Chronic Noncancer Pain and Opioid Addiction: Diagnostic and Management Challenges

INTRODUCTION

Chronic pain is defined as pain that either persists for or recurs for longer than 3 months.[12] Pain is one of the most prominent causes of years lived with disability and is associated with poor quality of life.[3] Chronic pain is also associated with higher rates of psychiatric comorbidity, including substance use disorders.[4] Patients with chronic pain often require opioids for their pain relief. Often, clinicians are reluctant to prescribe opioids to patients with chronic pain due to fear of patients becoming dependent on opioids. At times, this reluctance leads to underdosing with opioids, and results in partial improvement in pain, leading to dissatisfaction among patients.[5] This dilemma further deepens when a patient with chronic pain develops an addiction to the prescribed opioids. Diagnosing addiction in such cases is also challenging, as some of the symptoms of addiction overlap with those of physical dependence. The case presented below highlights some of the challenges one faces in the diagnosis and management of a patient with chronic pain who developed dependence to the opioid prescribed for the management of pain.

CASE REPORT

A 28-year-old married female educated up to Grade 12, belonging to the Hindu nuclear family of middle socioeconomic status, presented with a history of recurrent abdominal pain beginning at the age of 16 years. The abdominal pain was severe in nature originating in the epigastrium and left hypochondrium, further radiating to back and associated with vomiting. The pain used to get aggravated on the consumption of food for around 2 h, and relieved on bending forwards. The pain was episodic in nature, with each episode occurring once in 2–3 months and lasting for 3–4 days at a time. The patient was diagnosed to have chronic pancreatitis by a gastroenterology specialist and was prescribed pancreatic enzymes three times daily, along with tramadol 50 mg orally or injection as and when required for severe pain. The patient used to take Tramadol 50 mg orally or intravenously once in 2–3 months during episodes of severe pain. Around 2011, the patient underwent lateral pancreaticojejunostomy and was completely pain free following surgery for the next 2 years. Thereafter, in 2013, she again started to have similar pain as before and was given similar treatment (injection tramadol SOS for severe pain), which she would take once in 2–3 months. Two years later, the patient developed intermittent low mood, which gradually increased to persistent pervasive sadness of mood along with other depressive symptoms of moderate severity.

In 2017, when she had been again given injection tramadol intravenously for pain relief, the patient also experienced improvement in her mood and felt a sense of relaxation, which she liked. She continued getting herself injected with tramadol for pain relief daily for the next 1 week. However, after 1 week of continuous injection, the patient started to develop an intense desire to experience the relaxing effects of tramadol. Hence, she started to complain of pain (despite not having pain) to her family and got herself injected with tramadol daily. She started using one ampoule daily initially; however, she increased the dose gradually to 6–7 ampoules per day for 10 months, as she would not have the same effects with the previous dose. On days when she could not take the injection, she developed withdrawals in the form of severe anxiety, body ache, restlessness, lacrimation, and irritability, which used to get relieved only after taking the injection tramadol. She started to have repeated thoughts about when and where she can go and get herself injected again and started to neglect her household responsibilities, because of which her children had to shoulder the burden of household chores. She used to get herself injected always the help of trained persons such as doctors or chemists. She used to go to different medical shops in a single day itself to get injected and would spend even up to1 h waiting and convincing the local chemist or doctor to inject her under the plea of having severe abdominal pain. She developed scarring of veins, extravasation of injection leading to swelling, and seizures two to three times, despite which she continued to use the injections. She would be remorseful for her injection use behavior and think of stopping multiple times; however, she would not be able to control the use of injection tramadol.

The patient's depressive symptoms also persisted in the same intensity in this period. She also started to report of persistent abdominal pain daily, following which she was admitted to the gastroenterology department at the authors' institution. The patient continued to ask for tramadol injections in the gastroenterology ward and reported of depressive symptoms to the treating team, following which the patient was referred to the psychiatry department. In view of comorbid depressive symptoms and daily tramadol use, the patient was shifted to the psychiatry ward for further assessment and management.

THE DIAGNOSTIC CONUNDRUM – ADDICTION OR PHYSICAL DEPENDENCE?

In general, patients with comorbid chronic pain and misuse of prescribed opioids present a diagnostic challenge. On the face of it, the patient had opioid-related tolerance, withdrawals, and craving, which can point to a diagnosis of opioid dependence syndrome (ODS) (as per the International Classification of Diseases, [ICD]-10 criteria). However, it should be remembered here that daily use of prescribed opioids for a long-term can itself lead to physical dependence in the form of tolerance and withdrawal, due to the pharmacological property of the drug.[67] Similarly, patients who have not been given adequate pain relief may demand for more opioids, which might be mistaken to be “drug-seeking behavior” by the patient (“pseudoaddiction”).[89] Patients might also have a strong desire to take the drug to have a relief in withdrawal symptoms, which can be considered as “craving,” though the patient may not be “addicted” to opioids.[10] In such a situation, it becomes difficult to assess whether the patient has only physical dependence or “addiction” to opioids. Some studies show that neither the ICD-10 or Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria are appropriate to diagnose “addiction” in chronic patients who are prescribed opioids for pain relief.[11] Similarly, the criteria laid down in DSM-5 for diagnosing opioid use disorder may not always apply to chronic pain who are on prescribed opioids.[12]

A consensus document from the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine specialists have listed impaired control over drug use, compulsive use, continued use despite harm, and craving as addiction criteria.[13] The present case had all these factors –inability to reduce or stop her use even when she wanted to, continued use despite complications in the form of vein complications and seizures. She neglected her household responsibilities and spent a large amount of time in procuring and injecting the drug. She had a craving for the “high” obtained after injecting tramadol, because of which she used to take tramadol even on days when she did not have pain. These symptoms helped us in making a diagnosis of “ODS” in the patient. Literature also mentioned other patient-related behaviors (aberrant drug-related behaviors) such as frequent loss or report of theft of opioid medication, stealing or borrowing drugs, and forging prescriptions as indicative of opioid misuse in a patient with chronic pain.[1415] In our case, these behaviors were not exhibited or indeed required, as the patient was able to access her opioid of choice (tramadol) relatively easily at the neighborhood pharmacist shops or registered medical practitioners.

MANAGEMENT-RELATED CHALLENGES

CONCLUSION

The diagnosis and management of patients with comorbid opioid dependence and chronic noncancer pain is a challenge, which requires multidisciplinary treatment and collaboration with various departments. The challenge is for both the addiction treatment as well as pain management specialists. This case aptly illustrates this diagnostic and management challenges. There is a need for further research on the best ways to approach and manage such cases in a multidisciplinary setting.