BACKGROUND: Current guidelines suggest that chronic high-dose opioids are not beneficial for non-cancer patients with chronic pain. However, when patients do present on these regimens, successful management of weaning is... [ view full abstract ]
BACKGROUND: Current guidelines suggest that chronic high-dose opioids are not beneficial for non-cancer patients with chronic pain. However, when patients do present on these regimens, successful management of weaning is crucial. The following demonstrates an extreme case of chronic high-dose IV narcotic use and a successful weaning to a multimodal oral pain regimen.
CASE DESCRIPTION: A 59-year-old woman with a history of chronic pain due to complications of systemic lupus erythematous and a cervical radiculopathy presented to the emergency room in an acute pain flare. She was followed by an unaffiliated chronic pain clinic as an outpatient, and ten years prior she had been started on an at-home IV fentanyl infusion through a PICC line for her difficult to manage pain. This infusion was prescribed at a dose of 900 mcg/hr, in addition to 200mcg boluses every six hours. Her husband, who was a physician and active caregiver, admitted that she had figured out how to manipulate her infusion pump and was self administering up to 1700 mcg of fentanyl per hour on average (equivalent to 12,200 mg PO morphine daily). Despite these high doses, her pain was constantly rated 10/10 unless she was asleep or over-sedated. Her cervical radiculopathy had been slowly worsening over the month prior to presentation, and she was treated several times as an outpatient with epidural steroid injections. MRI on admission demonstrated a C5-6 discitis. Spinal surgeons were hesitant to intervene due to her high levels of narcotic dependence and poor functional status, so she was admitted for IV antibiotics and management of her acute pain crisis. She was initially continued on her home infusion of fentanyl with the addition of a lidocaine infusion, ketamine infusion, and hydromorphone PCA. Psychiatry was consulted for management of her extreme anxiety. Over the next week, she and her husband agreed to undergo a blind weaning of her fentanyl infusion. Her fentanyl was decreased by 100-200 mcg per day until it was completely discontinued. During the time, she was maintained on a ketamine infusion at 20-30mg/hr (in addition to other multimodal agents). She was successfully weaned completely off of all IV medications without demonstrating any signs of withdrawal. Subsequently, she was able to tolerate a cervical spinal fusion with improvement in her symptoms and without a significant pain flare. She was ultimately discharged on an oral pain regimen that included extended and immediate release oxycodone (equivalent to 255mg po morphine/day), gabapentin and acetaminophen. On discharge she was receiving a dramatically lower dose of opioids, was more alert and had increased function as well as lower pain scores.
DISCUSSION: A patient on a chronic high-dose fentanyl infusion was weaned to an oral pain regimen using a multimodal approach that included ketamine and lidocaine infusions. This approach may be useful in other patients on chronic high-dose opioid infusions that require inpatient transition to an oral regimen.
