Non-cardiogenic pulmonary edema after narcotic treatment for cancer pain

During recent years, better awareness of the problem of cancer pain has resulted in the use of increased doses of narcotics. We report the cases of 3 patients who presented non-cardiogenic pulmonary edema while receiving large doses of narcotics for cancer pain. In all cases, pulmonary edema occurred after patients required large increases in the dose of narcotic over a short period of time for rapidly progressing pain. Although pulmonary edema has been described after overdose of narcotics, it had not been previously reported during the course of treatment for cancer pain. Its mechanism appears to be increased capillary permeability because of immunoglobulin and complement deposition of the lung, or due to neurogenic increase in permeability by the effect of narcotics on the brain-stem. We conclude that narcotic-induced pulmonary edema should be suspected in patients who require massive increases in the dose of narcotics. The use of adjuvant pharmacologic and non-pharmacologic analgesic treatments in order to minimize the need for dose increase, as well as the prevention of precipitating factors such as over hydration, corticosteroids or excessive oxygen therapy, should be contemplated in this population.