Severe opioid withdrawal syndrome after a single dose of nalmefene

Abstract

Case 1 A 43-year-old man was brought by ambulance to the emergency department (ED) with severe agitation and clinical signs of severe opioid withdrawal approximately 2 h after a single dose of nalmefene (Selincro®, Lundbeck (Switzerland)) for his alcohol dependence. His medical history included paranoid schizophrenia, depression, and alcohol and codeine dependence. He consumed up to two bottles of Makatussin®Hustentropfen (GebropharmaAG, Liestal, Switzerland), a codeine-containing cough medicine, per day (equivalent to 636 mg codeine base per day). The psychiatrist who prescribed the nalmefene was unaware of the extent of the patient’s codeine abuse. The patient needed high bolus doses of midazolam (cumulative dose 25 mg, commenced in the community prior to transfer to the ED), morphine (10 mg), and propofol (40 mg) to treat the agitation. He was transferred to the intensive care unit (ICU) for further monitoring and treatment, where he received midazolam, propofol, morphine, and clonidine by continuous intravenous infusion. After the first 12 h, it was possible to withdraw clonidine and propofol; however, midazolam and morphine were continued for a further 48 h. Attempts to stop the medication before this point resulted in reemergence of the opioid withdrawal symptoms. After 3 days of ICU treatment, we were able to transfer the patient to psychiatric inpatient services.