My First Case of Algophobia? Or Münchausen Syndrome? Or maybe Just Another Patient with Opiate Induced Hyperalgesia, Allodynia, or Maybe Just Opiate Use Disorder?

Jimmy has a bad back. He’s fused at every level, some of them done twice. After many prescriptions of oral pain medication, he landed on Butrans, the buprenorphine patch that stays on for a week, hits the mu receptor for pain just like the regular opiates but not the depression inducing kappa receptor. It has fewer side effects in general and is less likely to cause respiratory depression if somebody were to double up on their dose. It’s even much safer in combination with benzodiazepines than traditional opiates.

My problem managing Jimmy’s medications is that he keeps getting hurt, more often than most other patients I have run into. And when he gets hurt, he reports more suffering than most other patients and he openly worries about how much things will hurt before they get better. For example, if the emergency room gives him a shot of Toradol and four days of pills to take my mouth, he worries that this will not be enough to handle the pain. I obviously tell him to wait and see, and not expect the worst. But that is what he tends to do.

Every doctor knows there are people with opiate use disorder who are just looking for their next kick and sometimes do stupid things to earn them that. We also have patients with various forms of allodynia like fibromyalgia. And opiate induced hyperalgesia is a very real phenomenon not usually triggered buprenorphine, but before Jimmy got onto that he had plenty of traditional opiates, so he may have some of that.

Real Münchausen syndrome is not about getting pain medicine. It’s about getting the medical attention that new symptoms, even if self inflicted, could bring.

My patient definitely has an anxiety disorder that could make him borrow trouble or anticipate more pain than a given diagnosis would be expected to cause him. As many times before, for example as I have written in Intuiting Alexithymia, I just had a thought that perhaps there is a diagnosis for something I am just starting to run into. With alexithymia it is the inability to describe one’s feelings. In Jimmy’s case, is there a word for when people are so worried about having pain that they are unable to be realistic about what to expect from any given injury or condition? And sure enough, there is a word for that: Algophobia. Check it out on Wikipedia and at the Cleveland Clinic.