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Indian J Psychiatry
Indian J Psychiatry
IJPsy
Indian J Psychiatry
Indian Journal of Psychiatry
0019-5545
1998-3794
Wolters Kluwer - Medknow India

IJPsy-66-668
10.4103/indianjpsychiatry.indianjpsychiatry_69_24
Case Series
Navigating opioid use in chronic noncancer pain conditions: A case series on pseudoaddiction
Dhagudu Naveen
Brar Manmeet K. 1
George Aishwariya B. 2
Ambekar Atul 1
Department of Psychiatry, ESIC Medical College and Hospital, Hyderabad, Telangana, India
1 Department of Psychiatry, NDDTC, AIIMS, New Delhi, India
2 Department of Psychiatry, Mental Health Action Trust, Calicut, Kerala, India
Address for correspondence: Dr. Manmeet K. Brar, Department of Psychiatry, AIIMS, New Delhi, India. E-mail: mksidhu27@gmail.com
7 2024
17 7 2024
66 7 668671
17 1 2024
02 7 2024
07 7 2024
Copyright: © 2024 Indian Journal of Psychiatry
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Opioid prescriptions for chronic non-cancer pain raise concerns of addiction risks. Understanding the nuanced intersection of chronic pain and opioid use is crucial in clinical settings. We present four case studies from two tertiary care hospitals illustrating the phenomenon of “pseudoaddiction” in CNCP referred to addiction specialists for management. Each case involves complex pain presentations like pancreatitis, avascular necrosis, and SLE intertwined with escalating opioid demands. Management involved psychoeducation, CBT, and opioid substitution, resulting in reduced pain and need for opioids. Differentiating between addiction and uncontrolled pain is crucial for tailored management, emphasizing individualized care for improved outcomes.

Addiction
chronic noncancer pain
CNCP
consultation-Liason
opioid
pain
pseudoaddiction
somatoform
substance use
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pmcINTRODUCTION

Pain is considered chronic when it persists beyond the estimated natural healing time for tissues, typically 3 months, present multiple times per week in the last month, with an intensity of at least 4/10. A meta-analysis from LMIC (lower middle income countries) found a higher prevalence, i.e., 33% of any chronic pain in the general adult population.[1] Estimates of substance use disorder prevalence in chronic pain patients vary from 3.2% to 45%.[2] Unlike severe acute or cancer-related pain, opioid use for CNCP (chronic noncancer pain) is contentious due to concerns about efficacy, outcomes, and potential iatrogenic addictions. The phenomenon of “pseudoaddiction” introduced in 1989 by Weissman and Haddox is described to have three phases: poor pain relief, distress causing the patient to exhibit behaviors to convince others of suffering, and resulting mistrust between the treating team and the patient.[3] One of the core principles of opioid therapy in such patients is that problematic drug-related behaviour can be triggered by uncontrolled pain and then eliminated with proper pain management.

We present four such cases where consultation was sought from addiction psychiatry team for concerns about excessive opioid use in the context of chronic pain.

Case study 1

A 24-year-old unmarried male student from a middle socioeconomic background was referred for management of irritability, sleep disturbances, severe abdominal pain due to idiopathic pancreatitis, and use of parenteral opioids. Initial pancreatitis episode was managed with parenteral nalbuphine (20 mg to 60 mg per day) and injectable NSAIDs (nonsteroidal anti-inflammatory drugs); however, he suffered four recurrent episodes. During the course of his illness, he came to rely increasingly on injections of nalbuphine to relieve pain and temporarily improve his mood, anxiety, and sleep. His nalbuphine doses and frequency were needed to increase to achieve his pain-free state. His physical condition deteriorated, causing weight loss, persistent weakness, and hindering academic activities. A diagnosis of mental and behavioral disorders due to use of opioids: dependence syndrome (F11.2) was made as per ICD-10 (International Classification of Diseases).

Upon presentation (at Hyderabad), his morphine equivalent daily dose (MEDD) was approximately 930 mg, with a pain rating of 9/10 on the VAS (Visual Analogue Scale). Anxiety and sleep disturbances were initially managed with the tablet imipramine and mirtazapine and later maintained on mirtazapine 30 mg. Over 8 months, he underwent 18 cognitive behavioral therapy (CBT) sessions for pain management, comprising engagement and rapport building, psychoeducation about chronic pain syndrome, case formulation of cognitive schema regarding pain perception, practicing negative automatic thought modification, anger management for irritability, lifestyle restructuring, time management for academic activities, and stress management. At the time of the last follow-up, he reported abstinence from opioids for 6 months, 15 kg of weight gain, reduced pain to 1/10, and increased self-esteem and quality of life.

