opioid induced formication

[cleansocks]

I was referred by surgeon a patient who has h/o severe pain after total shoulder. After block wore off had severe pain for several days. During pain episode, needed dilaudid 6mg PO every few hours. Problem is this caused severe ant-crawling sensation all over his body. Severe formication - not to be confused with a similar sounding word.

Now he will go for total hip which luckily is less painful. Nonetheless surgeon has asked me to come up with an opioid patient can get that won't cause this response. He's previously tried codeine, percocet, morphine, oxycodone, and dilaudid. All with the same reaction.

I had him try a 50-100mg tapentadol to see if this synthetic potent tramadol relative could be used and not cause that response. But no luck! He got the formication response again.


Aside from the obvious recommendation to opioid alternatives and using regional catheter, I still need to make a recommendation as to opioid use but I'm not sure what to recommend. I think systemic pruritis is treated primarily with H1 blockers, different than neuraxial pruritis which can respond to things like zofran, IV lido, droperidol, naloxone, nalbuphine. They would want an opioid to use at home.

Anyone dealt with this before and any further wisdom?

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[fittipaldi1of1]

QL block along with all the non opioid analgesics, if pains not controlled then tell him it’s either ants or pain.. choose one

 

[abolt18]

I was referred by surgeon a patient who has h/o severe pain after total shoulder. After block wore off had severe pain for several days. During pain episode, needed dilaudid 6mg PO every few hours. Problem is this caused severe ant-crawling sensation all over his body. Severe formication - not to be confused with a similar sounding word.

Now he will go for total hip which luckily is less painful. Nonetheless surgeon has asked me to come up with an opioid patient can get that won't cause this response. He's previously tried codeine, percocet, morphine, oxycodone, and dilaudid. All with the same reaction.

I had him try a 50-100mg tapentadol to see if this synthetic potent tramadol relative could be used and not cause that response. But no luck! He got the formication response again.


Aside from the obvious recommendation to opioid alternatives and using regional catheter, I still need to make a recommendation as to opioid use but I'm not sure what to recommend. I think systemic pruritis is treated primarily with H1 blockers, different than neuraxial pruritis which can respond to things like zofran, IV lido, droperidol, naloxone, nalbuphine. They would want an opioid to use at home.

Anyone dealt with this before and any further wisdom?

Have you considered buprenorphine?

 

[deleted875186]

Interesting. Can’t find much information about the sensation. I assume it is centrally mediated, but who knows, there are peripheral mu receptors. There’s a study suggesting methylnaltrexone and naloxone relieved opioid indices pruritus without effecting analgesia.
1. Maybe prescribe a dose of methylnaltrexone in case he gets symptoms at home? Certainly can’t hurt. It’s probably expensive though.
2. Try a different opioid while he’s in PACU. Maybe there’s one that doesn’t cause as severe symptoms.
3. Maybe ask some of the psychiatrists if they’ve treated this?

 

[Justice4all]

Have you considered buprenorphine?

Try buprenex. Might consider a naloxone infusion At low dose to minimize that distress. Psychology should be on board.
Spinal+ suprainguinal fascia iliaca home catheter (depending on surgical approach) .Can still do Tylenol toradol if not contraindicated.

 

[dchz]

give him a spinal with some morphine. XD

 

[deleted875186]

Try buprenex. Might consider a naloxone infusion At low dose to minimize that distress. Psychology should be on board.
Spinal+ suprainguinal fascia iliaca home catheter (depending on surgical approach) .Can still do Tylenol toradol if not contraindicated.

Naloxone certainly will work, but you can’t prescribe it outpatient.

 

[anbuitachi]

what about anti psychotics?

 

[marr65]

Why not some weed if it’s legal in your state?

 

[Heroic Combo]

I would add some moderate-high dose lyrica or gabapentin and max out ibuprofen/APAP. The gaba/lyrica may help with pain, but potentially modulate the side effect of formication also

In regards to opioids, this could buy you some space to move down the dosage of any previously tried opioid. I would still try doing buprenorphine though.

Duloxetine could improve pain too and possibly modulate the formication side effect to some extent but modulating formication from opioids with duloxetine would be theoretical/experimental and may not actually work for that purpose, but there is nevertheless some studies showing benefit in post-op pain ratings with duloxetine.

A first-generation antihistamine could be used for the formication if the patient can deal with the side effects of drowsiness. A second-generation antihistamine could be used instead, such as loratadine or cetirizine as they have minimal to no side effects at standard dosages

 

[deleted171991]

I was referred by surgeon a patient who has h/o severe pain after total shoulder. After block wore off had severe pain for several days. During pain episode, needed dilaudid 6mg PO every few hours. Problem is this caused severe ant-crawling sensation all over his body. Severe formication - not to be confused with a similar sounding word.

