High-Dose Opioids, Severe Depression, and a Request for Escalation
A 52-year-old woman has chronic low back and leg pain six years after L4–S1 fusion. She takes hydromorphone 8 mg three times daily plus oxycodone 10 mg every 6 hours as needed, approximately 180 MME/day. She scores 18 on the PHQ-9 and 38 on the Pain Catastrophizing Scale, has not worked since 2019, and reports pain of 9/10 every day. The prescription drug monitoring program shows a single prescriber and single pharmacy, and her urine drug test is consistent with her prescriptions. She has never had a trial of cognitive behavioral therapy or graded exercise, and says "talking doesn't fix hardware." Her primary physician is frustrated and has asked you to "take over the opioids or stop them."
1. Is this opioid use disorder? Justify your answer and explain what else you would screen for.
Read the worked answer
No - on the available information she does not meet criteria for OUD.
DSM-5 requires at least two of eleven criteria within twelve months, and tolerance and withdrawal do not count when the drug is taken as prescribed. She demonstrates none of the behavioral criteria: no craving, no loss of control over use, no hazardous use, no continued use despite social or interpersonal harm, no role failure attributable to the opioid, no deceptive behavior. Her PDMP shows one prescriber and one pharmacy, and her urine drug test is concordant - findings that argue strongly against misuse.
What she does have is undertreated suffering and a therapeutic plan that has never included anything but opioids.
Screen for instead:
- Depression and suicidality - PHQ-9 of 18 is moderately severe; ask directly about ideation.
- Catastrophizing and fear-avoidance - PCS 38 predicts poor response to biomedical-only care and predicts benefit from CBT.
- Central sensitization and possible opioid-induced hyperalgesia, given diffuse pain and a 9/10 daily rating.
- Sleep apnea and sedative co-use - alcohol, benzodiazepines, gabapentinoids.
- Function and disability dynamics, plus social determinants.
Conflating depression and catastrophizing with addiction is the most consequential error available in this case; it produces an abrupt taper that harms her and confirms her belief that no one is listening.
2. Design a management plan that addresses her pain, mood, and function, and specify how the opioid regimen fits into it.
Read the worked answer
Frame: the problem is not "opioids or nothing" but an inadequately treated biopsychosocial condition with a high-risk medication as its only component.
Opioid regimen
- No escalation. Current dose carries real risk (respiratory depression, endocrinopathy, falls) with little demonstrated functional benefit.
- Propose a slow, collaborative taper only if she agrees, at roughly 5–10% per month with planned pauses; this is optional rather than mandatory if her risk profile is stable - current guidance supports individualized decisions rather than forced dose reduction.
- If she wants to reduce, transition to buprenorphine offers analgesia with a ceiling on respiratory depression and is easier to taper.
- Co-prescribe naloxone and counsel the household regardless of the chosen path.
Non-opioid and behavioral
- Pain-focused CBT and pain neuroscience education - directly targeting the PCS score.
- Graded exercise and physical therapy with pacing, not bed rest.
- Treat the depression: SSRI/SNRI plus psychotherapy; duloxetine would address mood and neuropathic components simultaneously if not contraindicated.
- Sleep and activity goals rather than pain-score goals.
- Interdisciplinary pain program referral - this patient is the archetype for whom it works.
Monitoring: PHQ-9, PDMP, urine drug testing, functional measures, and explicit safety planning for suicidality.
3. How would you frame the conversation to engage her, and what outcomes would you use to judge success?
Read the worked answer
Framing Open by validating: "Nine out of ten every day for six years is exhausting, and I understand why you are skeptical of anything that sounds like talking." Then use her own objection as the entry point: "You're right that talking doesn't fix hardware. But the hardware is not what is keeping you in bed - the nervous system around it has turned the volume up, and that part responds to retraining."
Use motivational interviewing rather than persuasion: ask permission before giving information, elicit her own goals (grandchildren, sleep, driving), reflect ambivalence, and avoid arguing. Replace "I'm taking away your medication" with "I want to build a plan where the medication is one small part instead of the only part."
Expect the catastrophizing to appear in the room - she will predict disaster from tapering. Acknowledge it rather than debating it.
Outcomes that count
- Function: walking distance, sitting tolerance, activities of daily living, steps per day.
- Pain interference (e.g., PROMIS interference), not pain intensity - chasing a lower number rewards escalation.
- PHQ-9 and PCS trajectories.
- Engagement: attendance at CBT and physical therapy, which is itself a prognostic marker.
- Safety: absence of overdose, sedation, falls, and suicidal behavior.
Declare the metrics at the outset so that success is defined before the first difficult visit, and so that a stable opioid dose with improving function can be counted as a win rather than a stalemate.