7 ms·

Devil's advocate position (mostly from a book, "Dreamland", about this topic): "Pseudoaddiction" is deliberately defined such that it's indistinguishable from

by l_t 7y ago

Devil's advocate position (mostly from a book, "Dreamland", about this topic): "Pseudoaddiction" is deliberately defined such that it's indistinguishable from actual addiction. The concept was popularized by Purdue Pharma, who were trying to market OxyContin. At the time, providers were averse to prescribing opioids because of addiction concerns. Purdue created the "pseudoaddiction" term to teach providers that just because someone looks addicted, you can keep prescribing them opioids anyways. At the same time, they lied with statistics to tell doctors that opioids only caused "true" addiction in less than 1% of cases. Thus, the brunt of the message was that if you see addiction, there's a 99% chance that it's not real addiction. Many doctors were convinced. Now the nation is dealing with an opioid epidemic driven by OxyContin. Pseudoaddiction exists. But actual addiction also exists, and it's more dangerous and more likely to happen. Being afraid to diagnose "addiction" because of "pseudoaddiction", is just FUD.

l_t 7y ago
Beyond the devil's advocacy, my personal opinion is that the industry is currently swung too-heavily towards prescribing opioids. We need to swing back the other way. The trick will be not swinging too far, which is I think the brunt of this article's intent.
- jnbiche 7y ago
  > currently swung too-heavily towards prescribing opioids Ah, you would have been right about 10-15 years ago. Things have dramatically changed since then. I'm assuming you've not had any contact with the medical system requiring opiates for you or your relatives in recent years. Now, we've swung far, far too far to the other extreme, to the point that my WWII vet, community leader, church deacon grandfather was brutally undertreated for pain while he was dying of cancer. This is very typical now. Either that, or the medical system is very different in Silicon Valley or wherever you live.
  - l_t 7y ago
    I think you're right. You're not the only person in the thread with this feedback. I read this book and thought I could contribute, but I haven't read anything with more recent context. (Haven't even finished the book yet, still working on it.) So yeah, I appreciate this callout, I apologize, and I'll try to do better next time.
    - adamsb6 7y ago
      Something to keep in mind: very few people will write a book about how things are basically okay but could use some small tweaks.
- munk-a 7y ago
  Opioids aren't a great painkiller anyways - they're just a painkiller that can be patented.
tlb 7y ago
The article suggests that there isn't an easy way of distinguishing pseudoaddiction and actual addiction, no matter how the definition is clarified. It depends on how much pain the patient is experiencing, which is only truly knowable by the patient.
- l_t 7y ago
  Exactly, which is why it's such a valuable concept for opioid marketing. The line between addiction and pseudoaddiction is vague. Doctors can't judge it; nobody can judge it. Only the patient -- and the patient wants the drugs in this scenario.
- jnbiche 7y ago
  I think ultimately it (obviously) should be the doctor's call. But we've swung to such an extreme now that most people with severe chronic pain are undertreated or (more likely) untreated. I'm convinced that we're 5 years away from yet another backlash when we realize how many people with truly shitty, excruciating conditions are being forced to live in medieval medical conditions due to the current opiate hysteria. Once again, the number of deaths from prescription opiates is dwarfed by the number of opiate deaths from illegal opiates. There's not even a comparison. And the vast majority of the opiate deaths from illegal substances are from fentanyl and related substances, which are notoriously hard to dose and/or frequently spiked and/or passed off as drugs of lesser potency. Imagine the deaths we could prevent if we (as in Europe) allowed addicts to dose themselves with supervised, clean, hygienic, pharmaceutical-grade heroin while offering them treatment to get off of them if they so desired. Edit: I looked up current data and it looks like prescription opiates like oxycontin account for about 1/3 of opiates deaths. Maybe not quite "dwarfed" like I claimed above, but a definite minority of opiate deaths are caused by prescription narcotics. And given the current growth rate of deaths from illegal opiates, it could easily be only 10% in the next 1-2 years: https://www.cdc.gov/drugoverdose/epidemic/index.html https://www.cdc.gov/drugoverdose/epidemic/index.html
  - brohee 7y ago
    You need to look further than just the cause of death, prescription opioids have been the gateway to heroin for many people...
narrator 7y ago
When you give something a name, somehow it becomes more real in people's mind. You can also then build a whole superstructure of advocacy and theory on top of that false concept which a large amount of paid advocates and academics become invested in. A lot of modern economics that justifies endless financial engineering follows this model.
jnbiche 7y ago
> Pseudoaddiction exists. But actual addiction also exists, and it's more dangerous and more likely to happen. Many people kill themselves over chronic untreated or undertreated pain. I've seen studies showing that people with chronic pain kill themselves at twice the rate of those without chronic pain (even that seems low to me) [0] and various other similar studies. Assuming this is true, and that the two are causally related, then opiate deaths and suicide deaths due to chronic pain are in the same order of magnitude. If you any of you are unfortunate to end up with a condition that causes significant chronic nerve pain, you'll quickly understand how this can be. 0. https://annals.org/aim/fullarticle/2702061/chronic-pain-among-suicide-decedents-2003-2014-findings-from-national https://annals.org/aim/fullarticle/2702061/chronic-pain-amon...
- jotakami 7y ago
