Acute Amnestic Syndrome Associated with Fentanyl Overdose

Barash, Jed A.; Ganetsky, Michael; Boyle, Katherine L.; Raman, Vinod; Toce, Michael S.; Kaplan, Scott; Lev, Michael H.; Worth, Jonathan L.; DeMaria, Alfred

doi:10.1056/nejmc1716355

Cited by 46 publications

(55 citation statements)

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“…Although none of the 4 patients were known to have used fentanyl, the toxicology findings were consistent with the presence of fentanyl in heroin, an increasingly common finding. 4 Although the precise role that our patient's prescription medications (including another opioid, hydromorphone) played in her clinical presentation cannot be delineated in this case, no medication was taken in excess of the routinely prescribed dose. Our findings support the hypothesis that fentanyl has a direct role in the development of opioid-associated amnestic syndrome, although this is controversial.…”

Section: Discussionmentioning

confidence: 88%

“…A recent letter by Barash and colleagues described 4 patients with opioidassociated amnestic syndrome and a history of heroin use who tested positive for fentanyl and norfentanyl, a fentanyl metabolite. 4 In 2 patients, fentanyl was the only drug detected. Although none of the 4 patients were known to have used fentanyl, the toxicology findings were consistent with the presence of fentanyl in heroin, an increasingly common finding.…”

Section: Discussionmentioning

confidence: 99%

“…First is the importance of testing for synthetic opioids in patients with a history of opioid use, as has been described by Barash and colleagues. 4 Second, this case should alert clinicians to the possibility of an opioid-associated amnestic syndrome in cases of acute global amnesia and opioid overdose, including cases of prescription-fentanyl overdose. Finally, given the resolution of diffusion restriction observed in this case, early use of diffusion-weighted imaging may improve diagnosis in select patients with acute amnesia.…”

Section: Discussionmentioning

confidence: 99%

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Opioid-associated amnestic syndrome observed with fentanyl patch use

Taylor

Budhram

Lee

et al. 2019

CMAJ

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A 63-year-old woman with a history of multiple sclerosis and chronic musculoskeletal pain was found unresponsive in bed by her husband at about 1100 h. A year prior, the patient had been prescribed fentanyl patches for postoperative pain, which she did not use. Her usual daily medications included hydromorphone 9 mg 3 times per day, zopiclone 7.5 mg every night at bedtime and pregabalin 75 mg twice per day, all of which had been taken at the same dose at which they had been used for the last year, except for the hydromorphone. In the weeks before her presentation to hospital, the patient had not been taking her hydromorphone as prescribed because of adverse effects. At about 2300 h the evening before her arrival in the emergency department, the patient had reported increasing pain and applied three 12 µg fentanyl patches, doubling her daily morphine equivalent dose by the time she was found unresponsive 12 hours later. Her husband performed 10 minutes of cardiopulmonary resuscitation without checking for a pulse. When paramedics arrived, the patient had a pulse of 91 beats/min and was in normal sinus rhythm, with a blood pressure reading of 94/57 mm Hg and oxygen saturation of 84%. She awoke after naloxone infusion in the emergency department. Toxicology screening was positive for opiates only. Routine serology testing showed mild transient elevation in transaminase, troponin and creatine kinase levels. Over the following days, the patient showed profound anterograde amnesia and was unable to recall daily autobiographical details, despite meticulously recording them in a journal (Figure 1).Neurologic examination identified anisocoria and mild spastic paraparesis, which were unchanged from a previously documented examination 3 years earlier. Her Montreal Cognitive Assessment score was 19/30: she lost 3 points for date, month and day; 5 points on delayed recall despite intact immediate recall; and 1 point on each of trails, cube and repetition. No prior cognitive testing was available for comparison. Gadolinium-enhanced magnetic resonance imaging (MRI) of the head performed on day 7 showed striking bilateral gyriform hippocampal hyperintensity on T 2 -weighted imaging with corresponding restricted diffusivity on diffusion-weighted imaging (Figure 2), in addition to white-matter lesions compatible with multiple sclerosis that were stable on comparison with previous imaging. Electroencephalography done the same day showed no epileptiform activity. The patient's cerebrospinal fluid profile was unremarkable, and results of polymerase chain reaction testing for herpes simplex virus were negative. Results of testing for arbovirus and syphilis, and a routine paraneoplastic antibody panel were also negative.Magnetic resonance imaging of the head on day 12 showed complete resolution of the previously seen hippocampal diffusion PRACTICE | CASES VULNERABLE POPULATIONS CPD

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Section: Discussionmentioning

confidence: 88%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Opioid-associated amnestic syndrome observed with fentanyl patch use

Taylor

Budhram

Lee

et al. 2019

CMAJ

View full text Add to dashboard Cite

show abstract

“…His hippocampal injuries were thought to be due to a direct toxic effect of fentanyl and from hypoxaemia secondary to opioid-related hypoventilation. 1 He received supportive management, and workup for other potential aetiologies with bloodwork and electroencephalogram were unremarkable.…”

mentioning

confidence: 99%

“…2 This neuroimaging finding has recently been described in a cluster of cases in the context of fentanyl overdose. 1 Familiarity with this relationship is important given the ongoing opioid crisis in Canada, primarily driven by the use of fentanyl from both prescription and illegal sources. 3 The predilection for injury to the hippocampi in opioid use is supported by reversible hypoxia/ hypoglycaemia animal models demonstrating worse recovery to this brain region with opioid use.…”

mentioning

confidence: 99%