A 35-year-old woman presented to an ambulatory family medicine office with a 2-year history of neuropathic abdominal pain syndrome resulting from a prior history of Guillian-Barré syndrome. Her medical history was remarkable for depression with comorbid anxiety managed with escitalopram. The patient denied tobacco use but admitted to consuming 2 to 3 alcoholic beverages per week. Her family history was notable for a mother with bronchogenic carcinoma and a brother with major depressive disorder.
The patient's pain management regimen during the previous 2 years included oxycodone, hydrocodone bitartrate, hydromorphone hydrochloride, fentanyl (applied transdermally), and pregabalin. The patient was frequently admitted to the hospital because of her neuropathic pain syndrome, despite regularly scheduled outpatient follow-up and repeated use of opioid medications. Two years after the initiation of opioid medication treatment, the patient's prescribing physician was made aware by the patient's pharmacist that the patient had been receiving additional opioids that were prescribed by other local ambulatory care physicians during the same 2-year period. The physician also learned that the patient was diverting a portion of her opioids to a family member. All other ambulatory care physicians involved in her care were also notified of this behavior. The patient was referred for detoxification and her physician informed her that he would no longer prescribe opioid analgesics. The patient did not pursue detoxification and initiated care for her chronic pain with a different physician.
At the patient's initial visit with her new physician, the physician ordered a urine drug screen, which was negative for amphetamines, barbiturates, benzodiazepines, cannabinoid, cocaine, opiates, phencyclidine, and oxycodone. The patient voiced that she did not want to use opioid analgesics and questioned whether higher doses of pregabalin, which she had taken before, may be effective. A review of systems did not reveal symptoms of depression or anxiety. The patient and physician agreed to a treatment plan using nonopioid treatment with pregabalin. The dosage regimen of pregabalin was titrated over several weeks to the maximum dose of 200 mg, administered three times a day. The patient reported satisfactory pain relief for the first 2 months after the initiation of pregabalin treatment. However, 2 months after beginning treatment, the patient complained of worsening pain and requested increased amounts of pregabalin be added to her dosage regimen. Because the physician did not want to exceed the maximum recommended dose of pregabalin and could not identify the origin of her increased pain, he declined the patient's request and the patient was maintained on her total daily dosage of 600 mg per day. In addition, the physician referred the patient to specialty pain management for further assessment.
During the 4 weeks after her last appointment with her new physician, the patient presented to 3 different hospitals, complaining of abdominal pain, nausea, headache, and diarrhea. Each visit led to a brief hospital stay, during which multi-specialty workup for the patient's complaints resulted in discharge diagnoses of abdominal pain with uncertain origin. The patient was provided supportive care and discharged with a prescription for a 7-day supply of pregabalin on each occasion. Symptoms spontaneously resolved within 48 to 72 hours of each hospital admission.
At a follow-up appointment 2 weeks after her last hospitalization, the patient had no further complaints related to her hospitalization. In addition, she reported satisfactory control of her pain and cancelled her appointment for specialty pain management. The patient also refused to reschedule and ultimately declined specialty pain management despite continued recommendations by her physician. The patient was continued on the same dosage of pregabalin.
One week after the follow-up appointment, the patient's physician was informed by the patient's pharmacist that the patient had received prescriptions for pregabalin from 3 other physicians. Calls to other local pharmacies further revealed that there were additional prescribers. The patient often paid cash for the pregabalin despite having prescription coverage insurance. Over a 28-day period, the patient had received a total of 88,500 mg of pregabalin. At this time, the physician became suspicious of pregabalin abuse or diversion and, in accordance with state medical board guidelines, the patient was discharged from the practice and referred to a local detoxification center. It was later determined that the patient did not enter a detoxification program.