title: Intentional intrathecal opioid detoxification in 3 patients: characterization of the intrathecal opioid withdrawal syndrome.
abstract: OBJECTIVE
  Intrathecal (IT) drug delivery systems for patients with chronic non-malignant pain are intended to improve pain and quality of life and reduce side effects of systemic use. A subset of patients may have escalating pain, functional decline, and/or intolerable side effects even as IT opioid doses are increased. Discontinuation of IT medications may represent a viable treatment option but strategies to accomplish this are needed.
  
  
  METHODS
  Three patients with intrathecal drug delivery systems (IDDS), inadequate pain control, and declining functionality underwent abrupt IT opioid cessation. This was accomplished through a standardized protocol with symptom-triggered administration of clonidine and buprenorphine, monitored using the clinical opiate withdrawal scale.
  
  
  RESULTS
  Symptoms of IT withdrawal were similar in all patients and included diuresis, agitation, hyperalgesia, mild diarrhea, yawning, and taste and smell aversion. Hypertension and tachycardia were effectively controlled by clonidine administration. Classic symptoms of withdrawal, such as piloerection, chills, severe diarrhea, nausea, vomiting, diaphoresis, myoclonus, and mydriasis, were not noted. At 2 to 3 months follow-up, patients reported decreased, but ongoing pain, with improvements in functional capacity and quality of life.
  
  
  CONCLUSIONS
  This preliminary work demonstrates the safety of abrupt IT opioid cessation utilizing standardized inpatient withdrawal protocols. To our knowledge, these are among the first reported cases of intentional, controlled IT opioid cessation without initiation of an opioid bridge: self-reported pain scores, functional capacity, and quality of life improved. The IT opioid withdrawal syndrome is characterized based upon our observations and a review of the literature.
authors.affiliation: Division of Pain Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA. tracy.jackson@vanderbilt.edu
authors.forename: Tracy P
authors.initials: TP
authors.lastname: Jackson
authors.forename: Daniel F
authors.initials: DF
authors.lastname: Lonergan
authors.forename: R David
authors.initials: RD
authors.lastname: Todd
authors.forename: Peter R
authors.initials: PR
authors.lastname: Martin
mesh_terms: D058647:Adrenergic alpha-2 Receptor Agonists / Q000008:administration & dosage*; D000368:Aged; D000369:Aged, 80 and over; D000701:Analgesics, Opioid / Q000009:adverse effects; D059350:Chronic Pain / Q000188:drug therapy* / Q000523:psychology; D003000:Clonidine / Q000008:administration & dosage*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008658:Inactivation, Metabolic / Q000502:physiology; D007278:Injections, Spinal; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D011788:Quality of Life; D012720:Severity of Illness Index; D013375:Substance Withdrawal Syndrome / Q000188:drug therapy* / Q000209:etiology / Q000523:psychology
chemical_list: D058647:Adrenergic alpha-2 Receptor Agonists; D000701:Analgesics, Opioid; D003000:Clonidine