  To add to your argument, “addiction” is not a cause of death, it is a risk factor for various unnatural causes such as suicide and overdose. The same could be said for chronic pain, but it is pretty easy to understand why chronic, untreated pain would lead to suicide. The connection between addiction and suicide is much more complex, and may have more to do with the reality of being an addict in modern society than the medical consequences of the addiction itself.
- l_t 7y ago
  I don't want to detract from your point about sympathy for chronic pain. But you can't mainline oxycodone into everyone who claims to have chronic pain, because that system is easily abused, as we've seen. A more nuanced approach is needed. We need a balance, and IMO we need to improve our ability to objectively measure pain instead of relying on a 1-10 scale. I am curious about your conclusion that "opiate deaths and suicide deaths due to chronic pain are in the same order of magnitude", though. According to my simple Googling, opioids are the cause of death for 21.7 per 100,000 people in the US, while suicide is only 14 per 100,000. So per your link, chronic pain suicide is about 10% of that, or 1.4 per 100,000. That means opioid deaths are about 10-15x more common, or am I missing something? edit: I'm realizing my understanding of this debate is significantly out-of-date. So I apologize if anything I've written seems tone-deaf, that wasn't my intention.
jdminhbg 7y ago
> "Pseudoaddiction" is deliberately defined such that it's indistinguishable from actual addiction. The point of the article is that it's the other way around -- addiction is defined in a way that includes plenty of non-addicts. It's like the old D.A.R.E. pamphlets that tell you to watch out for teens who are sullen, sleep late, distrust authority, etc.
- l_t 7y ago
  Yeah, I think the article presents a good point, logically speaking. But I think it's brash to ignore the history of the "pseudoaddiction" term, which is a tool of FUD. Of course it exists and makes sense, this was marketed to doctors. They're not dumb. Pseudoaddiction is real and important, which is why it's such a good marketing tool. It's a really tough problem. That's why I think considering both sides is incredibly important. I'm not trying to bash the article, just provide a different perspective on why pseudoaddiction might have been bashed in the press. edit: Apparently reading a book doesn't make me an expert! I'm realizing that it's actually pseudoaddiction that's getting bashed right now. Which makes sense, given the context of the article. I was still thinking about it from the lens of opioids being over-prescribed but it seems the pendulum has swung in the other direction. Sorry for muddying the discussion.
f5thesystem 7y ago
> Many doctors were convinced. Fuck those doctors. They should have their medical license revoked for being fucking stupid and gullible.
- kelnos 7y ago
  Your tone is a bit inflammatory, but I can't help but agree a bit. If someone who is selling you something is doing so by trying to convince you of a medical phenomenon that you (as a doctor) aren't familiar with, it's the height of irresponsibility to just accept that at face value. It shouldn't be a secret in the medical community that big pharma sales can be... unsavory.
  - f5thesystem 7y ago
    It's also distressing that through undergrad, medschool, residency they never learned that opioids are fucking addicting as fuck and how to think for themselves. I mean, this opioid crisis didn't just begin this year, or last, but it's been decades in the making. So imo doctors happen to be just as part of the problem as big pharma.
    - projektfu 7y ago
      Give me a break.
      - f5thesystem 7y ago
        High value comment triple A+ good job!
  - refurb 7y ago
    As someone who has worked in the pharma industry, most doctors are very skeptical of anything a drug rep says, not in the sense that they're lying, but more that they're trying their best to make their products look good. One shouldn't underestimate other factors in opioid prescribing: 1) the idea that pain is the "fifth sign" and should be aggressively treated and 2) that good pain control leads to positive customer experience. It's not as simple to say "jesus those docs are stupid to believe Purdue". Some maybe are, but most probably never even saw their rep.
kelnos 7y ago
> But actual addiction also exists, and it's more dangerous and more likely to happen. Not sure that's obvious, or true. The article itself recounts two situations where the patients denied meds they needed became suicidal, and a third where if the patient hadn't pushed the issue to get his meds (insulin), he would have died.
- l_t 7y ago
  Yeah, I was wondering who would call me out on that! I'm not aware of any good studies that compare addiction vs. pseudo-addiction. It's definitely not obvious, because a lot of doctors were convinced to the contrary. By the way -- I'm not saying those individuals in the article aren't important, but whitewashed "case studies" that are full of snark and biased language and have no sources or timeframes, are not the best sources of evidence. In particular, the "pain management" space is rapidly evolving in the US and without timeframes, many of those anecdotes have negative utility. I'm not saying "pseudoaddiction" doesn't exist, obviously, but we need statistical arguments that are more nuanced than "does it exist or not." edit: I'm realizing that my understanding of this debate is out of date. So I'd like to apologize if my stance seems insensitive to what's going on right now w.r.t. opioid prescriptions. My gut feeling is that addiction is a bigger problem, but that varies depending on how freely opioids are prescribed. If opioids are under-prescribed then pseudoaddiction becomes a larger problem, for sure. Being dumb, I just assumed they were still being over-prescribed...
Scarblac 7y ago
And I guess that there are also a lot of cases that the right dose, that the patient really needs for his excruciating pain, will lead to addiction as an unwanted side effect. After long enough, it's going to be both.

