Managing Drug-Seeking Behavior in Suspected Substance Abuse

Initial Assessment Framework

The American College of Physicians recommends recognizing that apparent "drug-seeking" behavior often represents legitimate medical needs, including pseudoaddiction from undertreated pain, therapeutic dependence, or anxiety about symptom recurrence, and conducting a careful clinical assessment for objective evidence of pain before labeling patients as manipulative 1, 2
Pseudoaddiction is a condition where patients exhibit behavioral changes mimicking addiction but are actually secondary to inadequate pain control, and patients seek alternate sources or increased doses because prescribed analgesia provides insufficient relief 1, 4
Therapeutic dependence is a condition where patients with adequate pain relief demonstrate drug-seeking behaviors because they fear reemergence of pain or withdrawal symptoms, representing efforts to maintain comfort rather than addictive disease 1, 3
The American Academy of Family Physicians recommends distinguishing between types of drug-seeking behavior, including pseudoaddiction, therapeutic dependence, and true addiction 1, 3

The American College of Physicians recommends continuing the usual dose of Opioid Agonist Therapy (OAT) and providing aggressive pain management with additional opioid analgesics as needed for patients on OAT with acute pain, and never discontinuing maintenance therapy during acute pain episodes 1, 5, 2
The American Academy of Family Physicians recommends using higher doses of short-acting opioid analgesics at shorter intervals due to cross-tolerance and opioid-induced hyperalgesia for patients on OAT with acute pain 1, 3, 5
The American Society of Addiction Medicine recommends offering or arranging evidence-based treatment, preferably medication-assisted treatment with buprenorphine or methadone maintenance therapy combined with behavioral therapies, for patients with suspected opioid use disorder 2

The American College of Physicians recommends never allowing concerns about being manipulated to cloud clinical judgment about legitimate pain medication needs, and never discontinuing OAT during acute pain episodes 1, 5, 2
Undertreating acute pain can lead to decreased responsiveness to opioid analgesics, making subsequent pain control more difficult, and pain is always subjective, making assessment challenging, but this does not justify withholding appropriate treatment 1, 4, 2

The American Academy of Family Physicians recommends screening for comorbidities, including mental illness and intimate partner violence, which are common in patients with substance use disorders and require concurrent management 6, 7
The Centers for Disease Control and Prevention recommends assessing for infectious disease risks, such as HIV, hepatitis, STDs, and tuberculosis, in persons who use drugs illicitly 9, 10