The n e w e ng l a n d j o u r na l of m e dic i n e

Case Records of the Massachusetts General Hospital

Founded by Richard C. Cabot

Eric S. Rosenberg, M.D., Editor
Virginia M. Pierce, M.D., David M. Dudzinski, M.D., Meridale V. Baggett, M.D.,
Dennis C. Sgroi, M.D., Jo‑Anne O. Shepard, M.D., Associate Editors
Kathy M. Tran, M.D., Case Records Editorial Fellow
Emily K. McDonald, Sally H. Ebeling, Production Editors

Case 26-2019: A 27-Year-Old Woman

with Opioid Use Disorder and Suicidal Ideation
Mladen Nisavic, M.D., Efren J. Flores, M.D., Marilyn Heng, M.D., M.P.H.,
Nicholas J. Kontos, M.D., and Nadia Quijije, M.D.​​

Pr e sen tat ion of C a se

Dr. Andrew Cruz (Psychiatry): A 27-year-old woman was evaluated at this hospital From the Departments of Psychiatry
because of a suicide attempt. (M.N., N.J.K., N.Q.), Radiology (E.J.F.),
and Orthopedics (M.H.), Massachusetts
Approximately 3 months before admission, the patient became homeless and General Hospital, and the Departments
was staying intermittently with friends. Two months before admission, she began of Psychiatry (M.N., N.J.K., N.Q.), Radiol‑
to ingest clonazepam daily, and 3 weeks before admission, she began to use intra- ogy (E.J.F.), and Orthopedics (M.H.),
Harvard Medical School — both in Bos‑
nasal heroin daily. She had depression and anxiety, and 2 days before admission, ton.
she expressed that she felt “tired of living this life” and wanted “to end it all.”
N Engl J Med 2019;381:763-71.
On the evening of presentation, the patient reportedly smashed her cell phone DOI: 10.1056/NEJMcpc1904043
on the ground and ate the glass shards as a suicide attempt. Nausea and diffuse Copyright © 2019 Massachusetts Medical Society.
abdominal discomfort developed, and she reportedly had an episode vomiting, with
the vomit containing 2 teaspoons (10 ml) of blood. Three hours after the ingestion,
she presented to the emergency department of this hospital with throat, chest, and
abdominal pain. She reported that she had “regret” about the ingestion and
wanted “help” with her substance use and suicidality.
The patient reported past sexual trauma but did not provide details; she did not
report any previous suicide attempts, homicidal ideation, or hallucinations. A limit­
ed review of systems was notable for anorexia, diaphoresis, diarrhea, impaired
sleep, fatigue, mood lability, nightmares, and flashbacks. Her psychiatric history
included polysubstance use disorder (with the use of intravenous heroin, fentanyl,
benzodiazepines, and cocaine), cutting behavior during adolescence, and anxiety
and depression. She had never undergone psychiatric treatment or hospitalization.
Her medical history included hepatitis C virus infection, obesity, genital herpes
simplex virus infection, and a low-grade squamous intraepithelial lesion of the
cervix; in addition, a motor vehicle collision had led to open reduction and internal
fixation involving the left arm. She took no medications and had no known ad-
verse reactions to medications. She worked in a local store and had a small child.
She had smoked one and a half packs of cigarettes daily for the past 10 years and