by l_t 7y ago

l_t 7y ago

Beyond the devil's advocacy, my personal opinion is that the industry is currently swung too-heavily towards prescribing opioids. We need to swing back the other way. The trick will be not swinging too far, which is I think the brunt of this article's intent.

jnbiche 7y ago
> currently swung too-heavily towards prescribing opioids Ah, you would have been right about 10-15 years ago. Things have dramatically changed since then. I'm assuming you've not had any contact with the medical system requiring opiates for you or your relatives in recent years. Now, we've swung far, far too far to the other extreme, to the point that my WWII vet, community leader, church deacon grandfather was brutally undertreated for pain while he was dying of cancer. This is very typical now. Either that, or the medical system is very different in Silicon Valley or wherever you live.
- l_t 7y ago
  I think you're right. You're not the only person in the thread with this feedback. I read this book and thought I could contribute, but I haven't read anything with more recent context. (Haven't even finished the book yet, still working on it.) So yeah, I appreciate this callout, I apologize, and I'll try to do better next time.
  - adamsb6 7y ago
    Something to keep in mind: very few people will write a book about how things are basically okay but could use some small tweaks.
munk-a 7y ago
Opioids aren't a great painkiller anyways - they're just a painkiller that can be patented.

tlb 7y ago

The article suggests that there isn't an easy way of distinguishing pseudoaddiction and actual addiction, no matter how the definition is clarified. It depends on how much pain the patient is experiencing, which is only truly knowable by the patient.

