Misdiagnosis: Common Pain Remedy Mimics Schizophrenia Hallucinations

Schizophrenia is a serious mental illness that can cause symptoms such as hallucinations, when a person sees or hears things that aren't there. However, not every hallucination means someone has schizophrenia, as they can also be caused by other conditions or the use of certain medications. This was the case of a 67-year-old man who began experiencing hallucinations after taking opioid-based medications to treat back pain. When he stopped the medication, the symptoms disappeared. This example illustrates the importance of thoroughly investigating the causes of hallucinations before making a diagnosis of schizophrenia.

Schizophrenia is a complex mental health condition that profoundly affects how a person thinks, feels, and behaves. Individuals living with this disorder may have difficulty distinguishing between what is real and what is caused by changes in their brain, causing distress for both them and their families.

A diagnosis of schizophrenia requires a thorough investigation by psychiatrists, including detailed interviews, an analysis of the patient's life history and mental health, and tests to rule out other medical or psychological causes that may be causing similar symptoms.

One of the most striking symptoms is hallucinations, which occur when the brain creates false perceptions, causing the person to hear, see, feel, smell, or taste things that do not exist in their real environment.

While often directly associated with schizophrenia, hallucinations can also occur in a variety of other contexts, such as medication side effects, drug use or withdrawal, dementia, or delusions related to physical illness.

Among the possible medical causes of hallucinations, the use of opioids deserves attention, despite being little discussed. Opioids are medications used to control severe pain, often prescribed post-surgically or in cases of chronic pain. Studies report, for example, that approximately six percent of people receiving fentanyl after surgery experience hallucinations.

This number is likely higher, but it may be an underestimate because many patients do not report the symptom for fear of being perceived as mentally unstable. Despite the controversy surrounding their use in non-cancer-related pain, opioids are still widely prescribed in countries like the United States and Canada, especially for conditions like chronic low back pain. In these countries, prescription rates are two to three times higher than in Europe, demonstrating the widespread use of this class of drugs.

The case reported in the study clearly demonstrates how this side effect can confound psychiatric diagnoses. The case involved a sixty-seven-year-old African-American patient suffering from chronic low back pain who had been treated with Norco, a medication that combines hydrocodone and acetaminophen.

After starting this medication, he began experiencing auditory and visual hallucinations—that is, he began hearing and seeing things that were not there. The important detail is that the hallucinations increased in intensity when the medication dose was adjusted higher, but disappeared when he stopped taking the medication.

Despite this, the patient was initially referred to a psychiatric clinic with a diagnosis of unspecified schizophrenia, without considering the relationship between the onset of the hallucinations and the pain treatment.

This example shows how crucial it is for doctors, especially psychiatrists, to conduct a comprehensive and detailed assessment, taking into account the history of medication use, before making a diagnosis as shocking as schizophrenia.

When a patient experiences hallucinations, doctors follow a process of exclusion to understand the cause. First, they conduct detailed interviews to link the onset of symptoms to life events, medication use, or other illnesses. They also perform clinical and laboratory tests to rule out physical conditions such as infections, metabolic disorders, or drug side effects.

In the case of schizophrenia, the diagnosis is only considered if the symptoms persist for a prolonged period, if there is no other plausible medical explanation, and if they are associated with other characteristic signs of the disorder, such as disorganized thoughts or delusions.

However, when hallucinations appear in parallel with medication use and disappear when the medication is discontinued, this is a strong indication that the cause lies in the medication, not a primary psychiatric disorder.

When symptoms such as hallucinations appear, it is necessary to investigate whether they may be related to ongoing treatments, especially opioid use. This careful attention not only prevents misdiagnosis but also ensures that the patient receives the appropriate treatment for their actual condition.

The case also highlights the importance of patients talking openly about the side effects they experience, without fear of stigma, as this information can be crucial for determining the correct medical approach.

READ MORE:

Opioid-Induced Hallucinations: A Case Report

Arvind Dhanabalan, Sall Saveen, Christina Singh, Ramona Ramasamy, and Keerthiga Raveendran

Cureus, 16(12): e74915.

doi:10.7759/cureus.74915

Abstract: 

This article presents the case of a 67-year-old African American male patient who was referred to a psychiatry clinic by his Internal Medicine Provider with a diagnosis of "schizophrenia, unspecified." The patient reported the onset of auditory and visual hallucinations (AVHs) two years ago, coinciding with his starting Norco (hydrocodone 5 mg/acetaminophen 325 mg) for chronic back pain. He noted that his AVH worsened when he increased his prescribed Norco dosage (within his prescribed recommended range) and observed that the hallucinations ceased when he discontinued the medication. This case highlights the potential for opioid-induced AVH to be misdiagnosed as schizophrenia while emphasizing the importance of careful evaluation of opioid use in psychiatric assessments.