Butorphanol Dependence in a Woman With No Prior Substance Use

Butorphanol is a synthetic opioid with partial agonist-antagonist receptor activity in the μ and ĸ receptors.¹ It is approved by the US Food and Drug Administration as an analgesic. Because of the antagonist activity, the addiction potential is considered less than that of other opioids. Animal studies have found that butorphanol has rewarding properties and leads to the development of tolerance.¹ In addition, there have been reports on its dependence potential from Asian countries, especially among health care providers.^2,3 We present a case of butorphanol dependence in a woman, drawing attention to the need for careful opioid prescribing and monitoring in pain management contexts.

Case Report

Ms A, a 39-year-old widowed, graduate, homemaker, belonging to a joint family of lower middle socioeconomic status, presented to a tertiary care addiction treatment center with a 3-year history of butorphanol use. Initially, the butorphanol injection was administered intramuscularly by a doctor for a fall and soft tissue injury. Pain symptoms improved within 20 days. However, the patient perceived the relaxing effect of butorphanol and continued to use the injection. The use gradually increased to 2 injections (2 mg/1 mL) per week after 2 months. Ms A was able to purchase the injections from the nearby pharmacy by showing a previous prescription. She started to experience an intense urge to take the injection daily; when injections were delayed, she would experience diffused body pain, restlessness, irritability, rhinorrhea, lacrimation, fatigue, and sleep disturbance associated with an inability to perform household responsibilities. Injection use continued every day for the next 8 months. The dose was increased to 2-mg intramuscular injections twice/day, which was purchased from a pharmacy shop and administered by a home nursing assistant.

After 1.5 years of butorphanol use, the patient tried to quit by suddenly stopping; however, she was unable to get out of bed because of withdrawal symptoms. Due to these symptoms and associated cravings, she was forced to restart injection use after multiple unsuccessful attempts to stop. After about 2 years of regular use, her family discovered her injection use and consulted a private psychiatrist. Ms A was treated with 1.2 mg-4 mg sublingual buprenorphine in divided doses for the next 8 months and remained abstinent during this time.

About 2 years and 8 months after the injury and initiation of butorphanol, the patient developed reduced joint range of motion without pain. Due to functional impairment, she underwent physiotherapy, during which an acute fracture occurred. Postoperatively, butorphanol was restarted for pain, leading to a rapid relapse into prior use patterns. Although the fracture and mobility improved within 4 weeks, she continued injectable butorphanol use for 6 months due to persistent craving before presenting to our facility.

A diagnosis of opioid dependence, current use, was made with a plan of withdrawal management with sublingual buprenorphine along with psychosocial intervention and relapse prevention. Her blood investigations, including complete blood count and blood sugar, renal, and liver function tests, were found to be within the normal range.

Discussion

The present case adds to the limited but growing body of literature documenting butorphanol dependence. Earlier reports demonstrated physical dependence and withdrawal features associated with butorphanol use.⁴ Our patient reported subjective euphoric and relaxing effects, along with prominent craving and compulsive drug-seeking behavior in line with previous reports.^2,3 These features are consistent with preclinical studies that reported reinforcing properties and tolerance development in animal models.¹ The presence of craving and multiple unsuccessful attempts to terminate use and relapsing to use after a period of significant abstinence in this case is consistent with the conceptualization of butorphanol dependence as any other opioid dependence and not just neuroadaptation.

Butorphanol misuse, especially among women, is rarely reported in the published literature. The initiation of use for acute pain demonstrates the risk of iatrogenic dependence in a person who has no history of use of psychoactive substances. The transition from therapeutic use to escalation of use and dependence was similar to that of other prescription opioids and previous reports from the same center describing women who initiated pentazocine injections for pain relief.^5–7 This underscores the need for the judicious prescribing of opioid pain medications.

Butorphanol is a schedule IV medication in the United States. However, it is not scheduled as a narcotic or psychotropic under the UN drug conventions, since the critical review by the World Health Organization did not recommend its international scheduling.⁸ Accordingly, it is not classified as a controlled substance under the Indian Narcotic Drugs and Psychotropic Substances Act. As a pharmaceutical product, it is regulated in India as a schedule H medication (to be dispensed only with a prescription). However, as with many other medications, these rules are not strictly enforced.

To conclude, this case highlights the need to reconsider the perception of butorphanol as a low dependence risk opioid in the context of pain management. This calls for improved awareness regarding the dependence potential of butorphanol and future research.

Article Information

Published Online: October 20, 2026. https://doi.org/10.4088/PCC.26cr04253
© 2026 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2026;28(5):26cr04253
Submitted: April 15, 2026; accepted June 11, 2026.
To Cite: Muhammed JK, Mandal P, Ambekar A. Butorphanol dependence in a woman with no prior substance use. Prim Care Companion CNS Disord 2026; 28(5):26cr04253.
Author Affiliations: National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India (all authors).
Corresponding Author: Piyali Mandal, MD, National Drug Dependence Treatment Centre, Kamla Nehru Nagar, Ghaziabad, Uttar Pradesh, India ([email protected]).
Financial Disclosure: None.
Funding/Support: None.
Patient Consent: Consent was received from the patient to publish the case report, and information has been de-identified to protect patient anonymity.
ORCID: Jadeer K. Muhammed:
https://orcid.org/0009-0004-0429-8390; Piyali Mandal:
https://orcid.org/0000-0002-1636-7822; Atul Ambekar:
https://orcid.org/0000-0002-1116-7741