Pain Relief Needs Can Mask The Facade Of True Addiction
What are the primary causes of pseudoaddiction, and how can recognizing this phenomenon improve pain management in individuals undergoing addiction treatment?
In clinics and in families, the same scene plays out again and again, someone is in pain, they look anxious, they watch the clock, they ask for stronger medication, they call early, they sound desperate, and everyone in the room starts thinking the same thing, this looks like addiction. The problem is that desperation is not a diagnosis, and pain can make people behave in ways they do not recognise, especially when sleep has collapsed and fear has taken over. That is where the term pseudoaddiction entered the conversation, as an attempt to explain drug seeking behaviour that is driven by untreated pain rather than by addiction.
It sounds helpful on paper, but in the real world it can become a mess, because it sits right in the space where doctors fear overprescribing, patients fear being dismissed, and families fear being lied to, and everyone is trying to read intent from behaviour.
What Pseudoaddiction Means
Pseudoaddiction is usually described as addiction like behaviour caused by inadequate pain control, meaning the person looks like they are seeking drugs, but the driver is suffering rather than compulsion. The theory suggests that if pain is properly treated, the drug seeking behaviours settle down, because the person is no longer scrambling for relief. It was meant to protect pain patients from being labelled as addicts simply because they were persistent, frustrated, or scared.
In that context, the idea made sense, because there is a long history of people with severe pain being dismissed, especially when they do not look sick enough, or when their scans do not match their experience, or when they have a complicated mental health history. The label pseudoaddiction offered clinicians a way to say, do not punish someone for acting desperate when they are suffering, and do not confuse untreated pain with addiction.
The Problem You Only Know After The Fact
Here is the part people do not like admitting, the concept only works cleanly if you can run a clear test, treat the pain properly, then watch the drug seeking behaviour disappear. That sounds neat, but chronic pain is rarely neat, and many people have pain that fluctuates, pain that is tied to stress, pain that is worsened by poor sleep, and pain that is tangled up with anxiety and depression. In those cases, there is no simple moment where you can say, we treated the pain and the behaviour stopped, therefore it was pseudoaddiction and not addiction.
There is also the reality that opioid exposure changes the brain over time, even in people who started with legitimate pain, and once dependence develops, the person can be seeking relief from withdrawal and dysphoria as much as relief from pain. In that situation, the behaviour can still look like drug seeking, but the driver has become mixed, and labels stop helping if they make everyone pick one story and ignore the other.
Why Unmanaged Pain Can Make Someone Look Like An Addict
Severe pain is not only a sensation, it is a full body stress response that disrupts sleep, concentration, mood, appetite, and tolerance for frustration. When pain is constant, people become irritable, fearful, and flat, and their world narrows down to one goal, stop the suffering. If you have ever watched someone who has not slept properly in weeks, you know they do not sound calm and reasonable, even when they are telling the truth.
This is why pain patients can become pushy, repetitive, and demanding, because they are trying to regain control in a situation where they feel powerless. They may ask for early refills because the thought of running out scares them, not because they want to get high. They may focus intensely on medication because it is the one thing that has helped before. They may sound suspicious or defensive because they have been dismissed in the past. None of that proves addiction, but it also does not prove innocence, which is why careful assessment matters.
The Evidence Gap
Pseudoaddiction is a debated concept, and it is not strongly established as a distinct diagnostic entity in the way people talk about it online. That matters because loose concepts become tools, and tools get used in whatever direction people want. A patient can use the term to pressure a doctor into escalating opioids, claiming any caution is undertreating pain. A clinician can use the term to justify higher prescribing while ignoring clear risk signs. A family can use the term to deny addiction, telling themselves the person is only acting that way because of pain, even when life is clearly being shaped around pills.
When a term becomes a shield against scrutiny, it stops protecting patients and starts protecting bad decisions. The uncomfortable truth is that you can have real pain and still develop addiction, and you can have addiction and still have real pain, and pretending it is always one or the other is how people end up harmed.
How A Helpful Word Can Become Fuel For An Opioid Disaster
Critics argue that pseudoaddiction helped create a mindset where warning signs were reframed as undertreatment, and that mindset supported an era of aggressive opioid prescribing. The logic was seductive, if the patient looks drug seeking, maybe the dose is too low, and if you increase opioids, the behaviour will settle. In some acute pain situations, better pain control does reduce frantic behaviour, but in long term opioid exposure, increasing the dose can also increase dependence, increase tolerance, and deepen the trap.
When opioids are treated as the default answer to complex chronic pain, the end result can be a population of people who are still in pain, now dependent, and now at risk of overdose, withdrawal, and escalating conflict with the medical system. It is possible to care about pain patients and still say out loud that the opioid story went off the rails, and that we need better thinking than slogans.
Pain And Addiction Can Coexist
One of the most honest statements in this space is that pain and addiction often live together. Some people start as pain patients, then opioids become emotionally soothing, then dependence forms, then the person is chasing normality as much as pain relief. Some people start with substance use, then realise they have chronic pain, and they use to numb it. Some people have pain and trauma, and the drug becomes the quickest way to shut down both.
If you accept that overlap, then you stop trying to prove whether the person is good or bad, and you start asking better questions. What is the pain condition, what is the level of function, what is the medication history, what is the mental health picture, what is the pattern of use, and what is the risk profile, because those answers guide safer care than any label.
What Balanced Pain Management Looks Like
Balanced care starts with proper assessment and honest conversations about goals. Function matters, not only pain scores. The plan should include non opioid strategies where appropriate, because many chronic pain conditions improve more through movement, sleep repair, and nervous system calming than through escalating opioids. If opioids are used, they should be used with clear rules, clear monitoring, and clear timeframes, because vague open ended opioid use is where dependence quietly grows.
Mental health screening should be standard, because anxiety, depression, trauma, and insomnia can intensify pain and also increase substance risk. Family involvement can be helpful when it is safe and appropriate, because families can support structure rather than policing. The aim is not to moralise, the aim is to reduce suffering while reducing risk, and that requires planning rather than ideology.
Pseudoaddiction Should Not Be A Free Pass For Anyone
Pain deserves serious treatment and addiction deserves serious treatment, and the fastest way to destroy both is to pretend only one exists. Pseudoaddiction was meant to stop pain patients being punished for suffering, but when the term is used as a blanket explanation for every drug seeking behaviour, it can hide dependence and it can justify dangerous prescribing. The better approach is grounded, treat pain properly, track function, use a balanced plan, monitor risk honestly, and address substance use directly when it appears.
If opioids, alcohol, or sedatives are part of the picture and things feel unstable, get a professional assessment that looks at pain, mental health, and substance risk together, because you cannot build safe treatment on half the truth.