Lost in Transition: A Case Study of Oral Baclofen Withdrawal Presenting as Severe Pain

Baclofen, a gamma-aminobutyric acid type B (GABA-B) receptor agonist commonly used for spasticity management, is known to cause withdrawal symptoms after abrupt discontinuation. Unique clinical presentations of oral baclofen withdrawal are not well documented, and severe hyperalgesia-like pain disproportionate to expected postoperative recovery has not been well described in the context of oral baclofen withdrawal. This case study depicts a rare presentation of oral baclofen withdrawal in a 46-year-old woman with complete paraplegia and chronic spasticity (Modified Ashworth Scale Grade 4) following an inadvertent 75% dose reduction in her home baclofen regimen (postoperative day 0) at an outside facility during transitions between healthcare facilities. The patient presented with agitation, tachycardia, diaphoresis, insomnia, severe postoperative lower extremity pain, increased pain sensitivity out of proportion to expected postoperative recovery, and progressive muscle spasms after ankle surgery one week prior. On Hospital Day 1, she required 141.25 oral morphine equivalents (OMEs), including scheduled, one-time, and as-needed opioid doses. Her pain symptoms were worsening despite escalating opioid therapy and the absence of postoperative signs of infection or hardware malfunction on Hospital Day 2. A detailed medication reconciliation on Hospital Day 3 revealed that her chronic baclofen dose of 20 mg four times daily was mistakenly reduced to 20 mg once daily on the day of her surgery. She was given two additional doses of baclofen 20 mg on Hospital Day 3, and her OME was 117.5. Following restoration of her full home baclofen regimen on Hospital Day 4, the patient experienced significant improvement in pain, spasticity, sleep quality, and a proportionate decrease of opioid requirements (OME of 75). This case highlights the diagnostic challenge of oral baclofen withdrawal when it presents as refractory postoperative pain and emphasizes the clinical finding of hyperalgesia-like pain and rebound spasticity as a potentially unrecognized presentation of oral baclofen withdrawal. Further, it highlights the importance of accurate medication reconciliation, continuity of antispasmodic therapy, and patient education during transitions of care to prevent avoidable complications of baclofen withdrawal and unnecessary escalations of analgesic management.