Page 36 - Delaware Medical Journal - July/August 2020

Use of Ketamine to Rapidly Wean Chronic Opioid Use in a Patient with Sickle Cell Disease
Jonathan Li, MD; Shalini Vadalia, MD; Elissa Miller, MD
Figure 1 Visual representation of opioid and ketamine taper
BRIEF SUMMARY
We report on an 18-year-old patient with sickle cell disease (SCD) who was becoming progressively reliant but resistant to opioid analgesia and was admitted to our children’s hospital for a ketamine-assisted rapid opioid wean. This case illustrates the utility of ketamine for rapidly weaning patients off chronic opioids.
INTRODUCTION
Ketamine is a common anesthetic agent that has been gaining attention for its use as an opioid-sparing analgesic at sub-anesthetic doses. It has been shown to be effective in managing pain refractory to opioids and to
hyperalgesia (OIH). Patients with sickle cell disease (SCD) are a unique population at high risk for developing chronic pain reliance on opioids. Given the known risks of opioid use, this case illustrates the utility of ketamine for rapidly weaning patients off chronic opioids.
CASE DESCRIPTION
An 18-year-old female with SCD type SS presented with a complaint of pain and persistent, escalating opioid requirement 24 hours after discharge from an outside hospital. She denied that her pain was
due to acute vaso-occlusive crisis (VOC), and reported that this was her “chronic pain” that “would not go away.” Her SCD was complicated by history of acute chest syndrome, internal carotid artery occlusion
requiring chronic transfusion therapy, frequent VOCs resulting in chronic pain, and depression. Over the past nine months, she presented over 20 times to various hospitals for pain and was admitted eight times for inpatient pain management.
She spent more than half of the previous
two months admitted for intractable pain management. During these admissions, she had been treated with IV opioids including hydromorphone and IV fentanyl. Within 24 hours of her most recent hospital discharge, she had already used 10 of her 12 prescribed tabs of oxycodone-acetaminophen. Due to her escalating opioid medication use and uncontrolled pain in the setting of no active VOC, there was concern for opioid-induced hyperalgesia and a high likelihood of opioid withdrawal if opioid therapy was not weaned under close surveillance. The decision
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Del Med J | July/August 2020 | Vol. 92 | No. 4