l_t 7y ago
Exactly, which is why it's such a valuable concept for opioid marketing. The line between addiction and pseudoaddiction is vague. Doctors can't judge it; nobody can judge it. Only the patient -- and the patient wants the drugs in this scenario.
jnbiche 7y ago
I think ultimately it (obviously) should be the doctor's call. But we've swung to such an extreme now that most people with severe chronic pain are undertreated or (more likely) untreated. I'm convinced that we're 5 years away from yet another backlash when we realize how many people with truly shitty, excruciating conditions are being forced to live in medieval medical conditions due to the current opiate hysteria. Once again, the number of deaths from prescription opiates is dwarfed by the number of opiate deaths from illegal opiates. There's not even a comparison. And the vast majority of the opiate deaths from illegal substances are from fentanyl and related substances, which are notoriously hard to dose and/or frequently spiked and/or passed off as drugs of lesser potency. Imagine the deaths we could prevent if we (as in Europe) allowed addicts to dose themselves with supervised, clean, hygienic, pharmaceutical-grade heroin while offering them treatment to get off of them if they so desired. Edit: I looked up current data and it looks like prescription opiates like oxycontin account for about 1/3 of opiates deaths. Maybe not quite "dwarfed" like I claimed above, but a definite minority of opiate deaths are caused by prescription narcotics. And given the current growth rate of deaths from illegal opiates, it could easily be only 10% in the next 1-2 years: https://www.cdc.gov/drugoverdose/epidemic/index.html https://www.cdc.gov/drugoverdose/epidemic/index.html
- brohee 7y ago
  You need to look further than just the cause of death, prescription opioids have been the gateway to heroin for many people...

narrator 7y ago

When you give something a name, somehow it becomes more real in people's mind. You can also then build a whole superstructure of advocacy and theory on top of that false concept which a large amount of paid advocates and academics become invested in. A lot of modern economics that justifies endless financial engineering follows this model.

jnbiche 7y ago

> Pseudoaddiction exists. But actual addiction also exists, and it's more dangerous and more likely to happen. Many people kill themselves over chronic untreated or undertreated pain. I've seen studies showing that people with chronic pain kill themselves at twice the rate of those without chronic pain (even that seems low to me) [0] and various other similar studies. Assuming this is true, and that the two are causally related, then opiate deaths and suicide deaths due to chronic pain are in the same order of magnitude. If you any of you are unfortunate to end up with a condition that causes significant chronic nerve pain, you'll quickly understand how this can be. 0. https://annals.org/aim/fullarticle/2702061/chronic-pain-among-suicide-decedents-2003-2014-findings-from-national https://annals.org/aim/fullarticle/2702061/chronic-pain-amon...

jotakami 7y ago
To add to your argument, “addiction” is not a cause of death, it is a risk factor for various unnatural causes such as suicide and overdose. The same could be said for chronic pain, but it is pretty easy to understand why chronic, untreated pain would lead to suicide. The connection between addiction and suicide is much more complex, and may have more to do with the reality of being an addict in modern society than the medical consequences of the addiction itself.
l_t 7y ago
I don't want to detract from your point about sympathy for chronic pain. But you can't mainline oxycodone into everyone who claims to have chronic pain, because that system is easily abused, as we've seen. A more nuanced approach is needed. We need a balance, and IMO we need to improve our ability to objectively measure pain instead of relying on a 1-10 scale. I am curious about your conclusion that "opiate deaths and suicide deaths due to chronic pain are in the same order of magnitude", though. According to my simple Googling, opioids are the cause of death for 21.7 per 100,000 people in the US, while suicide is only 14 per 100,000. So per your link, chronic pain suicide is about 10% of that, or 1.4 per 100,000. That means opioid deaths are about 10-15x more common, or am I missing something? edit: I'm realizing my understanding of this debate is significantly out-of-date. So I apologize if anything I've written seems tone-deaf, that wasn't my intention.

