Ziconotide is used intrathecally in the management of severe
chronic pain that contains a warning against neuropsychiatric adverse events. The definition of psychiatric events is broad and management strategies are vague. This case report describes a 49-year-old female who was admitted to the acute psychiatric unit to address
auditory hallucinations and paranoid ideation persisting for 3 weeks. Approximately 3 months ago, an intrathecal pump with
ziconotide was implanted to treat
pain. Upon hospital admission, the pump was infusing at a rate of 4.9 mcg/24 hours. Because the
drug could not be immediately discontinued,
risperidone 0.5 mg nightly was initiated and subsequently, the pump was drained of
ziconotide, rinsed, and refilled with
normal saline. The patient reported no
hallucinations or apparent delusions several hours later and was eventually discharged with resolution of psychotic symptoms and continuation of
risperidone for 10 days. Despite the identification of neuropsychiatric effects, limited information is available to characterize the presentation and guide specific management aside from recommendations to discontinue the infusion and possible use of psychotropic medications or necessity for hospitalization. This case report characterizes one presentation of
hallucinations and
paranoia associated with
ziconotide intrathecal infusion. Clinicians should be aware of the management strategies to mediate these adverse effects, including expected time to adverse effect resolution, removal of
ziconotide from the pump, and role for short-term use of
antipsychotics.