Management of Hydrocodone in the Setting of Chronic Pain in a Patient with Aberrant Behaviors: A Case Report

Case Diagnosis: A 68-year-old male with chronic pain and aberrant behaviors in the setting of opioid use disorder.

Case Description or Program Description: This report examines a 68-year-old male with chronic pain and aberrant behaviors. Despite monthly urinalysis confirming appropriate hydrocodone metabolism, the patient continued reporting poor pain relief. External sources alleged recreational drug use, yet repeated urine screenings returned negative results. Further evaluation, including oral swab testing, revealed hidden patterns of drug misuse and deceptive behaviors.

Setting: Interventional Pain and Wellness Clinic in Fort Worth

Assessment/Results: Repeated urinalysis screenings consistently indicated medication compliance without evidence of recreational drug use. However, one test revealed an excessively dilute urine sample, raising suspicion of tampering: a follow-up urinalysis and an oral swab uncovered undisclosed recreational drug use and misuse of prescribed medication. Due to the nature of these deceptive behaviors, he was dismissed from the clinic and advised to explore alternative pain management strategies.

Discussion (relevance): Hydrocodone, a Schedule II opioid, commonly prescribed for chronic pain acts primarily on mu-opioid receptors and exhibits partial activity at delta and kappa receptors. Metabolized through the cytochrome P450 system, hydrocodone is converted to norhydrocodone (inactive) via CYP3A4 and hydromorphone (active) via CYP2D6. Variability in CYP2D6 enzyme activity affects efficacy, necessitating careful dose adjustments. Urinalysis remains key in adherence monitoring, but with limitations, especially when engaging in sample substitution or dilution. Oral swabs offer a complementary screening approach by detecting recent drug use that may not appear in urine tests. Utilizing both methodologies enhances detection accuracy.

Conclusions: Managing chronic pain with hydrocodone requires vigilance due to the potential for misuse. Patients exhibiting aberrant behaviors necessitate thorough assessment through multimodal screening tools. This case underscores the importance of utilizing both urinalysis and oral swabs to uncover medication misuse and ensure patient safety. Clinicians must be proactive in recognizing deceptive behaviors and adapting pain management strategies to prevent opioid-related harm.