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 12mg of intravenous hydromorphone with minimal pain relief. The decision was made to initiate patient-controlled analgesia (PCA) with hydromorphone started at 0.5mg 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 90mmHg bilaterally. The patient was taken for emergent bilateral fasciotomies. The hydromorphone PCA was increased to 0.8mg as needed with a 15-minute lockout and a basal rate of 0.5mg/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. © 2013 American Academy of Pain Medicine Wiley Periodicals, Inc.