Case report: The lesson from opioid withdrawal symptoms mimicking paraganglioma recurrence during opioid deprescribing in cancer pain

Abstract

Pain is one of the predominant and troublesome symptoms that burden cancer patients during their whole disease trajectory: adequate pain management is a fundamental component of cancer care. Opioid are the cornerstone of cancer pain relief therapy and their skillful management must be owned by physicians approaching cancer pain patients. In light of the increased survival of cancer patients due to advances in therapy, deprescription should be considered as a part of the opioid prescribing regime, from therapy initiation, dose titration, and changing or adding drugs, to switching or ceasing. In clinical practice, opioid tapering after pain remission could be challenging due to withdrawal symptoms' onset. Animal models and observations in patients with opioid addiction suggested that somatic and motivational symptoms accompanying opioid withdrawal are secondary to the activation of stress-related process (mainly cortisol and catecholamines mediated). In this narrative review, we highlight how the lack of validated guidelines and tools for cancer patients can lead to a lower diagnostic awareness of opioid-related disorders, increasing the risk of developing withdrawal symptoms. We also described an experience-based approach to opioid withdrawal, starting from a case-report of a symptomatic patient with a history of metastatic pheochromocytoma-paraganglioma.

Keywords: cancer pain; catecholamines; cortisol; opioid; opioid deprescribing; opioid withdrawal.

Figure 1

Timeline depicting the clinical history of the patient (in purple) and pain management (in green). On the right: osteolytic lesion of the posterior portion of thoracic vertebra (D10). Panel (A–C) Axial plane; panel (D) sagittal plane.

Figure 2

Balance among opioid tolerance and addiction. On the one hand we have the physiological mechanisms of tolerance and physical dependence on opioid. On the other hand, the alarm bells that every doctor must keep in mind during pain-relieving therapy with opioid. Not paying adequate attention to the risk factors which, even in the patient with cancer, can lead to addiction, causes the balance between the two aspects of opioid therapy to become unbalanced. A careful anamnesis and the close monitoring of the patient, allows the physician to keep the two pans of the scales in balance, obtaining the maximum pain response and minimizing the risks. Created with BioRender.com.

Figure 3

The journey of opioid prescription. At first, before prescription, the physician has to do a thorough assessment of the patient and the social context. The prescription of the pain-relief therapy must follow the guidelines, considering the clinical characteristics of the patient and the localization of the disease. Also, radiotherapy and physical rehabilitation have to be considered. The psychological aspects and non-pharmacological therapies should not be underestimated. Equal attention must be given to the tapering of pain-relieving therapy: each step must be shared with the patient, who has to be carefully monitored and instructed on the symptoms that may appear (i.e., hypertension, tachycardia, sweating, palpitations, …). A multidisciplinary path involving oncologists and pain specialists, shared with the patient, can significantly reduce the risk of developing OUD for the patient, especially in long survivors. Created with BioRender.com.