Sir, Administration of an opioid antagonist like naltrexone in a nonabstinent opioid user results in sudden onset of the withdrawal symptoms. We report a case who took tablet naltrexone in conjunction with heroin and suffered a life-threatening experience who did not improve with usual symptomatic medications initially, but later improved dramatically with tablet clonidine. A 36-year-old male presented to the Psychiatry Outpatient Department with complaints of severe agitation, projectile vomiting, diarrhea, cramping, pain abdomen, and sweating for 2 h. A history revealed that he was a chronic opioid abuser, started with chasing heroin initially followed by intravenous (IV) abuse in a dependence pattern for the last 7 years. There was no history of other substance abuse. Eight hours after his last intake of heroin, he consumed 100 mg naltrexone orally, followed by the onset of above symptoms within a gap of 15–20 min. There was no history of psychiatric illness, fever, head injury, or seizures, prior to the development of the symptoms. On examination, he was conscious but irritable. Glasgow Coma Scale (GCS) was 13/15. His pulse was 100/min, heart rate 120/min, respiratory rate 26/min; pupils were bilaterally dilated and sluggishly reactive to light. Blood pressure (BP) was 116/80 mmHg; oxygen saturation, blood glucose, and temperature were normal. The Clinical Opiate Withdrawal Scale (COWS) score was 37, indicating severe withdrawal. He was agitated and uncooperative and had no thought or perceptual abnormality. He was admitted in intensive care unit and symptomatic treatment was initiated. Injection furosemide 40 mg IV was added for diuresis. His agitation persisted and sensorium deteriorated gradually. In a span of 2 h, GCS came down to 8, and fall of oxygen saturation and BP were noted. Routine blood examination and computed tomography scan brain were within normal limits, except reactivity to the hepatitis C virus. Electrocardiogram (ECG) was suggestive of dysrhythmia. After 24 h, vitals were normal, but there was persistence in the withdrawal symptoms. Hence, clonidine 0.1 mg tablet was added on BD basis. The next day, improvement was evident by a decrease in size of pupils, no autonomic hyperactivity, improved urine output, decrease in frequency of loose stools, improvement in consciousness, normal ECG, and decrease score in COWS. Before administering naltrexone, the patient should be opioid free for a minimum period of 7–10 days, to prevent abrupt sign and symptoms of withdrawal as reported in the past.[123] Clonidine is an agonist at α-2 adrenergic autoreceptors and acts to reduce central and peripheral sympathetic activity and catecholamine concentration associated with opioid withdrawal. The advantages of clonidine are that it is not a controlled substance, has little risk of abuse, and can reduce the delay between stopping opioids and starting naltrexone.[45] It is possible that it was the combined effect of all regular drugs and clonidine that worked, but as improvement was not seen before administration of clonidine, it is also possible that clonidine had a greater contribution to the treatment. Hence, we conclude that it is worthwhile to give a trial of clonidine, which is an effective choice for this type of case. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgments The authors would like to thank the consultants of Department of Psychiatry and residents of Department of Anaesthesiology and ICU, Silchar Medical College and Hospital, for their tremendous support in managing the case.
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Apr 30, 2021
Natalie Perry + 1
