Accidental overdose of systemic morphine during intended refill of intrathecal infusion device.

ntrathecal morphine is an effective and wellrecognized method of alleviating intractable pain I in cancer patients (1,2). Several implantable systems have been developed to facilitate delivery of opioids on a long-term basis (3). Some of these devices incorporate a drug reservoir to eliminate the need for frequent injections and externalized hardware. When refilling the reservoir, there is the potential for a misplaced injection of a relatively large dose of opioid. This may occur despite the presence of alarm features. This report describes a case of an accidental massive, nonfatal overdose of subcutaneous morphine that occurred in the course of refilling the reservoir of a Medtronics Synchromed infusion Pump.