Stellate ganglion block combined with low-dose dexmedetomidine for refractory opioid dependence with cerebral atrophy and severe sympathetic storm after repeated detoxification failure: a case report

Abstract Background: Opioid use disorder is a chronic, relapsing condition, and a subset of patients fail repeated detoxification and develop a withdrawal syndrome dominated by sympathetic hyperactivity. We report a patient with mixed opioid dependence, cerebral atrophy and a refractory post-withdrawal sympathetic storm who was managed with stellate ganglion block combined with low-dose dexmedetomidine. Case presentation: A 38-year-old man with dependence on nalbuphine, buprenorphine and self-administered oxycodone had failed two standardized detoxifications and relapsed promptly after each discharge. After complete drug cessation he developed persistent chest tightness, agitation, hyperhidrosis, uncontrollable anxiety, total insomnia and intense drug craving. Brain magnetic resonance imaging showed diffuse cerebral atrophy, and GAD-7, PHQ-9 and PSQI indicated severe anxiety, depression and insomnia. Conventional supportive treatment was ineffective. Staged ultrasound-guided stellate ganglion block (lidocaine 10 mg + anisodamine 2 mg, twice daily initially and then nightly) combined with low-dose intravenous dexmedetomidine (1 µg/kg) and short-term lorazepam bridging terminated the sympathetic storm, restored sleep and mood, and eliminated craving. At the second discharge, heart rate variability still showed reduced parasympathetic indices and an elevated LF/HF ratio of 6.51, whereas the orthostatic response was normal. The patient remained abstinent without relapse at the 3-month follow-up. Conclusions: The combination of stellate ganglion block and dexmedetomidine was safe and effective in terminating a severe withdrawal sympathetic storm in this patient and supported sustained abstinence. Persisting sympathovagal imbalance at discharge indicates that autonomic recovery lags behind symptom control, and objective autonomic monitoring should be part of such management. The strategy merits evaluation in larger series.