title: 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.
  
  
  METHODS
  Case report.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors: The Rehabilitation Institute of Chicago/Northwestern McGaw Medical Center, Department of Physical Medicine and Rehabilitation, Chicago, Illinois, USA. zmccormi@gmail.com
authors: Zachary
authors: Z
authors: McCormick
authors: Samuel K
authors: SK
authors: Chu
authors: George C
authors: GC
authors: Chang-Chien
authors: Petra
authors: P
authors: Joseph
mesh_terms: D000082:Acetaminophen / Q000627:therapeutic use; D059787:Acute Pain / Q000188:drug therapy* / Q000209:etiology*; D016058:Analgesia, Patient-Controlled; D018712:Analgesics, Non-Narcotic / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D002047:Buprenorphine / Q000627:therapeutic use*; D003161:Compartment Syndromes / Q000188:drug therapy* / Q000209:etiology*; D003402:Creatine Kinase / Q000097:blood; D004338:Drug Combinations; D006012:Glycogen Storage Disease Type V / Q000150:complications*; D006801:Humans; D004091:Hydromorphone / Q000008:administration & dosage / Q000627:therapeutic use; D007273:Injections, Intramuscular; D008297:Male; D008875:Middle Aged; D009270:Naloxone / Q000627:therapeutic use*; D009292:Narcotic Antagonists / Q000627:therapeutic use*; D009293:Opioid-Related Disorders / Q000150:complications*; D010147:Pain Measurement; D012206:Rhabdomyolysis / Q000209:etiology
chemical_list: D018712:Analgesics, Non-Narcotic; D000701:Analgesics, Opioid; D004338:Drug Combinations; D009292:Narcotic Antagonists; D000082:Acetaminophen; D009270:Naloxone; D002047:Buprenorphine; D003402:Creatine Kinase; D004091:Hydromorphone
keywords: Buprenorphine/Naloxone; Compartment Syndrome; McArdle's Disease; Rhabdomyolysis; Suboxone