Category: Psychopharmacology & Therapeutics

080 - Quench the Fire! A Case Report of Burning Mouth Syndrome Treated with Low Dose Naltrexone After Failure of Response to Extensive Pain Management Trials

Thursday, Nov 9
5:15 PM – 7:45 PM

Background:


Central pain syndrome (CPS) is a neurological condition caused by damage to or dysfunction of the central nervous system, including the brain, brainstem, and spinal cord. It may affect a large portion of the body or be more restricted to specific areas. Pain is typically constant, burning, neuropathic type and is often made worse by touch, movement, emotions and temperature change.


Naltrexone, a competitive opioid receptor antagonist, was approved by FDA for the treatment of opioid use disorder (OUD). Low dose naltrexone (LDN) refers to dosages of naltrexone that are approximately 1/10th of the dose employed for treating an OUD (50.0–100.0 mg). It reportedly reduces symptom severity in CPS primarily via blocking mu opioid receptors thus promoting the production of endogenous opioids. The authors present the case of a patient with history of burning mouth syndrome -post thalamic stroke, with subsequent severe depression, whose pain responded remarkably to LDN, after failed trials of multiple medications.



Method:


PubMed search - low dose naltrexone, central pain syndrome, burning mouth syndrome, thalamic stroke.



Case Report:


66 year old male presented with history of chronic and severe burning mouth pain after a thalamic stroke. He endorsed symptoms of severe depression including episodes of suicidal thoughts with plans, but no attempts, when the pain worsened.


He failed to respond to a myriad of medication trials for pain management,  including opiates, anticonvulsants, benzodiazepines, tricyclic antidepressants, and medicinal marijuana. The CL psychiatry team in collaboration with pain management , prescribed LDN 4.5 mg daily and maintained him on duloxetine and gabapentin.  After few weeks on this regimen, he reported significant reduction in his pain, improvement in his mood and was able to discontinue medical marijuana use.



Discussion:


Burning mouth syndrome, which is a type of CPS, is caused by damage to the sensory pathways of the CNS, in our case, after a thalamic stroke. It can potentially disrupt an individual’s daily routine and affect his quality of life as the pain is agonizing and unrelenting.


LDN exhibits paradoxical properties, including analgesia and anti-inflammatory actions. It promotes enhancement of endogenous opioid production and exerts a novel anti-inflammatory action by glial cell attenuation, decreasing production of proinflammatory cytokines and neurotoxic superoxides.


Consultation and liaison psychiatrists should be cognizant of this novel treatment for CPS, as they are often consulted to manage the concomitant mood and anxiety disorders commonly associated with this disorder.  LDN can be utilized in these patients to treat their recalcitrant pain which would eventually result in improvement in their mood disorders. 


References:


Younger J, Parkitny L. The use of low-dose naltrexone as a novel anti-inflammatory treatment for chronic pain; Clin Rheumatology. 2014 Apr; 33(4):451-9.


Chopra P, Cooper MS. Treatment of Complex Regional Pain Syndrome Using Low Dose Naltrexone; J Neuroimmune Pharmacology. 2013 Jun; 8(3):470-6.

Arpita Goswami Banerjee

Assistant Professor Psychosomatic Medicine
University of Pennsylvania
Philadelphia, PA

I am curently working as a consultant psychiatrst for Penn Transpalnt Institute, University of Pennsylvania. I completed my fellowship in Psychosomatic Medicine at the University of Pennsylvania. I got interested in Psychosomatic Medicine early in my residency training and dedicated the last few years in developing skill sets in this specialized field of psychiatry. I have also endeavored to add new insights to my understanding of complex psychosomatic problems by authoring posters and publications in conferences (APA, APM, ANPA) and PubMed journals. In addition to my training experience, I have acquired leadership and administrative skills during my tenure as chief resident. During my fellowship , I developed special interest in transplant psychiatry and I plan to pursue a career in the same. I aspire to get involved in the diagnosis and management of complex pre and post transplant cases with psychiatric comorbidities, share my acquired knowledge and skills with peers in the field. I also aim to engage actively in academia, mentoring medical students, residents and fellows.

Martin Cheatle

Associate Professor and Director, Pain and Chemical Dependency Program
University of Pennsylvania
Philadelphia, PA

Dr. Cheatle is currently an Associate Professor and Director of Pain and Chemical Dependency Program at University of Pennsylvania.

Arpita Goswami Banerjee

Assistant Professor Psychosomatic Medicine
University of Pennsylvania
Philadelphia, PA

I am curently working as a consultant psychiatrst for Penn Transpalnt Institute, University of Pennsylvania. I completed my fellowship in Psychosomatic Medicine at the University of Pennsylvania. I got interested in Psychosomatic Medicine early in my residency training and dedicated the last few years in developing skill sets in this specialized field of psychiatry. I have also endeavored to add new insights to my understanding of complex psychosomatic problems by authoring posters and publications in conferences (APA, APM, ANPA) and PubMed journals. In addition to my training experience, I have acquired leadership and administrative skills during my tenure as chief resident. During my fellowship , I developed special interest in transplant psychiatry and I plan to pursue a career in the same. I aspire to get involved in the diagnosis and management of complex pre and post transplant cases with psychiatric comorbidities, share my acquired knowledge and skills with peers in the field. I also aim to engage actively in academia, mentoring medical students, residents and fellows.