Acute Pain Control Challenges with Buprenorphine/Naloxone Therapy in a Patient with Compartment Syndrome Secondary to McArdle's Disease: A Case Report and Review

• Published in: Pain medicine (Malden, Mass.) Vol. 14; no. 8; pp. 1187 - 1191
• Main Authors: McCormick, Zachary, Chu, Samuel K., Chang‐Chien, George C., Joseph, Petra
• Format: Journal Article
• Language: English
• Published: England Oxford University Press 01.08.2013
• Subjects: Acetaminophen - therapeutic use; Acute Pain - drug therapy; Acute Pain - etiology; Analgesia, Patient-Controlled; Analgesics; Analgesics, Non-Narcotic - therapeutic use; Analgesics, Opioid - therapeutic use; Buprenorphine - therapeutic use; Buprenorphine/Naloxone; Compartment Syndrome; Compartment Syndromes - drug therapy; Compartment Syndromes - etiology; Creatine Kinase - blood; Drug Combinations; Glycogen Storage Disease Type V - complications; Humans; Hydromorphone - administration & dosage; Hydromorphone - therapeutic use; Injections, Intramuscular; Male; McArdle's Disease; Middle Aged; Naloxone - therapeutic use; Narcotic Antagonists - therapeutic use; Opioid-Related Disorders - complications; Pain management; Pain Measurement; Rhabdomyolysis; Rhabdomyolysis - etiology; Suboxone; Buprenorphine/Naloxone; Compartment Syndrome; Rhabdomyolysis; Suboxone; McArdle's Disease
• ISSN: 1526-2375; 1526-4637
• DOI: 10.1111/pme.12135

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.