(Kiosk 5) Opioid Induced Adrenal Insufficiency Complicated by Adrenal Crisis: A Case Report

Case Diagnosis: A 65-year-old female on long-term opioid therapy for chronic back pain was found to have opioid induced adrenal insufficiency while in adrenal crisis, which resolved with glucocorticoid administration.

Case Description: The patient was a 65-year-old female who presented to the emergency room for syncope. On presentation, she was hypotensive, bradycardic, and had an inadequate fluid response requiring vasopressors. Traditional etiologies of shock were ruled out, but interestingly, her morning cortisol and adrenocorticotropic hormone (ACTH) levels were low. Additionally, a cosyntropin stimulation test was suboptimal. The results suggested central hypothalamic pituitary adrenal (HPA) axis suppression, which after discussion with Endocrinology indicated opioid induced adrenal insufficiency (OIAI) given her history.

Discussion: Long-term opioid use decreases cortisol production via HPA axis suppression, impeding the body’s inflammatory and metabolic response to stress. OIAI remains poorly recognized by clinicians despite its prevalence amongst chronic opioid users, likely due to nonspecific symptoms similar to chronic pain, and lack of a standardized diagnostic approach. To date, the best recommended diagnostic approach measures baseline levels of ACTH, morning cortisol, and dehydroepiandrosterone (DHEA). If inconclusive, a cosyntropin stimulation test or an insulin tolerance test can be performed. While prevention is the best treatment, a standardized diagnostic approach as well as more research into specific risk factors allows for prompt recognition of OIAI with decreased morbidity and mortality risk.

Setting: MICU and stepdown unit, level I trauma center

Assessment/Results: Shortly after steroid regimen initiation, the patient was weaned off of vasopressors, and after multiple taper trials was successfully sent home on a glucocorticoid regimen with Endocrinology follow up.

Conclusion: To date, there is limited investigation into OIAI despite its prevalence and the widespread use of opioid analgesics. Our case adds to the available literature on OIAI, and sheds light on its medical management complicated by adrenal crisis.