Psychosis After Switch in Opioid Maintenance Agonist and Risperidone-Induced Pisa Syndrome: Two Critical Incidents in Dual Diagnosis Treatment

ABSTRACT

Background and aims: Dual diagnosis commonly occurs among patients with an opioid use disorder. Treatment is ideally performed in an integrated fashion. We present a case that illustrates the complex and challenging psychiatric and medical therapy of such patients in the light of the literature. Case description: We report on a 56-year-old patient with schizophrenia and opioid dependence who experienced both risperidone-induced Pisa syndrome and, 3 years later, acute psychosis after switching the opioid substitution medication from methadone to slow-release oral morphine due to QT prolongation. Conclusions: With the current availability of a diversity of substitution opioids in Switzerland (methadone, buprenorphine, diacetylmorphine, sustained-release oral morphine), studies on differential effectiveness of these agents in opioid-dependent subpopulations with selective comorbidity profiles are desirable. The same is true for further investigation of the involvement of the opioid receptor system in schizophrenia. In clinical practice, any alteration of opioid medication in patients with dual diagnosis and a history of schizophrenia should be accompanied by close observation for psychotic symptoms.

KEYWORDS:

• Schizophrenia
• substance use disorder
• opioid use disorder
• Pisa syndrome
• risperidone
• opioid maintenance treatment
• methadone
• slow release morphine
• QT prolongation
• comorbidity

Acknowledgments

I would like to thank our patient, who gave her consent to present her medical story in this case report. I give special gratitude to Marc Vogel for introducing me to the idea of writing this report, developing the structure of the article, and editing as well as complementing the text several times. I also would like to thank Johannes Strasser, Kenneth Dürsteler, and Marc Walter for their useful comments, remarks, and engagement throughout the process of writing.

Disclosures

We declare that none of the authors had any conflict of interest relating to the subject of this manuscript. Manuel Sutter, Johannes Strasser, and Marc Walter do not report any compensation in any of the previous 3 years. Kenneth Dürsteler reports a research grant by Mundipharma. Marc Vogel has received travel support from Lundbeck and Reckitt Benckiser. In addition, he has received personal fees from Mundipharma. None of the authors has to report any additional income.