Managing Drug-Seeking Behavior
Recognize that apparent "drug-seeking" behavior most often represents legitimate medical needs—including pseudoaddiction from undertreated pain, therapeutic dependence, or anxiety about symptom recurrence—and conduct a careful clinical assessment for objective evidence of pain before labeling patients as manipulative. 1
Distinguish Between Three Critical Categories
The American Academy of Family Physicians emphasizes distinguishing between fundamentally different types of drug-seeking behavior that require completely different management approaches 1:
Pseudoaddiction: Behavioral changes that mimic addiction but are actually secondary to inadequate pain control, where patients seek alternate sources or increased doses because prescribed analgesia provides insufficient relief 1
Therapeutic dependence: Patients with adequate pain relief who demonstrate drug-seeking behaviors because they fear reemergence of pain or withdrawal symptoms, representing efforts to maintain comfort rather than addictive disease 1
True addiction/opioid use disorder: Should be assessed using DSM-5 criteria or through evaluation by a substance use disorder specialist 2
Management Algorithm for Patients on Opioid Agonist Therapy (OAT)
For patients already receiving methadone or buprenorphine maintenance therapy who present with acute pain:
Continue the usual dose of OAT and provide aggressive pain management with additional opioid analgesics as needed—never discontinue maintenance therapy during acute pain episodes 1, 2
Verify maintenance doses with the patient's methadone clinic or prescribing physician 2
Use higher doses of short-acting opioid analgesics at shorter intervals due to cross-tolerance and opioid-induced hyperalgesia 1
Reassure patients that their addiction history will not prevent adequate pain management, as patients dependent on opioids may be perceived as demanding when hospitalized due to distrust of the medical community, concern about stigmatization, and fears of undertreatment 2
Be aware that patients receiving OAT typically receive treatment doses that block most euphoric effects of additional opioids 2
Management for Suspected Opioid Use Disorder
Offer or arrange evidence-based treatment, preferably medication-assisted treatment with buprenorphine or methadone maintenance therapy combined with behavioral therapies 1, 2
- Identify treatment resources for opioid use disorder in your community and work to ensure sufficient treatment capacity 2
Critical Pitfalls to Avoid
Never allow concerns about being manipulated to cloud clinical judgment about legitimate pain medication needs 1, 2
Undertreating acute pain can lead to decreased responsiveness to opioid analgesics, making subsequent pain control more difficult 1, 2
Never discontinue OAT during acute pain episodes, as this can worsen pain due to increased sensitivity associated with opioid withdrawal 2
Do not use mixed agonist-antagonist opioids (pentazocine, butorphanol, nalbuphine) in patients on OAT as they may precipitate withdrawal 2, 3
Pain is always subjective, making assessment challenging, but this does not justify withholding appropriate treatment 1
Additional Assessment Considerations
Screen for comorbidities including mental illness and intimate partner violence, which are common in patients with substance use disorders and require concurrent management 1
Assess for infectious disease risks such as HIV, hepatitis, STDs, and tuberculosis in persons who use drugs illicitly 1
Address patient anxiety by discussing the pain management plan in a nonjudgmental manner 2