Interaction of serotonergic antidepressants and opioid analgesics: Is serotonin syndrome going undetected?
OBJECTIVE
To describe the potential for interaction between opioids and serotonergic antidepressants leading to the development of serotonin syndrome (SS), mechanism of the interaction, and the spectrum of SS in elderly residents of a long-term care facility.


METHODS
Case series.


METHODS
Long-term care facility (LTCF) in California.


METHODS
Four elderly LTCF residents treated with serotonergic antidepressants including selective serotonin reuptake inhibitor (SSRI) or mirtazapine and opioids.


METHODS
Signs and symptoms suggestive of SS.


RESULTS
We describe 4 cases of probable SS among elderly residents of a LTCF. The spectrum of serotonin toxicity ranged from visual hallucinations, muscle rigidity, myoclonus, or hypertension in patients taking an opiate with an SSRI to lethargy, hypotension, and hypoxia in a patient taking tramadol and mirtazapine.


CONCLUSIONS
While many can benefit from coadministration of serotonergic antidepressants and opioids, it appears that some individuals are at increased risk for SS. Since SS is a clinical diagnosis, heightened clinician awareness of the possibility of SS among patients receiving SSRI or mirtazapine in combination with opioids may lead to earlier detection and avoidance of potentially lethal consequences.
Gnanadesigan
Nallini
N
Jewish Home for the Aging, Reseda, CA, USA. nallini@pacbell.net
Espinoza
Randall T
RT
Smith
Rick
R
Israel
Michelle
M
Reuben
David B
DB
D000368:Aged; D000369:Aged, 80 and over; D000701:Analgesics, Opioid / Q000494:pharmacology*; D000928:Antidepressive Agents / Q000494:pharmacology*; D004347:Drug Interactions; D005260:Female; D006707:Homes for the Aged; D006801:Humans; D008803:Mianserin / Q000031:analogs & derivatives* / Q000494:pharmacology; D000078785:Mirtazapine; D009735:Nursing Homes; D018490:Serotonin Agents / Q000494:pharmacology*; D020230:Serotonin Syndrome / Q000209:etiology*
D000701:Analgesics, Opioid; D000928:Antidepressive Agents; D018490:Serotonin Agents; D008803:Mianserin; D000078785:Mirtazapine