Many issues involve the use of controlled substances and their potential inherent properties. Clinicians need to be comfortable in the use of medications for illness and pain, and be aware of medication use patterns in clients with a history of addiction. In some cases, Opioids have not been prescribed because of unwanted concerns about addiction.  We are concerned that behavior patterns, with the appearance of drug abuse or addiction, can be labeled as drug addiction, unfortunately ensnaring in the process, victims who are motivated to engage in these learned and acquired survival behaviors (due to the ravages of pain) in an attempt to cope with their lives.

When viewing these Acquired Prescription Drug Behaviors (APDB), the term “addiction” creates diagnostic confusion, resulting in a wide spectrum of diagnostic meaning. As a result, it becomes necessary to consider the social context in which the diagnosis of addiction is made in pain patients. A typical government sponsored edict entitled “War on Drugs” generates an atmosphere of fear and panic to main line clinicians across America. Chronic Pain patients on opioid treatment can be labeled as addicts, although some are not.  Clinicians and insurance adjusters are eager not to overlook any behavior that could later be pointed to as evidence that an Opioid addict may be missed.  This creates the impression of addiction, and an altered approach to treating that can be detrimental to the pain sufferer.

Defining the Problem

Clients with drug addiction and uncontrolled pain commonly have persistent intolerable pain, because of the multi-factorial complex issues of pain control and management.  Physicians should be concerned about writing prescriptions to those whose sole purpose is to acquire controlled substances for personal addictive use or diversion.  This caution of treating clients with illegal behaviors should not interfere with treating people with (APDB) It is also not uncommon that drug addicts with or without criminal behaviors have significant pain disorders.

Acquired prescription drug  behaviors  can occur in individuals with and  without prior genetic, or  psycho-social issues, or in the previously and/or currently alcoholic and/or  addicted individuals,  or can evolve later during the course of  treatment of these clients..

The Challenge of Opioid Addiction

For the past quarter century, scientific research has revealed that the prevalence of opioid addiction among patients treated for chronic pain is far lower than believed. Studies indicate that the rate of opioid addiction in populations of chronic pain sufferers is similar to the rate of opioid addiction within the general population. Other studies indicate that a history of previous substance abuse isn’t predictive of treatment failure in chronic pain sufferers treated with opioids.

Alterations in physiology and behavior

APDB’s evolve in the pain client as a result of ongoing illness and pain.  With or without prior genetic or psychological disposition, individuals develop behavioral sensitization to the ongoing trauma of illness, pain or disability, and living with illness.  Biologically and behaviorally sensitizations results in neuroplastic changes, and evolve into an allostatic state (homeostasis through adaptation) (8).

ALLOSTASIS

“Allostasis describes maintaining stability outside the homeostatic range by varying the internal milieu to match environmental demands.”

“This concept has been applied to neurobiological models of drug addiction and is thought to contribute to the vulnerability of drug addicts to relapse, as addicts continue to use drugs in order to maintain their psychological state within a homeostatic range.”(5)
 
“Allostatic load refers to the cumulative wear and tear on body systems caused by too much stress and/or inefficient management of the systems that promote adaptation through Allostasis.”(7)
 
 This new allostatic state now becomes the bio-behavioral state that we are treating!  This current physiological state can be maintained or worsened, changed by detoxification (reduction of the toxic property of a substance) (1), or corrected (partly or mainly, depending on potential for bio-behavioral healing).

The Psychiatric and American Pain Society’s Definition of Addiction
DSM-IV
(3 or more within one year)
1) Tolerance
2) Withdrawal
3) Larger amounts/longer period than intended
4) Increased amount of time spent in activity
5) Social, occupational, and recreational activities given up or reduced
7) Opioid use is continued despite adverse consequences

Definition from:
Consensus document from the American Pain Society, American Academy of Pain Management, American Society of Addiction Medicine

Addiction is a primary chronic neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

 Definitions of addiction to DSM IV definition relies on the terms dependency and addiction as being interchangeable.  American Pain Society’s definition is aimed at the predisposing factors for physiological instability that predisposed to neuroplastic changes, when addictive medications and pains behavioral effects merge physiologically.  Some view entry into the addiction arena on the grounds of illegal activities.  We should begin to look at these behaviors as to there evolution and origins and treatment requirements.