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 The n e w e ng l a n d j o u r na l
was a current smoker. She drank 1 pint of vodka
daily and reported no history of withdrawals or
blackouts. Multiple relatives, including both of
her parents, had a history of substance use dis-
order.
On examination, the temperature was 36.8°C,
the pulse 70 beats per minute, and the oxygen
saturation 96% while the patient was breathing
ambient air. She appeared disheveled, tearful,
and anxious. Abdominal examination revealed
mild tenderness on the right side on palpation.
On examination by a psychiatrist, she had limited
eye contact and mumbling speech, along with
poor concentration, depressed mood with a con-
gruent affect, and poor insight and judgment.
The complete blood count and levels of electro-
lytes, urea nitrogen, creatinine, lactate, bilirubin,
alkaline phosphatase, and albumin were normal;
the aspartate aminotransferase level was 162 U
per liter (reference range, 9 to 32), and the ala-
nine aminotransferase level was 52 U per liter
(reference range, 7 to 33). Ethanol was not de-
tected in the blood, and human chorionic gonado-
tropin was not detected in the urine. A urine
toxicology screen was positive for opioids and
cocaine metabolites. The findings on an electro-
cardiogram were normal and unchanged from a
tracing obtained 10 years earlier.
Dr. Efren J. Flores: The results of radiography of
the neck, chest, and abdomen were normal,
without a visible radiopaque foreign body. Com-
puted tomography (CT) of the abdomen and pel-
vis, performed after the administration of intra-
venous contrast material (Fig. 1), revealed
gallbladder wall thickening and trace perihepatic
fluid. These findings can be seen in patients with
acute hepatitis. There was no evidence of pneumo-
peritoneum or of a radiopaque foreign body.
Dr. Cruz: Intravenous normal saline, morphine
sulfate, and piperacillin–tazobactam were admin-
istered. The patient was evaluated by the surgery
and psychiatry services. Because of concern
about the patient’s risk of self-harm, an order
that authorized temporary involuntary hospital-
ization was implemented.
The next evening, the patient reported that
while she was trying to get out of a stretcher, she
“heard a pop” in her right elbow, which was ac-
companied by immediate pain without any numb-
ness or tingling. On examination by an orthope-
dic surgeon, the olecranon process appeared to
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of m e dic i n e
protrude posteriorly and medially without ecchy-
mosis. The patient was not able to move the arm
at the elbow, although range of motion was intact
at the shoulder and wrist.
Dr. Flores: A lateral image of the right elbow
(Fig. 2A) showed posterior dislocation of the el-
bow with impaction of the olecranon process of
the ulna into the distal humerus outside the
olecranon fossa. An anteroposterior image of
the right elbow (Fig. 2B) confirmed dislocation
of the elbow with malalignment of the ulnotroch-
lear and radiocapitellar joints.
Dr. Cruz: After the administration of aceta­
minophen, ibuprofen, oxycodone, and intrave-
nous morphine, the elbow was manually reduced
and a splint was applied. Additional radiograph-
ic images were obtained.
Dr. Flores: Lateral and anteroposterior images
of the right elbow obtained after closed reduc-
tion and splinting (Fig. 2C and 2D) showed nor-
mal alignment of the ulnotrochlear and radio-
capitellar joints.
Dr. Cruz: During the next 18 hours, the patient
remained under observation, with a plan for
transfer to an inpatient psychiatric hospital for
ongoing care. One hour before transfer, the pa-
tient went to the bathroom without her observer
and then reported that she could not move her
right arm.
Dr. Flores: A lateral image of the right elbow
showed that the splint was in place and showed
posterior dislocation of the elbow with impaction
of the olecranon process of the ulna into the
distal humerus outside the olecranon fossa. An
anteroposterior image of the right elbow con-
firmed dislocation of the elbow with predomi-
nant involvement of the radiocapitellar joint. There
was irregularity of the radial head and lateral
humeral epicondyle that was consistent with a
nondisplaced fracture.
Dr. Cruz: Intravenous morphine was adminis-
tered. The elbow was again reduced, and a cir-
cumferential fiberglass cast was placed.
Dr. Flores: A lateral image of the right elbow
obtained after the second closed reduction and
casting showed normal alignment and the pres-
ence of a cast.
Dr. Cruz: The next afternoon, after the plan for
transfer to a psychiatric hospital was shared with
the patient, she was found in the bathroom with-
out her observer, where she was banging her left
 Case Records of the Massachuset ts Gener al Hospital

