Acute pain control challenges with buprenorphine/naloxone therapy in a patient with compartment syndrome secondary to McArdle's disease: a case report and review.

Abstract

OBJECTIVE:

We report the first case of non-iatrogentic exertional rhabdomyolysis leading to acute compartment syndrome in a patient with McArdle's disease. We describe considerations of concurrent buprenorphine/naloxone therapy during episodes of severe acute pain.

DESIGN:

Case report.

CASE PRESENTATION:

A 50-year-old male with a history of McArdle's disease, taking buprenorphine/naloxone for chronic pain and opioid dependence, presented to the Emergency Department with severe bilateral anterior thigh pain. Over the following 8 hours, he was given a total of 12 mg of intravenous hydromorphone with minimal pain relief. The decision was made to initiate patient-controlled analgesia (PCA) with hydromorphone started at 0.5 mg as needed with a 15-minute lockout. Subsequently, the patient's anterior thighs were found to be extremely tense. His creatine kinase level rose to 198,688 units/L and compartment pressures were greater than 90 mm Hg bilaterally. The patient was taken for emergent bilateral fasciotomies. The hydromorphone PCA was increased to 0.8 mg as needed with a 15-minute lockout and a basal rate of 0.5 mg/h. The patient's reported pain plateaued at 3/10 intensity 2 days after surgery, and he was transitioned to oxycodone and hydrocodone/acetaminophen. He followed up with his pain management physician 2 months later who restarted suboxone and a buphrenorphine transdermal patch.

DISCUSSION:

Buprenorphine/naloxone is being prescribed off-label with increasing frequency for pain management in patients with or without a history of opioid abuse. Severe acute pain is more difficult to control with opioid analgesics in patients taking buprenorphine/naloxone, requiring higher than usual doses. If buprenorphine/naloxone is discontinued to better treat acute pain with other opioids, monitoring for overdose must take place for at least 72 hours.

• Authors: Zachary McCormick, Samuel K Chu, George C Chang-Chien, Petra Joseph
• Journal: Pain medicine (Malden, Mass.) (Pain Med) Vol. 14 Issue 8 Pg. 1187-91 (Aug 2013) ISSN: 1526-4637 [Electronic] England
• PMID: 23647815 (Publication Type: Case Reports, Journal Article)
• Copyright: Wiley Periodicals, Inc.

Chemical References

• Analgesics, Non-Narcotic
• Analgesics, Opioid
• Drug Combinations
• Narcotic Antagonists
• Acetaminophen
• Naloxone
• Buprenorphine
• Creatine Kinase
• Hydromorphone

Topics

• Acetaminophen (therapeutic use)
• Acute Pain (drug therapy, etiology)
• Analgesia, Patient-Controlled
• Analgesics, Non-Narcotic (therapeutic use)
• Analgesics, Opioid (therapeutic use)
• Buprenorphine (therapeutic use)
• Compartment Syndromes (drug therapy, etiology)
• Creatine Kinase (blood)
• Drug Combinations
• Glycogen Storage Disease Type V (complications)
• Humans
• Hydromorphone (administration & dosage, therapeutic use)
• Injections, Intramuscular
• Male
• Middle Aged
• Naloxone (therapeutic use)
• Narcotic Antagonists (therapeutic use)
• Opioid-Related Disorders (complications)
• Pain Measurement
• Rhabdomyolysis (etiology)