Fentanyl
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Misuse, opioid dependence syndrome and withdrawal symptoms: case report A 68-year-old man developed opioid dependence syndrome during treatment with fentanyl, and developed withdrawal symptoms following discontinuation of fentanyl. Additionally, he was taking fentanyl sublingual tablets for anxiety reduction, which was prescribed for low back pain. The man was referred and admitted to pain clinic for intractable low back pain. He had been using transdermal fentanyl [Fentos Tape] 6 mg/day patches and receiving sublingual fentanyl [Abstral] 100µg tablets as required, which was usually 0–2 times/day. His current hospitalisation was for a scheduled stent-graft insertion surgery secondary to thoracic aorta aneurysm. Following the surgery, his postoperative pain was not predominant. However, he complained worsening of his continuous low back pain and refused rehabilitation. An Xray revealed old L-4 lumbar compression fracture, but it did not sufficiently explain his severe pain. Additionally, behavioural problems like confronting to the medical staff when requesting for more opioids was observed. On anamnesis, his wife mentioned that he was taking fentanyl sublingual tablets not for pain management (originally prescribed) but for anxiety reduction (misuse). At the current presentation, short myoclonus-like convulsions during the night time were noted by physician and his attending nurse. He was suspected to have opioid-related disorders and his medical history was investigated for inadequate opioid use. Two years prior to the presentation, his family practitioner diagnosed him with terminal stage of cholangiocarcinoma. Erroneously believing that he had cancer, he became depressed and refused further examinations at that time. His low back pain worsened over these years. The cholangiocarcinoma was thought to be a misunderstanding, because the medical examinations at his current presentation including abdominal CT scans showed no sign of cancer. Initially, his analgesic therapy included paracetamol and duloxetine, but the results were not satisfactory. Hence, he only requested transdermal fentanyl (opioid prescription) for his low back pain. His medical records revealed that he had visited three different hospitals for his intractable pain symptom. At that time, the dose of transdermal fentanyl was gradually increased and he was also prescribed fentanyl sublingual tablet as needed. At current presentation, to rule out the possibility of pseudoaddiction or opioid tolerance, the man’s treatment with transdermal fentanyl was switched to morphine, but there was no significant change in the pain symptom as well as the requirement of fentanyl sublingual tablet. Hence, morphine was reverted to the transdermal fentanyl. In accordance with the International statistical classification of diseases and related health problems, he was diagnosed with opioid dependence syndrome. Hence, a treatment plan for fentanyl detoxification with tramadol replacement therapy was considered and the sublingual fentanyl was discontinued. Further, th
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