A Differ en t i a l Di agnosis

Dr. Mladen Nisavic: This 27-year-old woman with

B diaphoresis, and abdominal discomfort would
Figure 1. CT Scan of the Abdomen and Pelvis.
Coronal and axial images (Panels A and B, respectively)
of the abdomen and pelvis, obtained after the adminis‑
tration of intravenous contrast material, show gallblad‑
der wall thickening (arrows) and trace perihepatic fluid
(Panel A, arrowhead). These findings can be seen in
patients with acute hepatitis. There is no evidence of
pneumoperitoneum or of a foreign body.
arm against the wall. She reported pain, and oral
oxycodone and intramuscular hydromorphone
were administered.
Dr. Flores: A lateral image of the left elbow
obtained hours after the second reduction and
casting of the right elbow (Fig. 2E) showed pos-
terior dislocation of the left elbow and a frag-
ment from a displaced fracture of the trochlea.
There were two screws in the lateral humeral
epicondyle from previous open reduction and
internal fixation.
Dr. Cruz: Intraarticular nerve block was per-
formed. The left elbow was reduced, and a long-
arm circumferential fiberglass cast was placed.
Additional management decisions were made.
active polysubstance use disorder (with the use of
alcohol, benzodiazepines, cocaine, and opioids)
presented to the hospital after a reported suicide
attempt by means of foreign-body ingestion.
During the initial safety evaluation and surgical
stabilization, a history of polysubstance use, anxi-
ety, depressed mood, and trauma was elicited; she
reported no previous suicide attempts.
The patient’s initial vital signs were normal,
and she had no physical findings consistent with
active alcohol withdrawal. The report of diarrhea,
arouse concern about early opioid withdrawal,
given the recent use of opioids and reported his-
tory of opioid use disorder. Drug screening was
notable for the presence of opioids and cocaine.
Alcohol and benzodiazepines were not detected,
nor was the heroin-specific metabolite 6-mono-
acetylmorphine.
Initial plain radiography of the chest and
abdomen and abdominal CT did not reveal any
ingested foreign bodies. It is important to note
that small pieces of metal, glass, and plastic
(which are presumed components of most cell
phones) may not be reliably detected on imaging
studies. However, in this case, the complete ab-
sence of imaging findings raises the question of
whether the patient is being truthful about at-
tempting suicide.1 It is also important to note
that, despite the ultimate absence of trauma and
of evidence of foreign-body ingestion, the pa-
tient reported clinically significant pain and in-
travenous opioids were administered.
My concern regarding this patient’s overall
engagement and truthfulness with the team is
further confirmed on review of her subsequent
stay in the surgery unit. Over the course of 3 days,
the patient had two episodes of seemingly spon-
taneous dislocation of the right elbow before she
was observed actively attempting to dislocate her
left elbow. Despite the presence of an observer,
details regarding the way in which the first two
injuries occurred are scarce; in both cases, the
patient reported afterward that the dislocation
was spontaneous and claimed to have no insight
into the event. Despite prompt orthopedic treat-
ment, she reported clinically significant pain
with each dislocation and intravenous opioids

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 The n e w e ng l a n d j o u r na l of m e dic i n e

