Opioid-induced Mania in a Sickle Cell Disease Patient with Major Depressive Disorder: A Case Report and Literature Review

Abstract

Opioids are well-known potent medications used for moderate to severe pain management. They act mainly through binding to μ-opioid receptors in the brain as well as having an inhibitory effect on serotonin and noradrenalin reuptake centrally, thus, increasing their levels. Considering the fact that Selective Serotonin Reuptake Inhibitors (SSRIs) act similarly, concurrent use of SSRIs along with opioids can induce mania. In this case report, we discuss a patient known to have sickle cell disease (SCD) with frequent painful crises managed with opioid analgesics; namely Tramadol and occasionally Pethidine. In addition, patient has been struggling with unipolar depressive disorder for the past ten years for which she was taking Paroxetine, there was no history of mania till few weeks prior to her current atypical presentation which coincide with an increment in her antidepressant's dose as well as her escalating misuse of the opioid analgesics. She was brought to the emergency department with mixed features of depression and mania with bouts of severe agitation. She was admitted to the psychiatric ward, her basic work up and brain imaging were unremarkable. She was diagnosed to have bipolar disorder type 1 with the possibility of opioid induced mania.  Her management was a challenging process especially with her comorbid opioid misuse. She was stabilized on Aripiprazole 30mg, education about the importance of proper and cautious use of opioids was conducted to the patient and her family. The case highlights the importance of careful inquiry of concurrent opioid use in chronic painful conditions as well as adjunct use of SSRIs and other antidepressants. It also emphasizes the need to conduct longitudinal studies of the effects opioid may exert on the mood and behavior especially in individuals with mental disorders with chronic painful disorders.