Now he will go for total hip which luckily is less painful. Nonetheless surgeon has asked me to come up with an opioid patient can get that won't cause this response. He's previously tried codeine, percocet, morphine, oxycodone, and dilaudid. All with the same reaction.

I had him try a 50-100mg tapentadol to see if this synthetic potent tramadol relative could be used and not cause that response. But no luck! He got the formication response again.


Aside from the obvious recommendation to opioid alternatives and using regional catheter, I still need to make a recommendation as to opioid use but I'm not sure what to recommend. I think systemic pruritis is treated primarily with H1 blockers, different than neuraxial pruritis which can respond to things like zofran, IV lido, droperidol, naloxone, nalbuphine. They would want an opioid to use at home.

Anyone dealt with this before and any further wisdom?

This patient clearly has problems with opiates, as in they don't really work for him. This has regional or non-opiate analgesia (e.g. lidocaine or ketamine infusion) written all over it.

Tramadol is correctly spelled Tramadon't, because of its risks/benefits ratio. And short-term gabacrap mostly produces sedation, not real analgesia. One should not use medications with long half-times (i.e. long time to steady state, e.g. SSRIs, gabacrap etc.) to treat short-term problems.

You can also play the opiate game with a low-dose narcan drip (2 vials per liter of maintenance fluid), and see whether it works as well for formication as for itching.

 

[deleted875186]

I would add some moderate-high dose lyrica or gabapentin and max out ibuprofen/APAP. The gaba/lyrica may help with pain, but potentially modulate the side effect of formication

I searched and found no information on gabapentinoids doing anything for formication. I would stay away from any SSRI/SNRI type medication like Duloxitine since they’ve been implicated in formication as well.

Buprenorphine might work, but it’s also long acting, which is not that great if he gets symptoms.

 

[cleansocks]

Great replies thank you.

Recently talked to my psychiatrist colleague who does a lot of pain mgmt as well including buprenorphine. His initial thought was haldol .5mg and clonazepam .25mg, titrating latter to effect as sedation allows. Gotta ask him recommended frequency on those.

I run an outpatient pain clinic and a decent chunk of it is perioperative pain so I get these kinds of consults occaisonally and can try stuff before surgery. So I'll let y'all know what ends up working.

 

[Gern Blansten]

Enroll the patient in a faith based abstinence program.
Explain that "true love waits."

**edit-nevermind

 

[deleted162650]

Come in on POD1 in a Terminix uniform and tell him you’re there for the ant problem.

 

[MoMoGesiologist]

Would methadone cause less pruritis?

 

[deleted875186]

Would methadone cause less pruritis?

Maybe? Don’t know, but the risks of prescribing methadone for acute pain in an opioid naive patient as an outpatient are too high.

 

[AdmiralChz]

I keep reading this topic a little... differently.

 

[deleted171991]

Great replies thank you.

Recently talked to my psychiatrist colleague who does a lot of pain mgmt as well including buprenorphine. His initial thought was haldol .5mg and clonazepam .25mg, titrating latter to effect as sedation allows. Gotta ask him recommended frequency on those.

I run an outpatient pain clinic and a decent chunk of it is perioperative pain so I get these kinds of consults occaisonally and can try stuff before surgery. So I'll let y'all know what ends up working.

Btw, anything that causes enough sedation will probably work. It just won't be the right thing, in my book. But I'm not the (acute) pain specialist here.

 

[Hoya11]

I was referred by surgeon a patient who has h/o severe pain after total shoulder. After block wore off had severe pain for several days. During pain episode, needed dilaudid 6mg PO every few hours. Problem is this caused severe ant-crawling sensation all over his body. Severe formication - not to be confused with a similar sounding word.

Now he will go for total hip which luckily is less painful. Nonetheless surgeon has asked me to come up with an opioid patient can get that won't cause this response. He's previously tried codeine, percocet, morphine, oxycodone, and dilaudid. All with the same reaction.

I had him try a 50-100mg tapentadol to see if this synthetic potent tramadol relative could be used and not cause that response. But no luck! He got the formication response again.


Aside from the obvious recommendation to opioid alternatives and using regional catheter, I still need to make a recommendation as to opioid use but I'm not sure what to recommend. I think systemic pruritis is treated primarily with H1 blockers, different than neuraxial pruritis which can respond to things like zofran, IV lido, droperidol, naloxone, nalbuphine. They would want an opioid to use at home.