A B

C D

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 Case Records of the Massachuset ts Gener al Hospital
Figure 2 (facing page). Radiographs of the Elbows.
A lateral image of the right elbow obtained after the
patient reported that she “heard a pop” (Panel A) shows
posterior dislocation of the elbow with impaction of the
olecranon process of the ulna into the distal humerus
outside the olecranon fossa. An anteroposterior image
of the right elbow (Panel B) confirms dislocation of
the elbow with malalignment of the ulnotrochlear joint
(arrowhead) and radiocapitellar joint (arrow). A lateral
image of the right elbow obtained after closed reduc‑
tion and splinting (Panel C) shows normal alignment.
An anteroposterior image of the right elbow (Panel D)
confirms normal alignment of the ulnotrochlear and
radiocapitellar joints. A lateral image of the left elbow
(Panel E) shows posterior dislocation of the elbow and
a fragment from a displaced fracture of the trochlea.
There are two screws in the lateral humeral epicondyle
from previous open reduction and internal fixation.
were administered. Furthermore, the second and
third dislocations had a notable temporal correla-
tion with the planned transfer to an inpatient
psychiatric facility, with the injuries occurring
mere hours before the transfer was meant to occur.
In summary, a young woman with polysub-
stance use disorder self-presented after a self-
reported suicidal gesture, and ultimately, no
objective evidence of foreign-body ingestion was
discovered. During routine surgical observation
for clearance before planned transfer to an inpa-
tient psychiatric facility, the patient appears to
have engaged in repeated acts of self-harm, and
until she was discovered engaging in such an act,
she described each new injury as unintentional.
With each incident, she reported clinically sig-
nificant pain and intravenous opioids were ad-
ministered.
Which diagnosis or diagnoses may explain
this patient’s recurrent pattern of self-harm and
limited engagement with the team? It is impor-
tant to construct a broad differential diagnosis
even if the diagnosis initially appears certain.
Maintaining a broad differential diagnosis can
help us to adequately confirm the major problem
and to potentially identify less active or obvious
contributors to the clinical situation. During
psychiatric assessment, it is critical to consider
each major component of the psychiatric review
of symptoms and the way in which each compo-
nent may apply to the case and help us to under-
stand the patient’s behavior and actions. Such an
approach offers a thorough and methodical path
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toward establishing the pertinent diagnosis and
identifying any additional problems.
In gaining an understanding of this patient’s
presentation, some of the major components of
the history — such as depressed mood, anxiety,
and post-traumatic stress disorder — are notable.
Despite her initial endorsement of mood, anxiety,
and safety concerns, she quickly stopped report-
ing these symptoms during her stay in the sur-
gery unit. In addition, there are few findings
that would allow us to ascribe the patient’s be-
havior to an episode associated with untreated
major depressive disorder. An underlying thought
disorder or acute mania may be considered, pri-
marily given the bizarre nature of her recurrent
injuries. However, neither of these diagnoses
appears to be consistent with the remainder of
the history. The patient did not have a history of
clinically significant severe and persistent mental
illness, and no cardinal symptoms of either acute
mania or psychosis were described throughout
her hospitalization. No negative symptoms of a
major thought disorder were described, either.
Personality vulnerability or frank personality
disorders could also be considered, especially
given the patient’s history of trauma. However,
we do not have the necessary information to
support these diagnoses, and her brief hospital-
ization offers insufficient exposure to allow us
to make these diagnoses.
Multiple substance use disorders were noted in
this case, and I strongly suspect that substance
use is playing a considerable role in this patient’s
presentation. Acute intoxication (e.g., with co-
caine) may be associated with unusual behavior,
but repeated use while under strict observation
in the hospital would be unlikely. Withdrawal
from alcohol or benzodiazepines can be linked
with delirium, but the patient’s behavior appears
to be deliberate, methodical, and devoid of acute
confusion and of any other signs or symptoms
of acute withdrawal from one of these agents,
such as tremor or changes in vital signs. She
reported recent opioid use, and her initial ex-
amination was notable for some signs of early
opioid withdrawal. Furthermore, she requested
intravenous opioids at the time of the initial pre-
sentation and with each episode of self-injurious
behavior. Could opioid use disorder be the unify-
ing diagnosis in this case?
In the presence of intentional and repetitive
767
 The n e w e ng l a n d j o u r na l
self-harm, a diagnosis in the category of somatic
symptom and related disorders could also be
explored. A deception syndrome (factitious dis-
order or malingering) is a strong consideration,
given the multiple inconsistencies in the avail-
able information and ultimate evidence of de-
liberate self-infliction of injuries. To rule out an
occult medical cause, I performed a literature
search for spontaneous and recurrent elbow dis-
locations. The review offered limited data but
provided reassurance that spontaneous elbow
dislocation is an uncommon finding outside
specific populations (e.g., children and male
athletes), and when it occurs, it is often linked
with preexisting joint vulnerability.2-4
The patient’s history offers minimal evidence
that her behavior reflects an unconscious need
to maintain a sick role, a hallmark of factitious
disorder. Instead, there appears to be a strong
correlation between her behavior and opioid ad-
ministration, which would reflect secondary gain,
a hallmark of malingering. I suspect that the
best explanation of this patient’s behavior lies at
the intersection of substance use and deception
syndrome.
Dr . Ml a den Nis av ic’s Di agnosis
Severe opioid use disorder and malingering (de-
ception syndrome).
Ps ychi at r ic Di agnosis
Dr. Nicholas J. Kontos: After multiple psychiatric
interviews, the patient reported that she had lied
about her suicide attempt and had intentionally
dislocated her elbows. She also reported that her
goal in both cases was to obtain opioids, con-
firming the diagnosis of malingering.
The Diagnostic and Statistical Manual of Mental
Disorders, fifth edition,5 classifies malingering
among “other conditions that may be a focus of
clinical attention.” Malingering is not a psychiat-
ric disorder. It can be distinguished from facti-
tious disorder by the presence of behavior that is
directed toward tangible gains, as opposed to
behavior that is directed toward intangible sick-
role gains. Sick-role gains include receiving care,
being excused from duties, and being able to
place blame on sickness.6 The line between tan-
gible and intangible gains can be blurry; it is
sometimes more important to describe and try to
