ADDICTION OR PSEUDOADDICTION IN SICKLE CELL DISEASE PATIENTS: TIME TO DECIDE – A CASE SERIES

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T.R. Kotila¹, O.E. Busari¹, V. Makanjuola² and O.R. Eyelade³

1. Department of Haematology, University College Hospital, Ibadan, Nigeria.
2. Department of Psychiatry, College of Medicine, University of Ibadan, Nigeria.
3. Department of Anaesthesia, College of Medicine, University of Ibadan, Nigeria.

Abstract

Objective: The objective of this report is to highlight the background factors associated with opioid abuse among Sickle Cell Disease (SCD) patients.

Patients: Eleven patients aged 13-53 years (mean, 26.1yrs) which included six female and five male were seen in the last six year at a tertiary health facility. The modes of abuse ranged from obtaining analgesic prescription from multiple sources, injecting analgesics and sharing analgesics between patients in the hospital.

Results: Five female had either avascular necrosis of the femoral head or pathological fracture secondary to chronic osteomyelitis, so were classified as pseudo addiction while five male and one female without any identifiable cause of chronic pain were adjudged to be addicted to opioids. The role of a dysfunctional family background in the response of SCD patients to pain treatment and substance abuse is highlighted.

Conclusion: These cases reveal drug abuse as an emerging or understudied problem among SCD patients and its association with chronic pain in some patients. It is therefore necessary for pain physicians and SCD experts to address the use of opioid in chronic sickle cell pain and provide alternatives and a suitable guideline for their use.

Keywords: Opioid, chronic pain, sickle cell pain, psychosocial issues, substance abuse

Introduction

Sickle cell disease (SCD) is a genetic disorder characterized by recurrent acute painful episodes, the prevention and treatment of which is central to the management of the disorder. Opioids are often used in the management of these painful episodes; the extent of its use in the management of pain in this disorder is an issue of debate. Some physicians advocate minimal use of these drugs for fear of addiction^1,2 while others believe that the under use of these medications in the control of pain may result in pseudoaddiction.^3,4 There have also been reports in the literature of substance abuse by SCD patients,^5,6,7 though it is believed that the rate of drug abuse by SCD patients is not different from that of the general public.⁸ We report eleven cases of opioid abuse seen in a tertiary institution of a developing country over a six year period and highlight the role of chronic pain and a dysfunctional family background in this emerging problem.

Summary of the cases
Thirteen patients were seen over the six-year period but the case notes of two female patients were missing thus their data were not included in this presentation.

The patients presented here have a mean age of 26.1 years (a range of 13-53 years) and included six female and five male. The duration of abuse ranged from six months to five years, while the duration of abuse could not be ascertained from four patients. Pentazocine, a weak opioid which is readily available as an over the counter drug is the drug mostly abused, only two patients abused meperidine (pethidine) along with pentazocine. Those who misused meperidine either forged the signature of a doctor or used multiple prescriptions to obtain the drug. Five patients are from single parent homes while two are orphans with one living in an orphanage. The patients can be classified into two broad groups; those who had chronic pain because of comorbidities and those in whom there was no identifiable cause of chronic pain. There were five patients in the former category and six patients in the latter. All five patients in the first category had one form of bone complication warranting the use of analgesics while all but one (patient with priapism) in the second group had no associated comorbidity. All patients in the first category were therefore seen in the hospital for the comorbidity and the drug abuse secondarily discovered by nurses or doctors, but those in the second category were brought to the hospital by relatives for abusing analgesics. Two of the patients had to sell personal belongings to sustain the habit. The mode of abuse ranged from obtaining analgesic prescription from multiple sources, injecting and sharing analgesics while on admission in the hospital or forgery of doctors’ signatures. The mean duration of abuse in the first group was 2.8 years compared to 2.3 years in the second group, all the patients in the first category were female while there were five male and one female in the second category. Follow up was poor in these patients, though they were referred to a drug rehabilitation facility, it cannot be ascertained that they remained free of the abuse, two patients refused to keep appointment with the therapist because of the fear of stigmatization. The commonest complication is pyomyositis at the site of injection which was seen in two patients, another patient developed a pseudoaneurysm with multiple arteriovenous fistulae around the brachial artery from inadvertently injecting the drug into the brachial artery.