(17.13) Opioid-Induced Adrenal Insufficiency In a Patient Presenting with Acute Adrenal Crisis

Among several causes leading to adrenal insufficiency, opioid-induced adrenal insufficiency (OIAI) is an under-recognized condition that occurs secondary to prolonged exposure to opioids. OIAI can lead to a life-threatening adrenal crisis and may have serious adverse outcomes if left undetected or unmanaged.


Case(s) Description :

We present the case of a 64-year-old adult transgender female (on estrogen and spironolactone) with polysubstance abuse (crack cocaine and heroin). Patient was admitted to the medical intensive care unit for shock of unknown origin. On initial presentation, the patient was hypotensive to 54/33 mmHg and hypothermic to 35.3 degrees Celsius. She appeared lethargic and somnolent and was in acute distress. She was noted to have cool extremities, dehydrated mucous membranes, and bibasilar end-expiratory wheezes. She reported generalized weakness, fatigue, dizziness, cold intolerance, decreased oral intake, weight loss over the prior two weeks along with decreased urine output for several days. She also stated a recent heroin use for a couple of days prior to her admission.

Laboratory findings were remarkable for a potassium of 9.4 mmol/L [reference range: 3.5-5.2 mmol/L], sodium of 135 mmol/L [135-145 mmol/L], bicarbonate of 12 mmol/L [24-31 mmol/L], anion gap of 25 mEq/L [5-15 mEq/L], blood urea nitrogen of 167 mg/dL [8.0-23.0 mg/dL], creatinine of 13.34 mg/dL [0.7-1.2 mg/dL], and glucose of 70 mg/dL [70-99 mg/dL]. The patient was started on vasopressors. Urinary toxicology screen was positive for opioids. Further evaluation revealed a 12am cortisol of 2.75 ug/dl [6.20-19.40 ug/dl], 4am cortisol of 3.24 ug/dl [6.20-19.40 ug/dl], and adrenocorticotropic hormone of 6.7 pg/mL [7.2-63.3 pg/mL]. The rest of her pituitary panel (prolactin, follicle-stimulating hormone, luteinizing hormone, thyroid stimulating hormone, insulin-like growth factor 1) values were within normal limits. Imaging of the head showed no acute findings. Patient was started on hydrocortisone 20 mg in the morning and 10 mg in the afternoon.


Discussion : The patient experienced resolution of her symptoms following glucocorticoid replacement and Suboxone for her opioid use disorder. Adrenal insufficiency was deemed to be induced by her chronic opioid use. This case sheds light on how the use of recreational opioids and opioid therapy can induce hypoadrenalism that may be more common than is currently acknowledged. We hope that this report on OIAI will help clinicians in recognizing cases with this condition.