Cardiac Arrest Following Drug Abuse with Intravenous Tapentadol: Case Report and Literature Review

Abstract

Patient: Female, 32Final Diagnosis: Cardiac arrest after intravenous tapentadol abuseSymptoms: HeadacheMedication: —Clinical Procedure: Tapentadol drug levels in serumSpecialty: Forensic MedicineObjective:Rare diseaseBackground:Tapentadol is a centrally acting opioid analgesic, with a dual mode of action, as a norepinephrine reuptake inhibitor and an agonist of the μ-opioid receptor (MOR). Tapentadol is used for the management of musculoskeletal pain, and neuropathic pain associated with diabetic peripheral neuropathy.Case Report:A 32-year-old woman attended hospital for evaluation of an intractable headache. Computed tomography and magnetic resonance imaging of the brain were negative. She was found unresponsive in the bathroom on the day following hospital admission, and despite resuscitative measures, the patient died following cardiac arrest. Autopsy toxicology revealed significantly elevated levels of tapentadol, and bedside evidence suggested that the patient had self-administered this medication intravenously before her death.Conclusions:We report a rare adverse effect of tapentadol causing respiratory depression leading to cardiac arrest. Medical examiners and forensic toxicologists should be aware of the toxicity of this novel opiate drug.

Characteristics of fatal tapentadol‐related toxicity in Australia

“…The average blood tapentadol concentrations were comparable to those reported previously [7,12,19–26]. The upper range, however, far exceeded those of previous cases (the highest of which was 6.8 mg L −1 ) [7].…”

“…There are relatively few studies, mostly case reports, of death due to tapentadol‐related toxicity [7,12,20–27]. These comprise both intentional self‐harm and unintentional death, with blood tapentadol concentrations ranging from under 0.1 to 6.8 mg L −1 .…”

“…Despite its reputed lower toxicity, in one study of single drug toxicity clinical outcomes (respiratory depression, coma) were more severe for tapentadol than tramadol [15]. There are relatively few studies, mostly case reports, of death due to tapentadol-related toxicity [7,12,[20][21][22][23][24][25][26][27]. These comprise both intentional self-harm and unintentional death, with blood tapentadol concentrations ranging from under 0.1 to 6.8 mg L À1 .…”

Tapentadol Versus Tramadol: A Narrative and Comparative Review of Their Pharmacological, Efficacy and Safety Profiles in Adult Patients

“…The risk of diversion for non-medical purposes was taken into account in the development of tapentadol by marketing extended-release tablets designed to be difficult to crush and solubilise. However, cases of recreational use by chewing or inhaling have been reported with immediate-release tablets [110], as well as abuse by injection of crushed immediaterelease tablets, some of which have led to death by cardiorespiratory arrest [111]. In a study using data from a US prescription drug-monitoring system, the abuse potential of tapentadol was found to be significantly higher than that of tramadol, but equivalent to that of hydrocodone and lower than that of other strong opioids after adjustment for prescription volume [112].…”

Repeated Administration of Clinically Relevant Doses of the Prescription Opioids Tramadol and Tapentadol Causes Lung, Cardiac, and Brain Toxicity in Wistar Rats

“…Although tramadol and tapentadol are safe and effective in pain relief, they have already been associated with many cases of addiction and toxicity, some of which fatal [ 1 , 9 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 ]. Such observations emphasize the importance of understanding the mechanisms underlying their toxicity.…”