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of m e dic i n e
address the patient’s goals than to distinguish
between factitious disorder and malingering.
There is minimal evidence-based guidance for
the identification of clinically significant decep-
tion, particularly that involving psychological
symptoms. The method for making an action-
able diagnosis of malingering is unsettled, even
in forensic situations, in which dedicated neuro-
psychological tests are used.7,8 It is not surpris-
ing that underidentification of malingering in
the clinical setting is common.9,10
This patient reported a specific suicide at-
tempt, with a motive and associated pain and
fear, and she later reported elbow pain and im-
mobility. At face value, this patient’s history
warranted concern from clinicians who were
making decisions about safety precautions. How-
ever, because the patient did not have physical
findings (e.g., oropharyngeal lesions) or imag-
ing findings that would support the reported
ingestion and because she had disengaged from
subjects about which she had initially expressed
desperate concern, suspicions appropriately rose.
Such suspicions might be inhibited by concerns
about stigmatization, doctor–patient rapport, and
even liability.11 Allowing suspicion without cyni-
cism or premature closure is an early hurdle in
deception assessment.12
Some experts advise and others discourage
confrontation of patients who have possible de-
ception syndrome, and approaches to confronta-
tion are seldom defined. An approach that is
incremental, honestly poses and compares con-
flicting points of view, and attends to the ethical
implications of a potentially one-sided good-faith
relationship13 is consistent with a “feedback mod-
el,” in which rapport and attention to reasons for
deception are emphasized.14 In this case, con-
frontation of the patient began with an unrecip-
rocated attempt to engage and a statement of
helpful intent. Then, inconsistencies in the avail-
able information were addressed with curiosity
and met with irritation from the patient. The
next day, the patient explained her behavior but
otherwise remained irritably disengaged. Con-
tinued confrontation was eventually met with
meaningful engagement, including participation
in motivational interviewing.
Most patients with deceptive behaviors do not
readily explain those behaviors. Yet, misrepre-
sented psychological symptoms are strongly sus-
pected in up to 20% of psychiatric emergency
 Case Records of the Massachuset ts Gener al Hospital
department visits15 and reported anonymously by
8 to 10% of psychiatric inpatients.16-18 Nonethe-
less, it is important for physicians to remain
skeptical of their own intuitions about and
strong reactions against possible deception. Phy-
sicians have no special aptitude for detecting
deception in unfamiliar patients.19 Medical rec­
ords may provide a longitudinal perspective that
reveals consistencies across presentations or in-
consistencies within reports. A patient who is
unfamiliar to an individual physician may be
quite familiar at the institutional level. Close
review of available records may be valuable when
evaluating a patient with possible malingering.
Discussion of M a nagemen t
Orthopedic Management
Dr. Marilyn Heng: Because the elbow joint has
bony stability with a deep ulnohumeral contour
and capsular and ligamentous constraints, it is a
difficult joint to dislocate.20 Prompt restoration
of articular alignment by means of closed reduc-
tion is desired to reduce the risk of swelling,
damage to the articular cartilage, and neurovas-
cular compromise. Reduction of the dislocated
elbow usually results in pain relief for the pa-
tient. The administration of narcotic pain medi-
cation is not usually continued after reduction
for simple elbow dislocation; at most, only a short
course (1 to 2 days) is administered. Simple elbow
dislocation without associated fracture is usually
treated nonoperatively, with treatment followed
by a period of immobilization. In this patient, the
results of clinical examination and the previous
dislocation of the right elbow would lead to a
plan for a longer-than-usual period (2 to 3 weeks)
of immobilization.
The patient’s active attempts to redislocate
her elbow resulted in breakage of her splint.
Conversion to a circumferential fiberglass cast
prevented her from intentionally dislocating the
right elbow but then provoked her to dislocate
the left elbow. Closed reduction and long-arm
casting of the left elbow was performed. Surgery
for recurrent elbow dislocation consists of repair
of ligamentous structures, with or without exter-
nal fixation. However, a cautious approach should
be taken for patients who intentionally, habitu-
ally dislocate a joint for secondary gain. In such
patients, surgical treatment is associated with a
high risk of failure due to nonadherence to medi-
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cal recommendations. In this situation, the gen-
eral approach of the orthopedic surgeon would
be either to maintain prolonged casting or to do
nothing while the issues behind the behavior
leading to intentional dislocation are addressed.
Management of Deception Syndromes
Dr. Kontos: Only case reports and experience guide
the clinical management of malingering. In prac-
tice, management occurs in three domains: treat-
ment, shifting of the patient’s strategies, and
punishment. Treatment addresses the conse-
quences of self-harm; in this case, it involved
casting of the affected limbs. Treating an objec-
tive pathologic condition (e.g., an infection or
ingestion) must proceed independently of and
in parallel with addressing its cause. Psychiatric
treatment for malingering focuses on possible
coexisting conditions (e.g., substance use or per-
sonality disorder).
The confrontation and feedback involved in
the detection of malingering can engage the
patient in the work of shifting maladaptive life
strategies in favor of adaptive ones. The goal is
to “move the discussion from the traditional
reliance on medical or psychological causes to a
consideration of the reasons” behind malinger-
ing.14 Common reasons include addiction, legal
entanglements, and the need for food, shelter,
and safety. In some cases, the health care system
is unable to meet these needs other than by di-
recting the patient toward a different path. The
application of clinical tools to purely social
problems may do more harm than good.
A patient’s inability or unwillingness to recip-
rocate reasons-based engagement can necessitate
interventions with the appearance of punish-
ment or actual punishment. Sometimes, the only
good outcome of malingering is the prevention of
iatrogenic harm and the nonparticipation of the
clinician or institution in reinforcing maladap-
tive behaviors. A security-facilitated “therapeutic
discharge”21,22 may be needed for recalcitrant
patients. In extreme cases, criminal prosecution
for theft of service might be considered.11
Management of Opioid Use Disorder
Dr. Nadia Quijije: When treating a patient with
opioid use disorder and coexisting acute pain in
the inpatient setting, I keep three major compo-
nents in mind: opioid withdrawal, undertreated
pain, and longitudinal treatment through medi-
769
 The n e w e ng l a n d j o u r na l of m e dic i n e

