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Various toxicities secondary to buprenorphine and withdrawal symptoms following hydrocodone and fentanyl discontinuation: case report A 73-year-old man exhibited opioid use disorder, anxiety, pain, restless legs and insomnia as withdrawal symptoms following discontinuation of hydrocodone and fentanyl. Additionally, he developed haemodynamic instability, hypotension, bradycardia, central nervous system (CNS) depression and possible respiratory depression during treatment with buprenorphine for cravings and withdrawal [not all routes stated; duration of treatments to reactions onsets not stated]. The man, who had a 10 year history of chronic foot pain, coronary artery disease, hypertension and arthritis of the left hip and knee, followed by the pain clinic for the last 10 years. He was nonsmoker. He had been receiving treatment with hydrocodone 5mg, which was increased to 7.5mg and then to 10mg up to 4 times daily for pain. Additionally, fentanyl 25µg was added to the treatment regimen, which was icreased to 37µg and then to 50µg. Over the years, he started developing criteria for opioid use disorder comprising failure to fulfill role obligations at work, unsuccessful efforts to cut down on use of the medication and use of the medication in physically hazardous situations. He was asked to taper off the medication slowly. When he was looking for medication-assisted treatment, he was on fentanyl 12µg patch every 3 days and hydrocodone 10mg 1-2 times daily. Because, it was not possible to taper the treatment further without withdrawal symptoms. He was asked to stop the fentanyl and hydrocodone and was started on buprenorphine 4mg for cravings and withdrawal. At initial visit, he was on the third day of his fentanyl patch, which was discontinued that night with hydrocodone. Following discontinuation, he developed anxiety, pain, restless legs and insomnia as withdrawal symptoms. A clinical Opiate Withdrawal Scale showed score of 8, which was significant with mild withdrawal. The man was treated with ondansetron, clonidine and hydroxyzine as necessary for withdrawal symptoms. At clinic, he was started on sublingual buprenorphine 2mg. After the first dose, his symptoms improved and precipitated withdrawal was not observed. Following 2h, a second dose was given. He tolerated that dose very well and showed further improvement, but he was feeling dizzy and fatigue. At 10:15AM, before administration of the second dose of buprenorphine, his pulse rate 60bpm, blood pressure 113/62mm Hg. However, following administration of buprenorphine, he developed bradycardia and hypotension. Therefore, a rapid response team was called and it was observed that he was lethargic and having difficulty keeping his eyes open. He was transferred to the emergency department (ED). On arrival, he was somnolent and lethargic and was started on naloxone considering the suspicious diagnosis of buprenorphine toxicity/hypersensitivity. His respiratory rate was 10 breaths per minutes. Based on overall observations, a diagnoses of CNS and respiratory dep