Acquired Prescription Drug Behaviors

The path of development of abnormal drug related behaviors can occur without prior genetic risk of addiction or prior addiction, or may evolve in previously addicted and predisposed individuals. When treatment is aimed at the specific behaviors that evolve, evidence based medicine shows that these behaviors are treatable. Treatment approaches and level of care can be evaluated and addressed based on the following issues:

A Rational Approach to Categorizing and Interpreting the Challenge of Opioid Addiction

When patients question the effectiveness of their treatment, their clinicians may become skeptical of their patient’s need for additional medication management. The patient may experience increasing pain and fear, which may result in self medicating behaviors. The APDB’s, chemical coping, pseudo addiction, negative coping skills, negative self talk and aberrant behaviors, in the fullness of time may result in the diagnosis of an “addict,” or true addiction.  These behaviors are treatable.   Such behaviors can and have resulted in a diagnosis of addiction, and the consequences of being labeled as an addict.  Once a client is labeled by family, friends, work associates, or medical providers, then resistance to treatment and change can escalate and the evolution of pain problems can worsen. This can result in adverse consequences and/or stigmatization that impact their lives.

The Evolution of Acquired Prescription Drug Behaviors (APDB’s)

Chemical Coping

Evolution of APDBs clinically appear most commonly in the same formative age group as addictive disorders (15 to 25 years of age), and are more apparent when illness occurs earlier in childhood and when more sever.  Behaviors evolve when pain, discomfort, and/or psychological effects of ongoing illness persist resulting in learned behavior patterns. During initial or ongoing trauma or medical illnesses, “needs” are not fulfilled or are mainly met through therapeutic pharmacologic treatments; this series of events can cause developmental imprinting (more pronounced in formative developmental stages. in early years). The development of emotional coping with illness, when combined with medication management to treat discomforts by caring physicians, can be termed “chemical coping” (4). These behaviors, once needed to cope and survive the trauma of illness persist, can become pathological and result in ongoing abnormal behaviors or “chemical coping.”  These APDBs   may begin as coping mechanisms to get the attention of family, friends, or physicians in order to get their perceived needs met. The very act of   medicating physical or emotional feelings provides positive reinforcement for continued drug use for any physical and ultimately can be used to medicate emotional symptoms.  As a result, behaviorally the younger a patient starts with pain and medication, the more likely that behavior becomes ingrained. The illness itself   becomes the nidus for a traumatic psychic injury. This occurs during formative periods of development and or correlate with ongoing illness and psycho-social loses, and can lead to a “behavioral Allostasis” (8) as part of that phase of development.

Patients develop patterns of getting attention or acquire comfort medications, for   physical pain or discomfort, and emotional relief.

These coping skills may be protective and allow for survival from the enormity of the impact of illness (pain, depression, sleep, fear, anxiety and panic).  These coping skills   are frequently necessary to get through the initial phases of illness and as such are “acquired” during the course of illness and influence this stage of emotional development.  As time evolves, these behavior patterns may be modified by periods of exacerbations during medical treatments, disease progression or break through pain and if relief is perceived to be delayed or not coming, pseudo addiction behavioral responses occur.  In addition, dealing with life’s intolerable discomforts, the evolution of negative coping skills and negative self talk become pattern behaviors.  These individual behaviors evolve into a host of aberrant drug related behaviors (4), which may represent self medicating to get individual needs met.   The patient feels that they are not adequately taken care of and respond by learning ways to get their medical needs met. These are viewed as aberrances of behaviors and may achieve the form of classic addiction. At this juncture the client may be totally unaware of anything other than their attempts to cope, and the addiction world can call this D.E.N.I.A.L (Don’t Ever Know I Am Lying).

What happens next depends on the response of outside forces and how the future developments of behaviors are molded! Treatment is aimed at identifying abnormal behaviors, and processing the origins of behaviors.  We have formulated a program on behavioral pain management while stabilizing the biological and behavioral allostatic (5) changes.  This occurs by a process of habilitation or rehabilitation in an integrated treatment environment.

As practitioners, we are concerned about the issues of diversion and sales which can occur even in pain patients. But prescription abuse issues, occurring in patients being treated for pain, are best treated   as adverse effects of medications which may present as behavior issues, and physiological impairments and tolerance, as treatable conditions.

The corollary…..  We must realize that self-medicating occurs in both pain and addictive states.  Self-medicating is common in the dual diagnosis population, as well as in the pain and dual diagnosis combined disorders.  The behavioral approach and treatment of the individual’s psychological issues may represent the primary treatment modality.  Acceptance becomes the corner stone of treatment in the combined field of pain and addiction.

Behaviors result from processing incoming feelings, using developing defense mechanisms and patterns of denial, and then we as prescribing physicians get a look at the aberrant behaviors that are occurring. Then we are challenged to interpret these behaviors in order to continue to prescribe controlled medications.

We have to interpret and gauge the need for medications, which ones and what amounts are needed. These incoming messages assist the prescriber in making a judgment on the drugs and amounts given.
 
