Tramadol withdrawal\overdose
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Opioid use disorder and withdrawal syndrome: case report. A 45-year-old man developed opioid use disorder during treatment with escalating doses of tramadol and opioid withdrawal syndrome following withdrawal of tramadol. The man presented for assistance as he required escalating dose of tramadol. During the presentation, he was anxious and reported chronic use of tramadol from 150mg twice daily for chronic back pain to 500 and 1000mg daily since 2 to 3 months [route not stated]. He had history of hypertension, deep vein thrombosis, obstructive sleep apnea and chronic back pain. His medication included losartan, hydrochlorothiazide and tramadol. He had history of heavy drinking that stopped after opioid use. Due to unspecified side effects oxycodone was switched to tramadol, which was tolerable. The state prescription drug monitoring program (PDMP) database revealed prescriptions for hydrocodone/paracetamol and refill of tramadol. Subsequently, he was diagnosed with moderate opioid use disorder secondary totramadol due to its higher frequency than intended use, unsuccessful quit attempts, cravings and excessive effort to secure prescriptions. Therefore, the man was prescribed on buprenorphine for addiction and chronic pain. Several other treatment options were denied. In his office, he was not in active withdrawal. After abstaining from opioids for 18 hours, induction began next morning. He did not record exact score of the subjective opioid withdrawal scale. He reported anxiety, diaphoresis and nausea. He increased the dose of buprenorphine to 24mg daily, which decreased his anxiety. In follow up after 1 week, he reported constant nausea and diaphoresis. Additionally, he reported tinnitus, depressed mood, occasional myoclonic jerks and disequilibrium. These symptoms were suspecting tramadol withdrawal. He was started on escitalopram. After 1 week, his tinnitus, dizziness and nausea improved. For 1 day his mood was good, however, his mood declined thereafter and he desired to have another antidepressant. Therefore, duloxetine was started. After several days, myoclonic jerks aggravated, and a 15 second episode awoke him from sleep. He described lightning sensations down his legs. Seizures were misinterpreted and he visited emergency department. Examinations were normal except hypertension. Duloxetine was stopped but his mood declined. Therefore, escitalopram was restarted and his condition improved. Ultimately, after gabapentin administration his myoclonic jerks dramatically improved. After 6 weeks, he was stable but had prominent sexual side effects and a few constant depressive symptoms. Both were alleviated by bupropion initiation. In a follow up after 5 months, he was stable with escitalopram, bupropion and buprenorphine. He rarely required gabapentin. His pain and mood were improved with no other medication effects. Terasaki D, et al. Tramadol withdrawal in the setting of buprenorphine induction: A case report. Journal of Addiction Medicine 14: 264-266, No. 3, May-Jun 2020. Available 803517571 from: URL:
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