Recommendations for pain control in a patient with history of severe opiate intolerance
Question:
11/21/2018
A 16-year-old female with allergic rhinitis and asthma presents with her mother regarding testing for reactions to pain medication. Seven years ago the patient broke her foot and was given a dose of hydrocodone in the emergency room, within 30 minutes she developed wheezing, generalized hives, and throat discomfort. She was taken back to the emergency room by EMS and treated with 2 doses of epinephrine, antihistamines, systemic steroids, and nebulized bronchodilators, she required overnight admission. Since that time the patient has been treated for problems with shoulder pain, she has had a difficult time finding effective medication and she may require rotator cuff surgery. She has been able to tolerate hydromorphone without adverse reaction but doctors are reluctant to prescribe this for her due to addictive properties. She has also tolerated morphine without adverse reaction but it does not relieve her pain. Nasal application of fentanyl was also tolerated without adverse reaction but it does not relieve her pain. Tramadol causes mild itching but is also not effective at relieving this patient's pain. The patient does tolerate nonsteroidal anti-inflammatory drugs.
I explained to the patient and her mother that there is no reliable skin testing or laboratory diagnostic testing available for reactions to opiates. I discussed options for pain relief including intravenous ketorolac for perioperative pain. Since the patient has tolerated hydromorphone in the past this would also be reasonable option for perioperative pain. Are there any other options or testing procedures that might benefit this patient?
Answer:
We are grateful to expert panelist Dr Eric Macy who kindly provided the following recommendations.
First rechallenge with NSAIDs to either confirm tolerance or intolerance. I recommend checking a baseline tryptase. NSAIDs are the pain medications of choice for rotator cuff surgery in this setting. Avoid opiates if possible. All opiates can activate mast cells directly, and some individuals are more sensitive to this expected side effect than others. It is okay to use any opiate needed, at the lowest effective dose and the shortest period of time possible, and treat expected mast cell activation with antihistamines as needed. No testing, other than challenges, are useful in this setting for the suspected opiate intolerance.
We hope this information is useful to you.
Jacqueline A. Pongracic, MD, FAAAAI