In the past decade opioid pain reliever misuse among the U.S. population has increased to epidemic proportions. While the U.S. has only 4% of the world's population, Americans consume 86% of the world's opioids. In 2011, approximately 13 million people (5% of the U.S. population) reported nonmedical use of prescription opioids, which are now the second most commonly abused class of drug behind cannabis. There has been little in the way of formal study examining the association between mental illness and prescription opiate abuse, but preliminary evidence suggests a strong association. Neurobiological processes involved in psychosis and opiate abuse may partially explain this association. Despite compelling evidence of the growth in opiate misuse and the potential relationship with mental illness, patients with mental disorders and/or substance abuse are routinely excluded from randomized trials, making it impossible to better understand these phenomena. Treatment guidelines, especially regarding opioid agonists such as methadone and buprenorphine for people with mental illness, are woefully inadequate. We present the case of a young man with schizoaffective disorder who sustained an injury and developed chronic back pain. Opioids were prescribed and he quickly progressed to abusing increasing doses of opioids, which eventually led to daily heroin use. The young man struggled with repeated relapses, serious use-related consequences and suicide attempts. This case highlights the role of chronic pain and opioid prescribing, the segue from prescribed use to abuse and dependence, and the transition to heroin use. It demonstrates the difficulty patients may have in obtaining adequate treatment for co-occurring mental illness and substance abuse and how outcomes are improved when treatment is integrated to address both disorders. Comprehensive treatment must involve a combination of case management and medical management, including possible opioid replacement therapy.
Keywords: dual diagnosis; opiate dependence; schizophrenia.