J Korean Med Sci.  2020 Apr;35(15):e106. 10.3346/jkms.2020.35.e106.

Iatrogenic Opioid Withdrawal Syndrome in Critically Ill Patients: a Retrospective Cohort Study

• Hyun Dg
• Huh JW
• Hong SB
• Koh Y
• Lim CM

• KMID: 2500191
• DOI: http://doi.org/10.3346/jkms.2020.35.e106

Abstract

Background
Opioid withdrawal syndrome (OWS) may occur following the reduction or discontinuation of opioid analgesics. In critically ill pediatric patients, OWS is a common and clinically significant condition. However, OWS in adult patients has not been assessed in detail. Therefore, we aimed to investigate the incidence, risk factors, and clinical features of OWS in mechanically ventilated patients treated in an adult intensive care unit (ICU).
Methods
This study was a retrospective evaluation of data from patients treated in the medical ICU for > 3 days and who received only one type of opioid analgesic. OWS was assessed over a 24 hours period from discontinuation or reduction (by > 50%) of continuous opioid infusion. OWS was defined as the presence of ≥ 3 central nervous system or autonomic nervous system symptoms.
Results
In 126 patients treated with remifentanil (n = 58), fentanyl (n = 47), or morphine (n = 21), OWS was seen in 31.0%, 36.2%, and 9.5% of patients, respectively (P = 0.078). The most common symptom was a change in respiratory rate (remifentanil, 94.4%; fentanyl, 76.5%; morphine, 100%). Multivariate Cox-proportional hazards model showed that OWS was negatively associated with morphine treatment (hazard ratio [HR], 0.17; 95% confidence interval [CI], 0.037–0.743) and duration of opioid infusion (HR, 0.566; 95% CI, 0.451–0.712).
Conclusion
OWS is not uncommon in mechanically ventilated adult patients who received continuous infusion of opioids for > 3 days. The use of morphine may be associated with a decreased risk of OWS.

Keyword

Analgesics; Ventilators; Intensive Care Unit; Substance Withdrawal Syndrome; Incidence

Figure

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  Fig. 1 The study population framework.CNS = central nervous system.

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  Fig. 2 Onset time and duration time of symptoms during 24 hours after discontinuation or de-escalation of opioid infusion. (A) Onset time of remifentanil group. (B) Onset time of fentanyl group. (C) Onset time of morphine group. (D) Duration time of remifentanil group. (E) Duration time of fentanyl group. (F) Duration time of morphine group.OWS = opioid withdrawal syndrome, CAM = Confusion Assessment Method, CI = confidence interval, GCS = Glasgow Coma Scale, RASS = Richmond Agitation-Sedation Scale, RR = respiratory rate, HR = heart rate.avs. the remifentanil group; bvs. the morphine group.

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