Acute opioid withdrawal following administration of oral oxycodone–naloxone due to portosystemic shunts

Abstract

Background The management of pain in patients with advanced liver disease is a clinical challenge. Initial pharmacokinetic safety data advised against the use of oxycodone–naloxone in this population, but in clinical practice it is commonly used. Our case aims to illustrate a potential mechanism by which administration of oxycodone–naloxone can cause systemic opioid antagonism and harm to patients. Clinical details A 45‐year‐old man received two separate doses of oxycodone–naloxone in the immediate postoperative setting, resulting in symptoms and signs consistent with acute opioid withdrawal. A review of his imaging revealed significant portosystemic shunts. Outcomes Portosystemic shunts in patients with advanced liver disease may lead to a decrease in the Phase II hepatic metabolism of naloxone and increased systemic levels. In the case of someone with pre‐existing opioid dependence, this may precipitate acute opioid withdrawal. Conclusion The use of oxycodone–naloxone preparations should be avoided in patients with liver disease and portosystemic shunts.