Breaking the Cycle: The Devastating Functional Impact of Chronic Opioid and Steroid Use

Case Diagnosis: Chronic opioid and steroid use resulting in multiple medical complications and functional decline.

Case Description or Program Description: A 40-year-old female from an underserved area with severe asthma required lifelong steroids, leading to osteoporosis, myopathy, and uncontrolled diabetes, culminating in a below-knee amputation. She sustained L2-L3 compression fractures after a fall and T8-T12 fractures following a second fall. Given her severe osteoporosis, surgical intervention was limited to a T8 kyphoplasty. Chronic pain led to escalating opioid use (180 MME/day), while prolonged steroid use and respiratory impairment exacerbated her functional decline.

Setting: Acute care hospital followed by inpatient rehabilitation (IPR).

Assessment/Results: Despite preserved strength on initial IPR admission, as evidenced by manual muscle testing (MMT) of 4/5 in all extremities, severe pain and opioid-induced hyperalgesia significantly limited participation. A steroid taper led to respiratory failure, necessitating IMC transfer for NIPPV and steroid reinitiation. Endocrine workup revealed secondary adrenal insufficiency. On readmission to IPR, intractable pain, deconditioning, and medical instability hindered progress. Despite graded mobilization, neuromuscular re-education, and pain coping strategies, she remained non-ambulatory and was discharged at wheelchair level.

Discussion (relevance): This case highlights the destructive cycle of chronic opioid and steroid use. Opioid-induced hyperalgesia and respiratory compromise complicated pain management, while prolonged steroid use led to fractures, muscle weakness, and adrenal insufficiency. Limited healthcare access and specialist shortages in underserved areas prolong steroid reliance and delay alternative treatments, worsening complications. Earlier multimodal pain strategies—gabapentinoids, regional anesthesia, and behavioral interventions—could have reduced opioid dependence. Proactive osteoporosis management and structured steroid tapering might have prevented fractures and immobility, improving rehabilitation outcomes.

Conclusions: This case exemplifies the severe functional consequences of chronic opioid and steroid use. Physiatrists play a critical role in disrupting the cycle through early non-opioid pain optimization, interdisciplinary coordination, and proactive rehabilitation. Timely intervention is essential to preserving mobility, preventing disability, and improve long-term outcomes, especially in underserved populations.