Withdrawal reactions due to dextropropoxyphene have previously been reported in the medical literature [1-5]. Common symptoms are nausea, tremor, agitation, insomnia, diaphoresis, fever, and headache; however, confusion, psychotic reactions, and seizures have also been reported. I report a case of severe withdrawal syndrome due to dextropropoxyphene.

A 69-year-old woman had been receiving dextropropoxyphene (100 mg, 1 to 2 tablets as required) for a chronic pain syndrome. After surgery for a hip fracture, ketobemidone was administered for analgesia during the first 2 days after surgery. On the third day, the patient became increasingly confused, hallucinated, and sweated severely. She became unable to respond to questions and showed uncontrolled kicking movements. Despite treatment with dixyrazin (60 mg intravenously) and melperone (50 mg orally) during the night, her condition did not improve. In the morning, she was given ketobemidone (5 mg subcutaneously) and dextropropoxyphene (100 mg orally) and was transferred to the intensive care unit (ICU). After another 100 mg of dextropropoxyphene she became calm. Because of suspected dextropropoxyphene withdrawal symptoms, treatment with dextropropoxyphene (100 mg, 4 times daily, plus 1 to 2 tablets as required) was initiated. She was much calmer when released from the intensive care unit but was still confused.

Beginning on hospital day 7, dextropropoxyphene was reduced by 50 mg every other day. Her condition deteriorated, and on day 13 she was taken to the intensive care unit. She was stuporous and had dilated pupils; the Babinski sign was present bilaterally. Her temperature (42.3 °C) and heart rate (130 to 140 beats/min) were increased. She was placed on a respirator. Intravenous infusion of dobutamide was necessary when the patient's blood pressure decreased from 180/75 mm Hg to 80/50 mm Hg. Blood cultures, a pulmonary radiograph, and a cerebral computed tomographic scan could not explain her symptoms. A morphine infusion was initiated, and she improved gradually. On day 16, dextropropoxyphene was reinstituted at a dose of 900 to 100 mg/d and was reduced by 100 mg each week. No further withdrawal symptoms occurred. After 9 weeks, she no longer received dextropropoxyphene.

The patient had secretly consumed 1 to 3 g of dextropropoxyphene daily for at least 1 year. She had visited several physicians and manipulated her relatives to obtain these high doses.

This case shows that serious, nearly fatal withdrawal symptoms can develop after dextropropoxyphene abuse if initial symptoms are overlooked. Tranquilizers such as dixyrazine and melperone, commonly used for treatment of alcohol withdrawal, may be of little or no value for the treatment of opiate withdrawal. Dextropropoxyphene withdrawal symptoms can be prevented by slowly reducing the daily intake. Treatment with clonidine is an alternative [4, 5].