Our patient was a 50-year-old Caucasian man, with a body mass index (BMI) of 31 and a past medication history significant for chronic back, neck, and leg pain since early 2000 after he sustained a traumatic fall at work. Other medical co-morbidities included degenerative joint disease, bursitis, depression, type II diabetes mellitus, hypothyroidism, testicular hypofunction, and hyperlipidemia. His family history and social history were noncontributory. The severity of his work injury ultimately required a cervical and lumbar fusion. The majority of his pain was localized to his low back and posterior legs without symptoms of CRPS. Three different types of pain were described: a constant and dull back pain, electric shocking pain in his legs, and numbness and tingling in his feet. After failing conservative opioid analgesic management, an intrathecal pain pump, Medtronic SynchroMed IIB, was placed at a non-Mayo facility in 2006 (10 years prior to malfunction). Records were not available detailing the reason for using sufentanil. After placement, his pain was significantly improved with an average daily numerical rating scale of 2–3/10. His pump was originally programmed with sufentanil (50 mcg/mL) with a daily dose of 38.307 mcg/day. Home medications included hydrocodone-acetaminophen 5 mg-325 mg (two tablets in the morning and two tablets in the evening) along with gabapentin 300 mg three times a day for neuropathic pain. Two weeks after his pump was refilled, he was awoken by the sound of an alarm signal from his pump. He presented to a local emergency department where the device was interrogated and found to have a rotor stall. Referral was made to Mayo Clinic for possible withdrawal management and pump refill. Exact timeline details are in Fig.. Prior to transfer, his dose was changed from 38.307 mcg/day to 0.307 mcg/day to lower the risk of a possible overdose in the setting of a malfunctioning pump. No additional opioid was given at that time. At the time that he presented to our institution, he rated his pain at 6/10 and denied any dizziness, nausea, sweating, diarrhea, or myalgias. A physican examination revealed a well-healed abdominal scar with some scar tissue thought to be related to prior wound dehiscence. Interrogation of the pump revealed the lower dose of 0.307 mcg/day with an electric replacement indicator of 38 months. Drug was not being delivered despite an adequate reservoir volume, so the pump was deactivated and, again, it was thought to be related to a rotor stall malfunction. A fentanyl patch and patient-controlled analgesia (PCA) were provided for pain control and to prevent withdrawal symptoms. He reported no withdrawal feelings with stable vital signs that led the team to believe that his pump may not have been working for some time. After discharge, he had continued pain but elected to keep the pump in place.