Signs of Opioid-Seeking Behavior
The behaviors exhibited by patients attempting to obtain opioids are called "drug-seeking behaviors" or "aberrant drug-related behaviors," though these terms are critically misunderstood and often misapplied to patients with legitimate pain needs. 1
Understanding the Terminology
Drug-seeking behaviors are defined as concerted efforts by patients to obtain opioid medication, which may include engaging in illegal activities. 1 However, this term encompasses a spectrum from legitimate medical needs to true addiction, and distinguishing between these is essential for appropriate patient care. 1
The literature uses several overlapping terms:
- "Aberrant drug-related behaviors" or "aberrant opioid-related behaviors" - patient behavior patterns that should alert providers to reassess the risk-benefit ratio of treatment 1
- "Drug-seeking" - a commonly ill-defined term that may indicate addiction but can also reflect pain relief-seeking due to unrelieved pain or anxiety about pain management 1
Specific Behaviors That May Be Observed
The FDA drug label for buprenorphine and clinical guidelines identify these specific behaviors: 2
- Emergency calls or visits near the end of office hours 2
- Refusal to undergo appropriate examination, testing, or referral 2
- Repeated "loss" of prescriptions 2
- Tampering with prescriptions 2
- Reluctance to provide prior medical records or contact information for other treating providers 2
- "Doctor shopping" (visiting multiple prescribers to obtain additional prescriptions) 2
- Requests for early refills or escalating dosages 1
- Taking more medication than prescribed 1
- Unremitting focus during clinic encounters on obtaining controlled substance prescriptions or certain brand-name formulations 1
- Having multiple prescribers 1
- Prescription forgery 1
- Sale or diversion of prescriptions 1
Critical Distinctions: Three Conditions That Mimic Addiction
You must differentiate true addiction from pseudoaddiction and therapeutic dependence, as these require completely different management approaches. 3, 4
Pseudoaddiction
Pseudoaddiction is a phenomenon where drug-seeking behaviors arise when patients cannot obtain tolerable relief with prescribed analgesics and seek alternate sources or increased doses. 1 This condition is characterized by resolution of the behavior with effective pain treatment. 1 The key features distinguishing pseudoaddiction from true addiction are that patients exhibit behavioral changes mimicking addiction but these are actually secondary to inadequate pain control. 4
Therapeutic Dependence
Patients with adequate pain relief may demonstrate drug-seeking behaviors because they fear reemergence of pain or withdrawal symptoms, representing efforts to maintain comfort rather than addictive disease. 4
True Addiction
The four principal features of addiction are: impaired control over drug use, compulsive use, continued use despite harm, and craving. 1 True addiction involves a cluster of behavioral, cognitive, and physiological phenomena including strong desire to take the drug and giving higher priority to drug use than other activities and obligations. 1
Prevalence and Context
The prevalence of "aberrant analgesic use behaviors" varies widely depending on the population studied, ranging from 9% in persons without substance use history to 73% lifetime prevalence in urban indigent adults. 1 Among people living with HIV, 37% reported aberrant opioid behavior within 90 days, and 19% reported major aberrant behaviors. 1
Clinical Pitfall to Avoid
The most critical error is allowing concerns about being manipulated to cloud clinical judgment about legitimate pain medication needs. 3, 4 Preoccupation with achieving adequate pain relief can be appropriate behavior in a patient with inadequate pain control. 2 Undertreating acute pain can lead to decreased responsiveness to opioid analgesics, making subsequent pain control more difficult. 4 In fact, unrelieved pain is more likely to trigger relapse in patients with opioid use disorder than is adequate analgesia. 1