Anyone dealt with this before and any further wisdom?

the guy is nuts or looking for something particular as secondary gain

all opioids cause itch, this guy is just super sensitive

 

[AdmiralChz]

Great replies thank you.

Recently talked to my psychiatrist colleague who does a lot of pain mgmt as well including buprenorphine. His initial thought was haldol .5mg and clonazepam .25mg, titrating latter to effect as sedation allows. Gotta ask him recommended frequency on those.

I run an outpatient pain clinic and a decent chunk of it is perioperative pain so I get these kinds of consults occaisonally and can try stuff before surgery. So I'll let y'all know what ends up working.

Gosh, Klonopin and Haldol combo. I mean, you might as well just schedule round-the-clock IV Benadryl if you’re looking for a sedative like that. If it’s excruciating pain you could maybe try a postoperative ketamine infusion but that will probably buy an ICU admission - not great after a THA.

Have you considered secondary gain in this patient?

 

[MirrorTodd]

the guy is nuts or looking for something particular as secondary gain

all opioids cause itch, this guy is just super sensitive

He's either nuts, looking for secondary gain, or is super sensitive. Can't be all three. Which is it?

 

[deleted171991]

Always give the patient the reasonable doubt.

There isn't much to be gained here. He may just be ultrasensitive.

He may be nuts, just because he's getting two joints replaced. People used to survive very well with zero and PT.

 

[GASPER20]

LP catheter or QL3 single shot with lidocaine infusion post op. Lidocaine helps with analgesia and pruritus. Ketamine load intra op and continue PO post op along with other MMA.

 

[vector2]

Try stadol (butorphanol). The partial agonist / antagonist action may be of some help.

 

[joshmir]

If you have the ability to try buprenorphine preop you should do that

OTW regional, ketamine, Exparel, IV acetaminophen

can tunnel a regional catheter and let it go dry and have him come into your pain clinic to bolus through it. Or send home with elastomeric local anesthetic pump

 

[Hoya11]

He's either nuts, looking for secondary gain, or is super sensitive. Can't be all three. Which is it?

Pain patients are wierd - can definitely be all 3.

Hes likely crazy, gets an itch from the medicines, but is probably trying to get something out of this "issue" with the pain medicines

 

[Planktonmd]

Contrary to our cultural belief, you really don't always need opiates after surgery, actually in Europe they rarely give opiates and you get discharged with NSAIDS.
In this patient I would try a non opioiod anesthetic technique, maybe spinal with fascia iliaca block, then post-op discharge with NSAIDS, and Gabapentin.
Give also a sleeping pill for the night.
Make sure the surgeon and the patient understand that there will be some pain and that is absolutely normal.

 

[TheLoneWolf]

Why are some suggesting buprenorphine, half life 37 hours and high Affinity for opioid receptors. If he complains of increased pain postop you likely will be stuck placing him on PCA and increasing length of stay.

How about nubian, will help with pain, half life of 5 hours, will help with neuraxial related pruritus.

 

[Southpaw]

It’s a total hip. Don’t overthink it. Half the total hips I take care of feel better after surgery and need little to nothing. Give him a spinal, Tylenol, and ibuprofen. Single shot block at the most if you wanna get aggressive. Discharge on POD1.

 

[deleted162650]

It’s a total hip. Don’t overthink it. Half the total hips I take care of feel better after surgery and need little to nothing. Give him a spinal, Tylenol, and ibuprofen. Single shot block at the most if you wanna get aggressive. Discharge on POD1.

Yup. SAB for the case. PENG block if you wanna get cute, and scheduled Midol for the first 72H.

 

[Arch Guillotti]

It’s a total hip. Don’t overthink it. Half the total hips I take care of feel better after surgery and need little to nothing. Give him a spinal, Tylenol, and ibuprofen. Single shot block at the most if you wanna get aggressive. Discharge on POD1.

Or discharge on pod#0

 

[Justice4all]

Likely this patient going to be there POD#3.

 

[deleted875186]

Why are some suggesting buprenorphine, half life 37 hours and high Affinity for opioid receptors. If he complains of increased pain postop you likely will be stuck placing him on PCA and increasing length of stay.

How about nubian, will help with pain, half life of 5 hours, will help with neuraxial related pruritus.

I remember seeing a study suggesting a gender difference with nibain .... it seems to work for women but not so much for men .... or maybe they just have a higher pain tolerance :/

 

[TheLoneWolf]

I remember seeing a study suggesting a gender difference with nibain .... it seems to work for women but not so much for men .... or maybe they just have a higher pain tolerance :/

Sexual dimorphism well defined for kappa agonists in studies.

