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Exploring the patient history

Aberrant drug-related behaviours

Behaviours that may indicate addiction are known as aberrant drug-related behaviours. Generally speaking, these behaviours suggest a loss of control of using opioids.

However, aberrant behaviours do not always indicate addiction. For example, patients with inadequately treated pain sometimes run out of medication early and request higher doses. This situation is known as pseudoaddiction. The behaviour generally resolves with reasonable dose increases, whereas a patient with an addiction to opioids will continue to run out early and seek higher doses.

Aberrant drug-related behaviours that suggest addiction

  • Rapidly escalating the dose. Analgesic tolerance develops slowly. Patients with a stable pain condition are often able to remain on the same opioid dose for months or years (Ballantyne, 2006). In contrast, psychoactive tolerance develops within days or weeks, forcing a patient who is addicted to escalate the dose quickly to get the same effect. Patients with an opioid addiction often end up on doses well above what would normally be required for the pain condition (e.g., more than 200 mg morphine equivalent per day).
  • Taking larger doses than prescribed, and frequently running out early. Patients with an opioid addiction tend to binge to achieve the desired psychoactive effect. Running out often triggers other behaviours, such as demanding fit-in appointments, and experiencing anger and conflict.
  • Acquiring opioids from other sources. Sources can include family and friends, the street, double-doctoring and the emergency department.
  • Altering, stealing or selling prescriptions.
  • Chewing, smoking, injecting or snorting oral medications. This increases the speed of entry into the central nervous system, creating a more powerful euphoric effect.

Addiction indicators in the patient's history

Suspect addiction if the patient:

  • provides a dramatic, inconsistent history of analgesic response. Normally, patients report a modest, graded analgesic response. Patients with an addiction may say, "It's the only thing that works" or "I can't live without it," while also claiming that "The dose is barely adequate and only takes the edge off."
  • reports a past or current addiction to opioids or other drugs
  • reports social isolation or loss of function
  • describes withdrawal symptoms at the end of a dosing interval (e.g., myalgias, dysphoria, anxiety, magnification of pain)
  • has a history of depression or anxiety (particularly posttraumatic stress disorder)
  • reports immediately improved mood with opioid use, and possibly drug craving.