Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

372 IV. SPECIAL POPULATIONSTABLE 17.1. Aberrant Drug-Related BehaviorsBehaviors more suggestive of an addiction disorder• Selling prescription drugs• Prescription forgery• Stealing or “borrowing” drugs from others• Injecting oral formulations• Obtaining prescription drugs from nonmedical sources• Obtaining drugs from multiple medical sources without informing or despiteprohibition• Concurrent abuse of alcohol or illicit drugs• Multiple episodes of self-escalation of dose, despite warnings not to do so• Multiple episodes of prescription “loss”• Evidence of functional deterioration unexplained by the pain or other comorbidity• Repeated resistance to changes in therapy despite clear evidence of adverse effectsBehaviors less suggestive of an addiction disorder• Aggressive complaining about the need for more drug• Drug hoarding during periods of reduced symptoms• Requesting specific drugs• Openly acquiring similar drugs from other medical sources• Occasional unsanctioned dose escalation• Unapproved use of the drug to treat another symptom• Reporting psychic effects not intended by the clinician• Resistance to a change in therapy associated with “tolerable” adverse effects• Expression of family concerns(Weissman & Haddox, 1989), the term is now commonly applied to patientswith any type of chronic pain.Patients with addiction also may develop an increase in drug seeking thatis driven by uncontrolled pain. In some cases, this behavior reflects both addictionand pseudoaddiction. If the patient is receiving a prescribed opioid forpain, the diagnosis may only be clarified if medical access to the drug isincreased in a structured plan. Should drug-seeking behavior continue in thiscontext, the likelihood that pseudoaddiction predominates is less.TABLE 17.2. Differential Diagnosis of Aberrant Drug-Related Behavior• Addiction• Pseudoaddiction• Psychiatric disorders• Axis I disorders (e.g., depression, anxiety, somatoform)• Axis II disorders (e.g., borderline personality, sociopathic personality)• Encephalopathy (confusion in dose and interval of prescription)• Criminal intent