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Letters to the Editor


Acute Opioid Withdrawal Syndrome or Side Effects?

Eriator, Ike I. MD

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doi: 10.1213/00000539-199811000-00056
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To the Editor:

The case report by Sun [1] was quite interesting, but the described features were not necessarily a withdrawal syndrome after a single dose of epidural morphine. Naloxone has visible consequences when the endogenous opioid system has been activated, as in certain forms of stress [2]. Labor and parturition are moments of extreme physical stress with significantly increased levels of beta-endorphin [3]. The antagonistic action of naloxone on the endogenous opioid system probably contributed to the clinical features in this patient.

Moreover, the features described do not fit into the typical withdrawal features. No dysphoria, yawning, or upset stomach was noted [4]. Rather, the clinical features described may be explained on the basis of the known metabolic, analeptic, and hemodynamic effects of naloxone [5]. Side effects have been described in healthy young women with doses as small as 100 [micro sign]g IV [6]. The time course of the reported clinical effects is explained by the plasma half-life and duration of effects of naloxone [5]. Naloxone is not a benign medication, and careful titration of 20-40 [micro sign]g [7] or a prophylactic infusion of 5 [micro sign]g [center dot] kg-1 [center dot] h-1[8] is recommended.

Ike I. Eriator, MD

Department of Anesthesiology; University of Mississippi School of Medicine; Jackson, MS 39216


1. Sun HL. Naloxone-precipitated acute opioid withdrawal syndrome after epidural morphine. Anesth Analg 1998;86:544-5.
2. Reisine T, Pasternak G. Opioid analgesics and antagonists. In: Hardman JG, Gilman AG, Limbird LE, eds. Goodman and Gilman's the pharmacological basis of therapeutics. 9th ed. New York: McGraw-Hill, 1996:521-55.
3. Csontos K, Rust M, Hollt V, et al. Elevated plasma beta-endorphin levels in pregnant women and their neonates. Life Sci 1979;25:835-44.
4. Heishman SJ, Stitzer ML, Bigelow GE, Liebson IA. Acute opioid physical dependence in humans: effect of naloxone at 6 and 24 hours postmorphine. Pharmacol Biochem Behav 1990;36:393-9.
5. Bailey PL, Stanley TH. Intravenous opioid anesthetics. In: Miller RD, ed. Anesthesia. 4th ed. New York: Churchill-Livingstone, 1994;291-387.
6. Wong KC, Sundin JR. Pharmacology of inhalational and intravenous anesthetics. In: Bonica J, McDonald JS, eds. Principles and practice of obstetric analgesia and anesthesia. 2nd ed. Baltimore: Williams & Wilkins, 1995;615-46.
7. Coda BA. Opioids. In: Barash PG, ed. Clinical anesthesia. 3rd ed. Philadelphia: Lippincott-Raven, 1997;329-58.
8. Rawal N. Spinal opioids. In: Raj PP, ed. Practical management of pain. 2nd ed. St. Louis, MO: Mosby Yearbook, 1992;829-50.
© 1998 International Anesthesia Research Society