title: Intravenous Ketamine for Rapid Opioid Dose Reduction, Reversal of Opioid-Induced Neurotoxicity, and Pain Control in Terminal Care: Case Report and Literature Review.
abstract: OBJECTIVE
  We report a case of opioid-induced neurotoxicity (OIN) in an actively dying hospice patient, its reversal and improved analgesia that followed opioid dosage reduction made possible after addition of IV ketamine. We briefly review the diagnosis and treatment of OIN.
  
  
  METHODS
  OIN, particularly when associated with high dose opioid therapy in palliative care, may pose difficult diagnostic and treatment challenges. Few publications from end-of-life settings provide systematic approaches to management of OIN.
  
  
  METHODS
  We describe a case of OIN in a hospice patient receiving medical care at home while actively dying.
  
  
  METHODS
  Addition of IV ketamine and reduction of the patient's high-dose opioid regimen.
  
  
  RESULTS
  The patient's pain was controlled within 24 hours of initiation of IV ketamine while the total opioid dose was reduced. His symptoms of OIN (delirium, tremor, myoclonus, and hallucinations) also rapidly subsided.
  
  
  CONCLUSIONS
  OIN should be considered as an etiology of CNS dysfunction occurring with prolonged, high-dose opioid therapy. This case highlights the opioid-sparing and analgesic properties of low-dose ketamine, allowing reversal of OIN in the home hospice setting.
authors.affiliation: *The Medical Team Hospice, Livonia, Michigan, USA jwinegarden@medteam.com.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Winegarden
authors.affiliation: Department of Public Health and Community Medicine, Tufts University School of Medicine, Pain Research, Education and Policy Program, Boston, Massachusetts, USA.
authors.forename: Daniel B
authors.initials: DB
authors.lastname: Carr
authors.affiliation: Department of Public Health and Community Medicine, Tufts University School of Medicine, Pain Research, Education and Policy Program, Boston, Massachusetts, USA.
authors.forename: Ylisabyth S
authors.initials: YS
authors.lastname: Bradshaw
mesh_terms: D000328:Adult; D000701:Analgesics, Opioid / Q000009:adverse effects*; D000778:Anesthetics, Dissociative / Q000627:therapeutic use*; D017051:Hospice Care / Q000379:methods; D006801:Humans; D007262:Infusions, Intravenous; D007649:Ketamine / Q000627:therapeutic use*; D008297:Male; D020258:Neurotoxicity Syndromes / Q000188:drug therapy* / Q000209:etiology*; D059408:Pain Management / Q000009:adverse effects / Q000379:methods; D013727:Terminal Care / Q000379:methods
chemical_list: D000701:Analgesics, Opioid; D000778:Anesthetics, Dissociative; D007649:Ketamine
keywords: Cancer; Hyperalgesia; Ketamine; Opioid-Induced Neurotoxicity