Case study 2

A 42-year-old unmarried man, belonging to a nuclear family of upper-middle socioeconomic status presented with a history of smokeless tobacco use in dependent pattern for 18 years, alcohol dependence for 14 years, and frequent, unexplained abdominal pain that was under evaluation. At the time of consultation (at Hyderabad), he was taking multiple doses of nalbuphine per day with a MEDD of 100 mg/day and had an Edmonton Symptom Assessment System (ESAS) pain score of 7. Over the next 4 weeks, he required opioid titration with a fentanyl patch 150 mcg/hour with injectable nalbuphine, due to uncontrolled pain. Over the course of 2 years, he felt that his abdominal pain persisted throughout the day and that he needed opioids, particularly nalbuphine, four times a day for his undertreated pain condition. However, he used both concomitantly without informing the physician. His MEDD increased to 630 mg/day over the span of 6 months amid stress from business losses and his father’s death.

Treatment included duloxetine (40 mg) for 6 months, short-term clonazepam (0.5 mg) for sleep, and 20 sessions of CBT. Therapy addressed the role of psychological factors in acute exacerbations of chronic pain, sleep hygiene, and a functional analysis of pain exacerbations that elicited cognitive errors such as magnification and negative automatic thoughts. He was encouraged to maintain a thought diary, which was used in therapy. Over 8 weeks, his opioid drug seeking behavior reduced, pain severity lowered to 2/10, and he reengaged in his business and regular physical activity as part of day structuring.

Case study 3

A 36-year-old physician from an upper-class joint family presented to the OPD (outpatient department), reporting severe, persisting pain in both hip joints for the past 18 months. Diagnosed with advanced avascular necrosis bilaterally, the pain caused functional impairment, anxiety, sadness, hopelessness and helplessness, severe stress, and an inability to work. He had a history of right femur fracture, depressive episode (treated with desvenlafaxine eight years ago), and mental and behavioral disorders due to use alcohol: dependence syndrome, currently in remission (F10.20) with a family history of recurrent depressive disorder in father.

The individual engaged in self-administration of injectable nalbuphine or butorphanol for a duration of 8 months, following its prescription by their physician as an analgesic. In the beginning, the individual required an escalation in the quantity and regularity of their emergency pain reliever in order to attain the desired level of pain management. Subsequently, he experienced heightened irritability upon the cessation of the effects, which he linked to the reoccurrence of untreated pain conditions. He reported preoccupation with injecting and spent significant time procuring the medicines, primarily due to anxiety over the return of intolerable pain. Despite experiencing severe complications like deep venous thrombosis and sepsis, he injected increasing doses of midazolam in the month prior to the first OPD visit to prolong the effects of sedation from the opioids. The management focused on chronic pain complications and potential addiction to opioids, benzodiazepines, or both. Admitted for diagnostic clarification (at Hyderabad), he received buprenorphine (8 mg/day sublingually in divided doses) for pain relief and opioid withdrawal. A tapering regimen of diazepam (up to 50 mg) was given for benzodiazepine withdrawal. A diagnosis of mental and behavioral disorders due to use of opioids: dependence syndrome (F11.2 as per ICD-10) and mental and behavioral disorders due to use of sedatives and hypnotics: harmful use (F13.1) was made. The multidisciplinary pain management team involved consultants from anesthesia, orthopedics, and physiotherapy. This approach, coupled with CBT, physiotherapy, and a gradual increase in physical activity, effectively relieved pain without additional opioids, allowing for a reduction in buprenorphine dosage to 5 mg/day by discharge. A daily pain control record at home and stringent risk mitigation including supervised doses by a family member, restricting extra doses, and managing breakthrough pain with paracetamol and other NSAIDs were implemented.

Case study 4

A 31-year-old female, a graduate, and married homemaker from a nuclear family in Ghaziabad, presented with severe, persistent generalized body pain for 4 years. Pain was perceived as severe enough to be distressing and caused heightened anxiety, reducing her engagement in household chores and social interactions. In the past, she regularly used tramadol in combination with paracetamol for a period of 2 years but discontinued due to inadequate pain relief. Following this, she was prescribed sublingual buprenorphine (up to 2.4 mg/day), but after initial temporary relief, the pain and dysfunction recurred. She did not have any history of using opioids without being prescribed or made any unsupervised alterations to the dose. Dysfunction in her daily functioning had set in even prior to regular use of opioids due to her preoccupation with pain and associated behaviors.

