Undertreatment
Sociocultural Influences
Disease-related Variables
Operationalizing the Definitions of Abuse and Addiction

Undertreatment, sociocultural influence on the definition of aberrancy, and disease-related variables are concerns that increase the difficulty of assessing drug-taking behavior.

Clinical observation suggests that inadequate management of symptoms may be an impetus for aberrant drug-related behaviors. This concept has been extensively explored in the area of cancer pain. There is compelling evidence that pain is undertreated in populations of medically ill patients, including those with cancer and AIDS.[1,2] The term pseudoaddiction was coined to depict the distress and drug-seeking that can occur in the context of unrelieved cancer pain.[3] The cardinal feature of this syndrome is that the aberrant behaviors disappear when an effective analgesic intervention is administered. In the cancer population, first-line intervention is often a higher dose of an opioid.

Assessment for pseudoaddiction in the population of known substance abusers who develop painful medical disease is a challenge for clinicians. Clinical experience suggests that aberrant behaviors driven by unrelieved pain can become dramatic or particularly worrisome in substance abusers. Some patients appear to return to illicit drug use as a means of self-medication, at least in part. Others adopt patterns of behavior with health care providers that also generate intense concern about the possibility of true addiction. Although it may be clear that the drug-related behaviors are aberrant, the meaning of these behaviors may be difficult to discern in the context of unrelieved symptoms. Management strategies must reflect the diagnostic complexity.

When a drug is prescribed for a legitimate medical purpose, there is decreasing certainty about the behaviors that could be characterized as aberrant, abusive, or addictive. Although the aberrancy of some behaviors would not be argued (e.g., prescription forgery or the intravenous injection of an oral formulation), many other behaviors are less clear-cut. For example, is it aberrant for the patient with unrelieved pain to consume extra doses of a prescribed opioid, particularly if this behavior was not specifically prescribed by the clinician? Is it aberrant to use an opioid drug prescribed for pain as a nighttime hypnotic?

The importance of social and cultural norms raises the possibility of bias in determinations of aberrancy. Bias against a social group, even if subtle, could influence the willingness of clinicians to label a questionable drug-related behavior as aberrant when performed by a member of that group. Clinical observation suggests that this type of bias is common in the assessment of drug-related behaviors of patients with substance abuse histories. Questionable behaviors by such patients may be promptly labeled as abuse or addiction, even if the drug abuse history was in the remote past. In a similar way, the possibility of bias in the assessment of drug-related behaviors exists for patients who are members of racial or ethnic groups different from that of the clinician.

The core concepts used to define addiction may also be complicated by changes resulting from progressive disease. Deterioration in physical or psychosocial functioning that is caused by the disease and its treatment may be difficult to separate from the morbidity caused by substance abuse. This may particularly complicate efforts to evaluate the concept of “use despite harm,” which is critical to the diagnosis of addiction. For example, the nature of questionable drug-related behaviors can be difficult to discern in the patient who develops social withdrawal or cognitive changes following brain irradiation for metastases. Even if impaired cognition is clearly related to the drugs used to treat symptoms, this outcome might reflect a low therapeutic index rather than the patient's desire for these psychic effects.

The accurate assessment of drug-related behaviors in patients with advanced medical disease usually requires detailed information about the role of the drug in the patient’s life. Time spent out of bed or the existence of mild mental clouding may be less meaningful than other outcomes, such as noncompliance with primary therapy because of drug use or behaviors that jeopardize relationships with physicians, other health care providers, or family members.

The foregoing discussion emphasizes the difficulties inherent in formulating and applying a nomenclature that would allow appropriate diagnosis of drug-related phenomena in the medically ill. Previous definitions that include phenomena related to physical dependence or tolerance cannot be the model terminology for medically ill populations who receive potentially abusable drugs for legitimate medical purposes. A more appropriate model definition of addiction notes that it is a chronic disorder characterized by “the compulsive use of a substance resulting in physical, psychological or social harm to the user and continued use despite that harm.”[4] Although this definition was developed from experience in populations of addicts who do not have medical illness, it appropriately emphasizes that addiction is, fundamentally, a psychological and behavioral syndrome. Any appropriate definition of addiction must include several important characteristics, including loss of control over drug use, compulsive drug use, and continued use despite harm.

Even appropriate definitions will have limited utility unless operationalized for a clinical setting. The concept of aberrant drug-related behavior is a useful first step in operationalizing the definitions of abuse and addiction. The concept also recognizes the broad range of behaviors that may be considered problematic by prescribers. Although the assessment and interpretation of these behaviors can be challenging, the occurrence of aberrant behavior signals the need to re-evaluate and manage drug-taking, even in the context of an appropriate medical indication for a drug.

In assessing the differential diagnosis for drug-related behavior, it is useful to consider the degree of aberrancy. Less aberrant behaviors (such as aggressively complaining about the need for medications) are more likely to reflect untreated distress of some type, rather than addiction-related concerns. Conversely, more aberrant behaviors (such as injection of an oral formulation) are more likely to reflect true addiction. Although empirical studies are needed to validate this conceptualization, it may be a useful model when evaluating aberrant behaviors.

References

1. Breitbart W, Rosenfeld BD, Passik SD, et al.: The undertreatment of pain in ambulatory AIDS patients. Pain 65 (2-3): 243-9, 1996 May-Jun.  [PUBMED Abstract]
   
   
2. Cleeland CS, Gonin R, Hatfield AK, et al.: Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 330 (9): 592-6, 1994.  [PUBMED Abstract]
   
   
3. Weissman DE, Haddox JD: Opioid pseudoaddiction--an iatrogenic syndrome. Pain 36 (3): 363-6, 1989.  [PUBMED Abstract]
   
   
4. Rinaldi RC, Steindler EM, Wilford BB, et al.: Clarification and standardization of substance abuse terminology. JAMA 259 (4): 555-7, 1988 Jan 22-29.  [PUBMED Abstract]
   
   

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