Accidental overdosing with intraspinal morphine caused by misprogrammation of a Synchromed pump: a report of two cases.

Spinally administered opioids must be a last step in the therapeutical arsenal of chronic benigne pain. It is an invasive technique not free from adverse effects. Two chronic pain patients received an implantable Synchromed pump for treatment with spinal opiates after a trial period of resp. 3.5 and 5.5 months. Due to a misprogrammation (both on the same day) they received very high doses of spinal opiates. This caused relatively few side effects, which did not seem to require immediate treatment. A short time development of tolerance to life threatening side-effects has been proven by this accidental administration of high-dose intraspinal opiates. It is critical that care providers are knowledgeable and well-trained about implantable infusion systems. Programmation and refills must always be performed with care.