LG is a 44-year-old white, non-Hispanic man with a history of severe, debilitating chronic low back pain. His surgical history includes multiple lumbar surgeries with resultant hardware in place. In addition to taking oral pain medication, LG is seen routinely for interventional treatment. He is currently on a high-dose opioid regimen that includes oxycodone 40 mg (1) every 12 hours and immediate-release oxycodone 10 mg (1-2) up to 3 times daily for a total daily oxycodone dosage of 140 mg (morphine equivalent = 210 mg/d). When originally seen in clinic, LG’s oxycodone dosage was decreased by 80 mg/d from his previous oxycodone daily regimen with an understanding that further increases would not take place at this facility. However, he was informed that an opioid rotation could be considered if the opioid regimen issued through this clinic did not provide effective pain relief.
After being placed on his current opioid regimen, LG became severely ill with an upper respiratory infection for several days that subsequently developed into pneumonia requiring hospitalization. Prior his admission, his family reports finding him obtunded at home; he responded favorably to naloxone rescue. It was understood that no more than what was prescribed had been taken by LG.
LG was transferred to the intensive care unit due to septicemia with renal failure. Although LG was receiving a lower daily dose of opioid than he had previously been taking, it was felt that his renal condition did not allow for appropriate clearance of the pain medication. This may have resulted in an elevated serum concentration of oxycodone—both parent compound and metabolites—that led to LG becoming obtunded while still at home prior to being admitted to the hospital, despite previous tolerance to even higher doses of opioid medication.
As the cold and flu season begins, discussion with patients regarding opioid dose reductions in the event a patient becomes severely ill may be warranted, as it is not known if renal or hepatic functioning will be ultimately affected by the illness. As a safety measure, routine patient care protocols for temporary opioid reductions might be established when severe acute illnesses are reported by patients on chronic opioid treatment.
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