Undetected Ultracet™ dependence in an adolescent with nonmalignant back pain

Nabil A. Khan, BA; Maria A. Sullivan, MD, PhD; Michael G. Vitale, MD, MPH; Mary Ellen Tresgallo, DNP, MPH, MS; John M. Saroyan, MD

doi:10.5055/jom.2013.0163

Authors

Nabil A. Khan, BA Harvard University Harvard Divinity School 3 Kent Court, Apt. 2 Somerville, MA 02143 7176238795 7176238795
Maria A. Sullivan, MD, PhD Columbia University College of Physicians and Surgeons Department of Psychiatry 630 W. 168th St, New York, NY 10032 (212) 543-6525 N/A (fax)
Michael G. Vitale, MD, MPH Columbia University College of Physicians and Surgeons Department of Orthopaedic Surgery 600 W. 168th St. 7th Floor New York, New York 10032 (212) 305-4565 (212) 305-8271 (fax)
Mary Ellen Tresgallo, DNP, MPH, MS Columbia University School of Nursing 617 W. 168th St. New York, New York 10032 (212) 305-2500 (212) 305-8883 (fax)
John M. Saroyan, MD Columbia University Anesthesiology and Pediatrics 622 West 168th Street PH5-500 New York, NY 10032 2123057114 2123054042 (First Alternate Telephone) 2123058883 (fax)

DOI:

https://doi.org/10.5055/jom.2013.0163

Abstract

Addiction to painkillers or other substances in pediatric and adolescent cases of noncancer chronic pain is an understudied phenomenon, even amidst documented increases in rates of prescription opioid use and misuse. Case studies can inform the training of clinicians in ethically negotiating a balance between optimizing analgesia and mitigating risk of aberrant drug-taking behaviors. This report discusses an 18-year-old woman with idiopathic scoliosis and clinical depression secondary to undertreated refractory chronic back pain who underwent surgery to correct pseudoarthrosis after a prior spinal instrumentation operation. This intervention in conjunction with a course of patient-controlled analgesia, hydromorphone, and outpatient tramadol, naproxen, methadone, and gabapentin was successful in addressing her long-standing lumbar pain. The patient, however, continued to complain to her pain management team of postsurgical discomfort and insisted on being prescribed Ultracet™ (acetaminophentramadol) rather than generic tramadol. The patient’s eventual disclosure of severe withdrawal discomfort and history of covert abuse of Ultracet ™ is discussed with respect to key warning signs, gaps, and contingencies in the screening, surgical, and pain management processes.

Keywords: adolescent, chronic pain, prescription opioid abuse, tramadol

DOI:10.5055/jom.2013.0163

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