We see we are basing our decisions on a series of events that make it difficult for us to interpret what the clients needs are. In the end we are sometimes faced with relying on the distorted signals, amplifications, minimizations,  partial truths, and at times only here the patients interpretation through there  D.E.N.I.A.L( were even the patient is unaware of the reality of the quality, quantity or locations of their own bodily discomforts and sight of injury). This later distortion of bodily awareness although quite rare is a not uncommon finding in the extreme illnesses requiring long term residential treatment at Bay Recovery Centers.

Prescription Drug Seeking Behaviors

Pseudo addiction

Pseudo addiction (3) represents drug seeking behaviors created by the patient’s fear and perception that their pain relief is inadequate. The term “pseudo addiction” was coined in 1989, to describe chronic pain victims mistakenly diagnosed as suffering from opioid addiction, after they were driven, by under-treated pain, to display certain drug seeking behaviors (13). The misconception of the term addiction can harm the patient suffering from pain. In reality, both drug addicts and non- addicts may have pseudo addiction. When patients display certain med seeking behaviors; they may unjustly be denied a necessary and appropriate change of medications or any further treatment at all. To complicate matters, similar behavioral patterns seen in addiction may evolve creating a behavioral pseudo addiction (BPA), even after the pain is correctly managed.

Coping Skills

To fully understand how aberrant drug related behaviors affect the patient, we need to look at their harsh realities of treatment, and the responsibility that many professionals share. (2)  Negative and positive reinforcement, in part, are nurtured by the medical and/or clinical helping professions.  Over the length of a genuine physical malady that may last for years, the development of Acquired Prescription Drug Behaviors (APDB) evolves. These APDB behaviors are, at times, mistaken for addiction. With or without a trained eye, it is difficult to differentiate between the two behaviors, learned and/or addictive. In fact, these behaviors can be identical in presentation with classic addictive behaviors. Frequently, the patient has no knowledge of the (APDB), is unaware and, in effect, in a pattern of denial.  What have evolved from positive well meaning coping devices that may have been life saving has now become negative coping devices. This behavioral Allostasis “homeostasis through adaptation” (9) has now become a negative adaptation (negative coping skills) manifested by these acquired aberrant behaviors.

All or nothing:  Seeing things in extremes, e.g. always do your best; “No one likes me.”
Labeling: Giving yourself labels that have all or none quality, e.g. “I’m a loser, or gee, am I dumb.”
Filtering:  Paying close attention to some points and not others, “All I think about is my pain.”
Rigid expectations:  Have lots of rules, e.g. “I should always give 100%, and if I fail I’m an idiot.”
Self focus:  Blaming oneself, e.g. “I’m being punished for being ill.”

Psychic reasoning:  Assume one knows how things are going to turn out, e.g. “Ill always be ill, and I’ll always be in pain.”
Emotional reasoning:  Relying on negative feelings to interpret reality, “I feel so useless, therefore I am useless.”
Helplessness:  Feelings and self-esteem are controlled by outside factors, e.g. “I can’t help feeling scared”.

Here is a secondary list of negative coping skills.  Negative coping skills cost you, every time you use them.  They will mask the problem.

Aberrant Drug Behaviors

An estimated 43% of pain patients on narcotics have at least three of the following behaviors.

Drug-Related Behaviors Likely Indicative of Under-treated Pain

The basic under-treatment of chronic pain should be considered first on the list of differential diagnoses when considering the cause of worrisome, and aberrant drug-related behaviors. Some of these behaviors include:

• Borrowing another patient’s drugs
• Obtaining prescription drugs from non-medical sources
• Unsanctioned dosage escalations
• Aggressive complaining about need for higher doses
• Drug hoarding during periods of reduced symptoms
• Requesting specific drugs
• Acquisition of similar drugs from medical sources

Serious Drug-Related Behaviors Possibly Suggestive of Under treated Pain

Once these behaviors occur, under-treated pain should still be suspected first. But these behaviors are more serious than the above behaviors and may indicate other problems, occurring either by or in addition to under-treated pain:

• Prescription Forgery
• Stealing Another Patient’s Drugs
• Recurrent Prescription Losses

If these behaviors do indicate a substance abuse problem, this should be recognized. Also, noted by the clinician is the possible use of other drugs. This doesn’t occur the majority of the time. There exists a socially ordained predisposition on the part of physicians to automatically attribute the drug-related behaviors to opioid abuse. This is not a rational assumption, because other substance abuse problems have a much higher prevalence in society than opioid abuse. Correctly diagnosing substance abuse when it is present is important, because a mistaken diagnosis of opioid addiction when another substance is actually to blame may result in the patient being denied pain treatment as well as treatment for the actual substance-abuse problem.