jdminhbg 7y ago

> "Pseudoaddiction" is deliberately defined such that it's indistinguishable from actual addiction. The point of the article is that it's the other way around -- addiction is defined in a way that includes plenty of non-addicts. It's like the old D.A.R.E. pamphlets that tell you to watch out for teens who are sullen, sleep late, distrust authority, etc.

l_t 7y ago
Yeah, I think the article presents a good point, logically speaking. But I think it's brash to ignore the history of the "pseudoaddiction" term, which is a tool of FUD. Of course it exists and makes sense, this was marketed to doctors. They're not dumb. Pseudoaddiction is real and important, which is why it's such a good marketing tool. It's a really tough problem. That's why I think considering both sides is incredibly important. I'm not trying to bash the article, just provide a different perspective on why pseudoaddiction might have been bashed in the press. edit: Apparently reading a book doesn't make me an expert! I'm realizing that it's actually pseudoaddiction that's getting bashed right now. Which makes sense, given the context of the article. I was still thinking about it from the lens of opioids being over-prescribed but it seems the pendulum has swung in the other direction. Sorry for muddying the discussion.

f5thesystem 7y ago

> Many doctors were convinced. Fuck those doctors. They should have their medical license revoked for being fucking stupid and gullible.

kelnos 7y ago
Your tone is a bit inflammatory, but I can't help but agree a bit. If someone who is selling you something is doing so by trying to convince you of a medical phenomenon that you (as a doctor) aren't familiar with, it's the height of irresponsibility to just accept that at face value. It shouldn't be a secret in the medical community that big pharma sales can be... unsavory.
- f5thesystem 7y ago
  It's also distressing that through undergrad, medschool, residency they never learned that opioids are fucking addicting as fuck and how to think for themselves. I mean, this opioid crisis didn't just begin this year, or last, but it's been decades in the making. So imo doctors happen to be just as part of the problem as big pharma.
  - projektfu 7y ago
    Give me a break.
    - f5thesystem 7y ago
      High value comment triple A+ good job!
- refurb 7y ago
  As someone who has worked in the pharma industry, most doctors are very skeptical of anything a drug rep says, not in the sense that they're lying, but more that they're trying their best to make their products look good. One shouldn't underestimate other factors in opioid prescribing: 1) the idea that pain is the "fifth sign" and should be aggressively treated and 2) that good pain control leads to positive customer experience. It's not as simple to say "jesus those docs are stupid to believe Purdue". Some maybe are, but most probably never even saw their rep.

kelnos 7y ago

> But actual addiction also exists, and it's more dangerous and more likely to happen. Not sure that's obvious, or true. The article itself recounts two situations where the patients denied meds they needed became suicidal, and a third where if the patient hadn't pushed the issue to get his meds (insulin), he would have died.

l_t 7y ago
Yeah, I was wondering who would call me out on that! I'm not aware of any good studies that compare addiction vs. pseudo-addiction. It's definitely not obvious, because a lot of doctors were convinced to the contrary. By the way -- I'm not saying those individuals in the article aren't important, but whitewashed "case studies" that are full of snark and biased language and have no sources or timeframes, are not the best sources of evidence. In particular, the "pain management" space is rapidly evolving in the US and without timeframes, many of those anecdotes have negative utility. I'm not saying "pseudoaddiction" doesn't exist, obviously, but we need statistical arguments that are more nuanced than "does it exist or not." edit: I'm realizing that my understanding of this debate is out of date. So I'd like to apologize if my stance seems insensitive to what's going on right now w.r.t. opioid prescriptions. My gut feeling is that addiction is a bigger problem, but that varies depending on how freely opioids are prescribed. If opioids are under-prescribed then pseudoaddiction becomes a larger problem, for sure. Being dumb, I just assumed they were still being over-prescribed...

Scarblac 7y ago

And I guess that there are also a lot of cases that the right dose, that the patient really needs for his excruciating pain, will lead to addiction as an unwanted side effect. After long enough, it's going to be both.