cation-assisted strategies (suboxone or metha-
done maintenance therapy). In this case, I was
concerned about the patient’s risk of opioid
withdrawal, given her consistent use of heroin.
When I met the patient, it had been 3 days since
her last opioid use, so she was still within the
window for withdrawal symptoms but had been
receiving short-acting opioids for pain along with
agents for the management of opioid withdrawal
symptoms (dicyclomine for abdominal cramps
and acetaminophen for muscle aches). In the
management of opioid withdrawal, it is impor-
tant to assess for both subjective symptoms
(anxiety, abdominal cramps, and muscle aches)
and objective symptoms (diaphoresis, dilated
pupils, and piloerection). This patient reported
and seemed most distressed about “sweats
and anxiety,” for which I recommended the addi-
tion of clonidine, which can specifically relieve
these symptoms by means of norepinephrine
dampening.23
During the treatment of this patient’s pain,
she reported feeling comfortable with the pre-
scribed oxycodone, and therefore, we did not
recommend changing the agent or adjusting the
dose. However, it is important to keep in mind
that patients with opioid use disorder are likely
to have a high tolerance for opioids and will
therefore probably need a high dose of opioids
for treatment, especially when they are undergo-
ing surgical or medical procedures, as in this
case.24 This is also an opportunity to discuss
medication-assisted treatments, such as suboxone
and methadone, for both the management of
acute pain and the longitudinal treatment of
opioid use disorder.25 This patient was not inter-
ested in receiving methadone; she was agreeable
to the initiation of suboxone as medication-
assisted treatment for opioid use disorder but
not for the management of acute pain. It was
recommended that suboxone be initiated after
immediate needs were resolved to allow for ad-
equate pain management and to avoid suboxone-
induced opioid withdrawal.26 The inpatient set-
ting is a prime place to set up aftercare treatment
with intensive outpatient programs, methadone
maintenance clinics, suboxone prescribers, recov-
ery coaches, or Narcotics Anonymous.27 We had
planned to transfer this patient to a dual-diag-
nosis inpatient unit to obtain treatment for acute
substance use disorder and to establish aftercare
planning.
Dr. Cruz: The patient declined treatment for
substance use disorder and social-work assis-
tance with shelter. After discharge from the
hospital, she presented to the emergency depart-
ment five times in the following week. On the
final presentation, she asked that the arm casts
be removed, and she has not presented to the
emergency department in more than 6 months.
Fina l Di agnosis
Opioid use disorder and malingering.
This case was presented at Psychiatry Grand Rounds.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
We thank Dr. John Taylor for assistance with selection of this
case and organization of the conference.

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