This is probably the paper you remember

Agonist/antagonist properties of nalbuphine, butorphanol and (-)-pentazocine in male vs. female rats - PubMed

To determine whether sex differences in the effects of mixed-action opioids could be due to differential activity at mu or kappa receptors, agonist/antagonist properties of nalbuphine, butorphanol and (-)-pentazocine were compared in male vs. female rats using a diuresis test. In water-loaded...

pubmed.ncbi.nlm.nih.gov

Women required lower dose to produce analgesia through both males and females had exhibited dose dependent improvements in pain. Also good paper stated the doses given and responses.

 

[Heroic Combo]

I searched and found no information on gabapentinoids doing anything for formication. I would stay away from any SSRI/SNRI type medication like Duloxitine since they’ve been implicated in formication as well.

Buprenorphine might work, but it’s also long acting, which is not that great if he gets symptoms.

My primary reason for mentioning gabapentinoids/duloxetine is for pain control effect to reduce opiate need. Say you can reduce opioid to by half or less, you might avoid the formication in the first place. Helping in formication DIRECTLY was just a theoretical possibility which I didn't have any solid resources for

 

[deleted875186]

My primary reason for mentioning gabapentinoids/duloxetine is for pain control effect to reduce opiate need. Say you can reduce opioid to by half or less, you might avoid the formication in the first place. Helping in formication DIRECTLY was just a theoretical possibility which I didn't have any solid resources for

Interesting aside, does anyone believe gavalentinoids actually have any analgesic effect in acute surgical pain. I have read many studies, and I personally believe they are only opioid sparing in as much as they are sedating. And certainly the magnitude is not as great as a 50% reduction in opioids. What do others think?

 

[TheLoneWolf]

Great question. I did a pain fellowship with a busy acute and chronic pain service at a major metropolitan tertiary center. We routinely added gabapentin to the regimen for it's so called opiate sparing effect.

New data suggests initiation of gabapentin perioperatively increases respiratory events while contributing little to no benefit in terms of analgesia. Sedating and anxiolytic yes but poor choice for somatic pain complaints, which comprise the majority of post operative pain.

We are relatively limited in both choice and efficacy of non opiate oral medications in the postoperative period.

Interesting aside, does anyone believe gavalentinoids actually have any analgesic effect in acute surgical pain. I have read many studies, and I personally believe they are only opioid sparing in as much as they are sedating. And certainly the magnitude is not as great as a 50% reduction in opioids. What do others think?

 

[cleansocks]

To follow up,

Prior to surgery we tried a couple things as outlined below.

• Single dose of tapentadol 50mg produced less formication compared to the equi-potent dosing of meds he had tried in the past (dilaudid, oxy, etc).

• Then I tried pre-treatment with haldol .5mg and clonazepam .25mg, 2 hours prior to test dose of tapentadol. This eliminated the itchies completely. These have a long halflife so likely a Q12h PRN dose of these could be useful if he needs the opioid based pain relief.

Decided against trying buprenorphine given its long halflife.

This will give the surgical team and patient an opioid based option although I've recommended other options primarily.


thx for all the input

 

[deleted875186]

To follow up,

Prior to surgery we tried a couple things as outlined below.

• Single dose of tapentadol 50mg produced less formication compared to the equi-potent dosing of meds he had tried in the past (dilaudid, oxy, etc).

• Then I tried pre-treatment with haldol .5mg and clonazepam .25mg, 2 hours prior to test dose of tapentadol. This eliminated the itchies completely. These have a long halflife so likely a Q12h PRN dose of these could be useful if he needs the opioid based pain relief.

Decided against trying buprenorphine given its long halflife.

This will give the surgical team and patient an opioid based option although I've recommended other options primarily.


thx for all the input

Thanks for following up, interesting regimen, glad it worked.

 

[abolt18]

First I've heard of tapentadol. Learn something every day.

To follow up,

Prior to surgery we tried a couple things as outlined below.

• Single dose of tapentadol 50mg produced less formication compared to the equi-potent dosing of meds he had tried in the past (dilaudid, oxy, etc).

• Then I tried pre-treatment with haldol .5mg and clonazepam .25mg, 2 hours prior to test dose of tapentadol. This eliminated the itchies completely. These have a long halflife so likely a Q12h PRN dose of these could be useful if he needs the opioid based pain relief.

Decided against trying buprenorphine given its long halflife.

This will give the surgical team and patient an opioid based option although I've recommended other options primarily.


thx for all the input