow transplant for leukemia with chest wall pain. No one believed he had pain despite an exam and an X-ray that both suggested a lung infection as a cause of the pain for which he is seeking pain relief. The staff then thinks he’s addicted to opioids because they interpret his requests for extra pain medicines as “drug seeking.” Interestingly with appropriate pain control and disease management, his pain goes away as does his need for opioids.

Now may this situation have been used by others to justify the unquestioning use of opioids for the treatment of pain. Maybe!  But misinterpretation or misapplication of the concept doesn’t directly undermine the concept’s validity.  I see nothing but the thoughtful and sensitive management of a young man living with the consequences of his cancer therapy.

Your thoughts?…..


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