THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 28, NO. 6, 2015 284 © The National Medical Journal of India 2015 ——————————————————————————————— All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India POOJA PATNAIK KUPPILLI, ROSHAN BHAD, RAVINDRA RAO, PRABHU DAYAL, ATUL AMBEKAR Department of Psychiatry ·············································································································································· Correspondence to RAVINDRA RAO; drrvrao@gmail.com Misuse of prescription opioids in chronic non-cancer pain POOJA PATNAIK KUPPILLI, ROSHAN BHAD, RAVINDRA RAO, PRABHU DAYAL, ATUL AMBEKAR ABSTRACT ABSTRACT ABSTRACT ABSTRACT ABSTRACT Somatization disorder is a common cause of chronic non-cancer pain. The use of opioids in such conditions carries a risk of their potential abuse. Lax regulations coupled with sub-optimal medical training in India lead to the rampant use of prescription opioids. We present a case of somatization disorder along with injection pentazocine dependence in a woman, in whom use of pentazocine was initiated by a registered medical practitioner for somatoform pain management, followed by self-injection because of its easy availability in local pharmacy shops. We highlight the need for education of medical practitioners on appropriate use of pharmaceutical opioids, need for regulation of local pharmacy shops, and development of guidelines for use of opioids in chronic non-cancer pain. Natl Med J India 2015;28:284–5 INTRODUCTION Psychiatric illnesses are often the cause as well as comorbid conditions in patients presenting with pain. 1,2 Somatization disorder is a commonly assigned diagnosis in such patients. The main features of somatization disorder (according to the International Classification of Diseases and Related Health Problems, ICD, version-10) are presence of multiple and variable physical symptoms without adequate physical explanation, persistent refusal to accept a doctor’s advice that there is no physical basis to the symptoms, and impairment of social and family function attributable to the nature of symptoms. Somatization disorders present a challenge to physicians in the diagnosis as well as management. 3 Though most guidelines suggest minimal use of pain medications in management of somatoform disorders, clinicians often use analgesics, including opioids, for pain relief. 4–6 Studies suggest that opioids are used in 3%–66% of chronic pain conditions. 7 Misuse of oral and injecting prescription opioids is a growing concern throughout the world. A recent multisite survey found that prescription opioids are the predominant opioids injected in India as compared to heroin. 8 Several factors are associated with the increased misuse of prescription opioids. We present a woman with somatization disorder and misuse of prescription opioids. THE CASE A 43-year-old widow presented to us with intramuscular use of pentazocine for 13 years along with multiple somatic complaints for 19 years. The illness began with multiple, frequently changing, physical symptoms characterized by headache, backache, abdominal pain, pain during urination and menstruation, nausea, bloating, occasional vomiting, amenorrhoea and difficulty in swallowing. Various investigations by treating physicians were normal. Pentazocine was administered intravenously 3–4 times a week for exacerbation of pain. With these injections, the patient also started experiencing drowsiness, mental relaxation and relief from ongoing family conflicts, and hence, the patient started lying to get injections of pentazocine. Within a month, due to intense craving, the frequency increased to daily intramuscular injections of pentazocine. This pattern continued till the time of seeking treatment, when the patient was using about 14 ml (420 mg) of pentazocine mixed with 70 ml chlorphenaramine maleate (28 mg) in divided doses. She had extensive ulcers on her upper limbs and gluteal area, and had to give up her job due to injections. She also developed two episodes of moderate depression, each lasting for 6–9 months, for which no treatment was sought. She did not use any other psychoactive substance. The patient lived with her son in her mother’s house along with her mother and two brothers. One brother was dependent on alcohol, while another was dependent on injection buprenorphine. The expenses of the patient (including injections) were borne by her mother. At admission, investigations to rule out physical causes of somatic complaints were normal. Injection-related ulcers were treated by surgical specialists. A diagnosis of opioid dependence syndrome with somatization disorder according to ICD-10 criteria was made. Opioid withdrawal was treated with sublingual buprenorphine followed by maintenance treatment with naltrexone. For the somatization disorder, cognitive behavioural therapy along with tablet amitriptyline 50 mg/day was started. Motivation enhancement and relapse prevention sessions were also undertaken. The patient was lost to follow-up after two visits, during which she was abstinent. DISCUSSION Chronic pain and use of opioids share a complex relationship. While opioids are useful for chronic cancer pain, their use in non- cancer pain management is fraught with problems. 9,10 Chronic opioid administration can cause hyperalgesia and worsening of the underlying pain. 11 Psychiatric illnesses such as somatization disorders are important causes of chronic non-cancer pain. General practitioners are often the first point of contact for such patients, and opioids are often used to obtain rapid pain relief. 12,13 Several factors can be attributed to the abuse of prescription opioids. The risk is greatest when three factors (psychosocial, drug-related and genetic) are present in the same person. Our patient had multiple risk factors such as family history of substance dependence (in particular opioid dependence), multiple family stressors (death of husband, conflicts with family members), and relief of stress with pentazocine. Careful assessment of and addressing these factors in a timely manner could have avoided development of dependence. Unfortunately, training in management of pain and psychiatric illnesses is not optimal for most undergraduate medical trainees in India, resulting in over- or under-prescription of opioids. Cases of ‘iatrogenic’ dependence can be minimized with adequate medical training. As per the law in India, pharmacists are required to dispense narcotics/psychotropics only upon production of a prescription from a registered medical practitioner (RMP); this practice is often not followed, as is evident from our patient. 14 On the one