An inpatient admission (in NCR in July 2019) was done for diagnostic clarification. She had subjective and objective opioid withdrawal symptoms with need for escalating opioid doses for pain relief. Physical examination showed pallor, mild joint fullness, and local warmth and tenderness on the medial side of the right knee and multiple tender points at several joints. Initial assessment showed that the patient had tested negative for RF, ANA, and anti-CCP in the past. Rheumatology evaluations suggested secondary Sjogren’s syndrome due to symptoms like body pain, dental caries, alopecia, and sicca symptoms (dry mouth and eyes). Treatment involved intra-articular methylprednisolone (80 ug) in both knees. Fresh investigations showed RF-negative (rheumatic factor), anti-CCP-<0.5 U/ml-negative, and ANA-title: 1:100 with a homogenous pattern and intensity. 2+: strongly positive; anti-dsDNA: positive; anti-Ro- 45.8: moderately positive; anti-La- 2.87: negative. Nuclear scintigraphy showed normal tracer extraction and sialogogue action in the bilateral parotid and submandibular glands. Ophthalmology assessment and Schirmer’s test revealed severe dryness in the right eye and moderate dryness in the left eye, with instantaneous tear-breakup time. The final diagnoses, as per ICD 10, were persistent somatoform pain disorder (F45.4), systemic lupus erythematosus (SLE), Sjogren’s syndrome, and long-term (current) use of opiate analgesic (Z79.891). She was started on tablets amitriptyline 50 mg (for somatoform disorder), methotrexate (15 mg once a week with folic acid supplementation), hydroxychloroquine (300 mg), hydroxypropyl methylcellulose eye gel, and carboxymethylcellulose eye drops (for dry eye). Psychoeducation about Sjogren’s syndrome and a management plan for tapering of all dependence-producing medications and CBT for somatization were crucial. Ten CBT sessions during her 4-week inpatient stay showed remarkable improvement in her functionality and reduced pain preoccupation. Prior to discharge, the medical team successfully tapered her off sublingual buprenorphine. The patient reported significant improvement in quality of life without relapse to opioid use when contacted in June 2023. The patient was misdiagnosed as having opioid dependence and was also prescribed sublingual buprenorphine before inpatient admission at our centre due to inadequate pain control and an untreated underlying pain condition. This particular case exemplifies a paradigmatic instance of “pseudoaddiction,” wherein accurate identification of pain condition and effective pain management can result in improved patient outcomes.

DISCUSSION

Opioids exercise their analgesic effect through mu opioid receptors distributed in the insula, amygdala, hippocampus, hypothalamus, periaqueductal gray matter, medulla, and spinal cord. The role of opioids in treating acute pain of moderate to severe intensity, where tissue injury is recent, is well-established. However, in chronically painful conditions, the mechanisms of pain and its perception are different. From this basic difference stems the controversy over using opioids in CNCP.

A patient presenting with nonprescription opioid use or use in excess of what was prescribed is often labelled as having an aberrant drug using behaviour. However, it is important to recognise that there may be underlying reasons for this behaviour beyond opioid addiction. Such issues of “pseudoaddiction” may stem from undertreated pain, a wrong diagnosis of the cause of pain, a poor coping strategy for pain, or other emotional stressors in an individual’s life, as highlighted in the cases described above. “Pseudotolerance,” which is caused by disease progression, new disease, increased physical activity, lack of compliance, medication change, drug interaction, addiction, and deviant behaviour, must also be distinguished from “pseudoaddiction.”[4]

The concept of “pseudoaddiction” and “chemical coping” has been revisited recently, and some authors suggest the use of term Undertreated pain, risky opioid use (e.g. self-titration of meds, etc.) related to undertreated pain (instead of pseudoaddiction).[5] Some writers propose a more concise definition of pseudoaddiction based on empirically derived and weighted lists of aberrant drug behaviours that indicate addiction (vs. alternative “aetiology,” such as self-treatment of an anxiety or mood disorder or drug divergence).[6]

International guidelines on pain management recommend using nonpharmacological and nonopioid options first, avoiding opioids for those with substance use disorders, stabilizing psychiatric conditions, clear prescription indications, frequent review of the need to continue opioids at every visit, prescribing the smallest dose for the minimum duration required, constant pain monitoring, short-acting opioids, selecting low-reward potential opioids, avoiding injectable formulations, timely identification of relapse to substance use, and multidisciplinary case management.[78] Due to the risks of addiction and overdoses, systematic assessments like the USFDA’s Risk Evaluation and Mitigation Strategies are crucial, which include patient education about risks and prescriber guidelines on safe use.[9] Tools like screener and opioid assessment for patients with pain and the current opioid misuse measure can be used to differentiate between an opioid use disorder and pseudoaddiction.[10]

Psychoeducation and CBT play vital roles in chronic pain treatment, focusing on correcting perceptions about pain, activity pacing, and relaxation techniques. Collaboration between addiction medicine practitioners and pain management practitioners is essential for managing chronic pain in patients with active substance use disorders. Managing pain in patients with opioid use disorders presents additional challenges, as opioid maintenance programs use full mu agonist methadone and partial mu agonist buprenorphine, which may require additional doses or adjunctive drugs for pain relief. Buprenorphine has a high mu receptor affinity and may displace other opioids used for pain management. Its kappa receptor agonism could prevent or reverse the development of hyperalgesia that develops with chronic opioid use.[11] Managing chronic pain and opioid use disorders requires a nuanced approach, balancing pain relief needs with the risks of opioid dependence, necessitating collaborative efforts between medical specialties, and emphasizing nonpharmacological interventions alongside meticulous opioid usage monitoring.

Key messages

This case series presents four diverse cases with common themes of opioid use, chronic pain, and the role of psychiatric comorbidity in influencing opioid use and pain perception, and how utilizing CBT and a multidisciplinary team approach is key to handling such cases for a better quality of life for patients with CNCP.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

ESIC, Hyderabad and NDDTC, Ghaziabad.

Conflicts of interest

There are no conflicts of interest.
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