Opioid Induced Adrenal Insufficiency Complicated by Adrenal Crisis-A Case Report

Abstract

Introduction: 1 in 5 people experience chronic pain that limits their ability to carry out activities of daily living. Opioid analgesics are one of the pharmaceutical interventions utilized to treat chronic pain. In fact, chronic pain is one of the most common reasons opioids are prescribed. Although many of the secondary effects of opioids are well known, a lesser-known side effect is opioid induced adrenal insufficiency (OIAI). OIAI can cause significant morbidity and has the potential to result in adrenal crisis, profound hypotension, and potential cardiovascular collapse, resulting in death. With sparse literature on OIAI, we present a case of OIAI complicated by adrenal crisis to expand awareness and discussion on the topic. Methods: The patient was a 65-year-old female on chronic opioid therapy for back pain who presented to the emergency room for syncope. On presentation, patient was hypotensive, bradycardic, and had an inadequate fluid response requiring pressors. Traditional etiologies of shock were ruled out, but interestingly morning cortisol and adrenocorticotropic hormone (ACTH) levels were low. Additionally, the cosyntropin stimulation test was suboptimal. Results suggested central hypothalamic pituitary axis suppression, which after discussion with Endocrinology indicated OIAI given the patient’s history. Results: Shortly after steroid regimen initiation the patient was weaned off pressors, and after multiple taper trials was successfully sent home on a steroid taper with Endocrinology follow up. Conclusion: Long term opioid use to treat chronic pain can decrease cortisol production via HPA axis suppression resulting in OIAI. To date, there is limited investigation into OIAI despite its increased prevalence and widespread use of opioids. The case adds to the available literature on OIAI, and sheds light on adrenal crisis as its initial presentation.