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934 - Crisis on Crisis: Opioid-Induced Adrenal Insufficiency Amid the Opioid Crisis

Thursday, February 27, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

ML

Matthew League, DO

Internal Medicine Preliminary Resident - PGY-1
University of Louisville Internal Medicine
Louisville, Kentucky, United States

Co-Author(s)

RA

Ramsey Amoudi, BS

Medical Student, MS-III
University of Louisville School of Medicine
Louisville, Kentucky, United States
JK

Justin Kingery, MD, PhD

Associate Program Director, Attending Physician
University of Louisville
Louisville, Kentucky, United States

Case Diagnosis: Opioid-induced central adrenal insufficiency

Case Description: A 33-year-old male with a past medical history of hepatitis and opiate use disorder on Suboxone presented with complaints of diffuse abdominal pain, hematemesis, and melena. He was found to have hemoglobin of 3.7 and admitted to MICU where he was hemodynamically stabilized with two units of packed red blood cells. Endoscopy and colonoscopy performed were unrevealing. During his admission, recurrent nocturnal hypotension was observed in the 80's/40's mmHg range prompting adrenal insufficiency workup. Morning cortisol was measured at 1.4 mcg/dL. During ACTH stimulation test cortisol rose from 2.8 to 17 mcg/dL after cosyntropin administration, suggesting central adrenal insufficiency. Abdominal imaging was unremarkable and no other causes of adrenal insufficiency were identified. Suboxone was discontinued and he was treated with hydrocortisone. On the night following initiation of steroid therapy, the patient’s blood pressure normalized to the 110/80 mmHg range and he was discharged in stable condition.

Discussions: With profound clinical use of opioids in the treatment of opioid use disorder and chronic pain, overlooked and underdiagnosed adverse events, like adrenal insufficiency, are emerging into the spotlight. Opioid exposure to the brain via g-protein coupled mu opioid receptors suppresses the hypothalamic pituitary adrenal (HPA) axis through negative feedback inhibition resulting in ineffective adrenal stimulation. This can precipitate adrenal crisis which significantly increases mortality, especially in those with concomitant cardiac, pulmonary, or infectious disease.

Conclusions: Given the growing implementation of opioid use disorder therapies, like Suboxone, early identification and treatment of adrenal insufficiency can prevent mortality-increasing adrenal crises. While opioid-induced endocrinopathies have an estimated prevalence of 10-30%, only 10% receive proper diagnosis. Physiatrists treating patients on any opioid containing medications should have a low threshold for testing for OIAI in those complaining of nocturnal hypotension, dizziness, or fatigue.