Hydromorphone Overdose in a Patient with Chronic Noncancer Pain
Background:Opioid use in cancer, intraoperative and postoperative pain is undisputed. However, their use in long-term chronic noncancer pain (CNCP) management is controversial. Major concerns are effectiveness, addiction potential and safety1. The case presented is a reminder of this problematic.

Case Report:We report a case of 75 year old male, seen at the Chronic Pain Unit (CPU) since 2008 with Chronic Low Back Pain due to bone degenerative disease. He was submitted to several back surgeries without pain improvement. In 2012 was diagnosed with Failled Back Surgery Syndrome. Throughout the years several methods for pain control were attempted, not always with the patients full cooperation given his constant search for fast and total absence of pain. The methods used included several systemic opioids and in 2 different occasions the patient was diagnosed with opioid abuse presenting with prostration, without the need for further intervention. The scheme that best suited this patient included the use of fast and short acting opioids (sublingual fentanyl). The patients’ medical assistant was changed, and the new one decided to change to hydromorphone 64mg (x2/day). Two days after this new scheme he was admitted to the emergency with opioid intoxication: he had taken 6 pills of hydromorphone 64mg in one day. He was sleepy, reactive only to verbal stimuli, disoriented, bradypneic. He was given naloxone and was discharged on the 2nd day. After an intense effort from the CPU staff to help him understand what happened and learn how to manage pain, he has been kept on tapentadol 100mg 2id, paracetamol 1g 3id, paroxetine and mirtazapine with relatively good pain control.

Discussion: The use of opioids in Chronic Pain, particularly CNCP, has grown exponentially in the past years despite limited scientific evidence to back it up. Simultaneously, there was a considerable increase in opioid abuse and in deaths related to prescribed opioids. Revision studies show little evidence in efficacy of long term opioid use for CNCP and consider inconclusive its’ impact in quality of life (QoL) and in function.2

References:1-Curr Op Anaesthesiol 2010;2-Pain Physician 2012 

Learning points:This case serves as an alert for this matter and demonstrates the fine line between opioid use for QoL improvement and its’ abuse, reminding the medical community of the need for studies to clarify the role and safety profile of opioids in long term CNCP management.

Hydromorphone overdose in a patient with chronic noncancer pain