Table 1 Substances and dosing at presentation to hospital and during admission

Community (at time of presentation to hospital)

Crack cocaine 10–12 times per month

SROM^* 60 mg three times per day

Morphine IR^** 10 mg four times per day

24-h total morphine: 220 mg oral daily equivalents (+ crack cocaine)

Patient had impaired mobility from generalized weakness and had not been able to access crack cocaine in the period prior to admission. She may have been experiencing withdrawal symptoms from crack on arrival to hospital

We overlooked the possibility that her community morphine dose had not stabilized her opioid needs and thus she was simultaneously using crack cocaine

Emergency Department

Initially Hydromorphone 1.5 mg sc q3hr

20 h later, rotated to morphine 8 mg sc q3h with no PRN dosing ordered

20 h after admission, patient was described as “irritated and upset with pain control”

Palliative Care was consulted to optimize pain medication

In the first 24 h, patient received a reduced morphine equivalent dose from 220 mg to 24 h in community to 128 mg to 24 h. She became increasingly agitated with no signs of overdose. Consideration of PRN dosing may have prevented withdrawal

Acute care days 1–2

24 h into admission,

Subcutaneous morphine 3 mg/hr continuous infusion with breakthrough dose of 2 mg every one hour PRN via CADD pump

24-h total morphine: ~ 140 mg oral daily equivalents

Although prescribed SROM in the community, the patient was crushing, heating and injecting her opioids (because she was unable to swallow tablets), thus converting opioids into an immediate release formulation

It was unclear to what extent she was successfully injecting due to her impaired vision

The precise bioavailability of sustained release oral morphine when injected is unknown

The patient was new to the team and there were questions about exact dosing in the community; however, the patient was clearly presenting with signs of withdrawal

Morphine equivalent dose of 140 mg/24 h was an increase from what she received in the first 24 h in ER; however, there was still an 80 mg discrepancy from her community dose

In retrospect there was an abundance of caution in watching for oversedation and insufficient attention to the discrepancy leading to withdrawal symptoms

Acute Care Day 3

Subcutaneous morphine 5 mg/hr continuous infusion with breakthrough dose 5 mg every hour PRN via CADD pump)

In addition to the CADD pump, Morphine 15 mg subcutaneous QID while titrating CADD pump to manage withdrawal symptoms

Lorazepam 1 mg every 4 h PRN for agitation with withdrawal

On Day 3 of admission, the patient was experiencing withdrawal symptoms (agitated, restless, muscle twitches and insomnia) and it was evident that her baseline opioid coverage was insufficient

More rapid uptitration was warranted to address withdrawal symptoms

Acute Care Day 4

ADD pump basal rate was discontinued and the bolus rate increased to 5 mg every one hour PRN. Morphine 15 mg subcutaneous QID PRN was continued. Ativan was decreased to 1 mg TID PRN

Patient left AMA^α overnight and returned the next morning. She presented as drowsy, coherent at times but predominantly slurring words

Esophageal stricture was treated with dilation later in day

The patient did not acknowledge using a substance in the community. The patient was monitored for oversedation and, however, was continued on morphine to prevent another episode of withdrawal

Acute Care Day 5 until discharge on Day 21

Post-esophageal dilatation, she was transitioned to SROM 60 mg TID

CADD pump remained in situ for breakthrough 8 mg morphine every hour as needed

Once patient was able to tolerate oral medications, morphine was provided orally but the CADD pump remained for breakthrough dosing

The patient did not display any further signs of withdrawal and remained engaged with care. She typically used the breakthrough dose available and had numerous additional attempts. The CADD pump provided the patient with autonomy and avoided the numerous requests for breakthrough dosing and decreased the nursing workload