Behaviors Suggestive of Opioid Addiction

The first two behaviors listed below erases any doubt that the patient displaying them is engaged in abuse of Opioids, although the occurrence of these behaviors does not necessarily mean that the patient is not experiencing a true pain problem. The third item, sale of prescribed drugs, is the most flagrant form of diversion. This may indicate addiction to Opioids or the abuse of some other substance, or it may simply reflect a profit motive.  Some pain patients even sell partial prescriptions and use the remainder to treat their own pain.  The income from the sales of their medication: 1) May support their other addictions, i.e. heroin, cocaine, THC, crystal meth; 2) Use the income to support themselves. Other problematic behaviors are:

• Injection of substances prescribed for oral use
• Concurrent use of related illegal drugs
• Selling prescription drugs

Discussion

When pain is not in a tolerable range, it remains a trigger for aberrant drug related behaviors. The most common infraction includes unsanctioned dosage escalation. Multitudes of pain victims have been accused of drug addiction, and their treatment terminated by suspicious clinicians, simply because the pain sufferer was bold or naive enough to admit that they used up their medication sooner than they were instructed. As a result, patients who have suffered from chronic pain for any extended period of time may have learned from bitter experience not to reveal to their doctor that they have engaged in unsanctioned dosage escalations.  Although, it is, at times, necessary for them to do so in order to function. Patients often continue to engage in this behavior behind the physicians back, after learning that revealing it will be held against them. This has serious implications for the quality of the patient/physician relationship.

Legitimate patients are frequently suspected of drug addiction when they exhibit “problematic” behaviors, such as requesting treatment with a specific opioid, which they already know, from experience, will help them. Using a rigid addictive behavior mentality, one can misinterpret the intent of the patient. This breeds distrust and puts the pain patient in jeopardy of being labeled.  It eliminates honest communication in the patient/physician relationship and substitutes a don’t ask/don’t tell relationship. It is a tragedy when such behaviors come to the attention of a physician who mistakenly diagnoses addiction, and ends treatment as a result. Even in the most experienced hands, a clear diagnosis is difficult.  Patients can display addictive and/or pain behaviors at any given time, for any given reason.

Because intolerable pain occurs, and the risk of opioid addiction is low, the recommended response to possibly APDB behaviors needs restructuring. In the past it was thought that a rigid structured program of opioid prescribing was needed. This is based on the concern that patients who display these behaviors are at risk for abusing their medications rather than APDB, and consequently must be tightly controlled in order to prevent their descent into addiction. When the described drug-related behaviors show up, doctors should think first about the “horse” of pain not yet tolerated, not the “zebra” of addiction.

Addicts engage in continued substance abuse, despite the harmful effects.  This is one of the diagnostic criteria of addiction.  In contrast, pain sufferers treated successfully with Opioids function better, and their lives improve. This allows physicians to objectively discern whether a patient is benefiting from treatment with Opioids, or may be engaging in substance abuse or actual addiction with detrimental consequences.

The physician finding these behaviors in a clinical setting, before making any assumptions about substance abuse or addiction, must first determine whether the principle of titration (medication management) to optimal functioning has been correctly applied. Re-evaluation of medical management, opiate rotation, combination opiate treatments, or opiate maintenance should be evaluated. In this manner, diagnosis of under-treated pain will be facilitated, as it should be. Substance abuse issues can then be considered in an appropriate secondary manner, if the suspect behaviors continue following effective titration.

In viewing APDB behaviors, to differentiate addiction vs. chronic pain behaviors, we can understand how drug use for the purpose of euphoric effects (getting high) is different than self-medicating the conditions of illness and pain in an attempt to alleviate suffering.

Conclusions

Awareness of aberrant behaviors resulting from the treatment of pain and illness can reasonably be characterized as APDB behavior on the part of the medical profession. Misunderstandings about the significance of drug-related behaviors disrupts the therapeutic relationship between patient and physician, contributes to the difficulty of treating chronic pain, and places practitioners at risk for unwarranted administrative and criminal prosecutions. It is therefore important not to jump to mistaken conclusions when abnormal behaviors are observed. It is also important to access consultation on the high risk patient by use of the “share the risk” model (10), in order to collaborate with other specialists.

The solution depends on recognizing the problem of intolerable pain, when it occurs, and placing it at the top of the differential diagnosis, when suspected drug-related behaviors are observed. By being aware of evolving pain behaviors, negative self talk and coping skills, and aberrant behaviors, we can glimpse on how deteriorating function and pain behaviors evolve, and how patients spiral down the dysfunctional path of pain and chemical dependency. Before hitting bottom we can bring treatment to our patients. By raising the bottom, and intervening when these behaviors develop, we can provide therapeutic support to our patients and restore them to a functional lifestyle.

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