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Indian Health Service The Federal Health Program for American Indians and Alaska Natives

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Non-adherent Patients

Move methodically; don’t rush to judgment.

Differentiate addiction from pseudoaddiction.

Rely on close observation, testing, and involvement of other clinicians.

Doctors who suspect their patients are violating their treatment agreements need to move methodically and not rush to judgment. Chronic pain patients can be difficult to manage; however, putting them on the defensive can have adverse effects on treatment.

A big challenge for physicians is being able to differentiate addiction from pseudoaddiction. Chronic pain patients who seek increased dosages of opioids in most cases are not addicted (loss of control, compulsion, etc.), but pseudoaddicted. Signs of pseudoaddiction include asking for drugs by name, demanding behavior, getting opioids from more than one doctor, and hoarding medications. See the table on the Adherence Monitoring page to see examples of addictive and nonaddictive behaviors. The Adherence Monitoring page also explains screening tools and drug tests that are used to maintain adherence to a treatment regimen.

A doctor who has suspicions should rely on close observation, testing, and involvement of other clinicians, such as psychiatrists or drug treatment specialists. And, relying on a written doctor-patient agreement that details the treatment process and the patient's obligations can put the patient in a less defensive mood. The Informed Consent page has a sample doctor-patient agreement.

Reference

Fishman, MD, Scott M. Responsible Opioid Prescribing: A Physician’s Guide. Washington, DC: Waterford Life Sciences, 2007. pp. 61–64.