Open AccessOpioid Induced Hyperalgesia: Clinical Implications for the Pain Practitioner
Author(s) -
Sanford M. Silverman
Publication year - 2009
Publication title -
pain physician
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.31
H-Index - 99
eISSN - 2150-1149
pISSN - 1533-3159
DOI - 10.36076/ppj.2009/12/679
Subject(s) - medicine , opioid , chronic pain , hyperalgesia , rostral ventromedial medulla , population , intensive care medicine , nociception , psychiatry , receptor , environmental health
Opioids have been and continue to be used for the treatment of chronic pain. Evidencesupports the notion that opioids can be safely administered in patients with chronic painwithout the development of addiction or chemical dependency. However, over the pastseveral years, concerns have arisen with respect to administration of opioids for the treatmentof chronic pain, particularly non-cancer pain. Many of these involve legal issues with respectto diversion and prescription opioid abuse. Amongst these, opioid induced hyperalgesia (OIH)is becoming more prevalent as the population receiving opioids for chronic pain increases.OIH is a recognized complication of opioid therapy. It is a pro-nocioceptive process whichis related to, but different from, tolerance. This focused review will elaborate on theneurobiological mechanisms of OIH as well as summarize the pre-clinical and clinical studiessupporting the existence of OIH. In particular, the role of the excitatory neurotransmitter, Nmethyl-D-aspartate appears to play a central, but not the only, role in OIH. Other mechanismsof OIH include the role of spinal dynorphins and descending facilitation from the rostralventromedial medulla. The links between pain, tolerance, and OIH will be discussed withrespect to their common neurobiology.Practical considerations for diagnosis and treatment for OIH will be discussed. It is crucial forthe pain specialist to differentiate amongst clinically worsening pain, tolerance, and OIH sincethe treatment of these conditions differ. Tolerance is a necessary condition for OIH but theconverse is not necessarily true.Office-based detoxification, reduction of opioid dose, opioid rotation, and the use of specificNMDA receptor antagonists are all viable treatment options for OIH. The role of sublingualbuprenorphine appears to be an attractive, simple option for the treatment of OIH and isparticularly advantageous for a busy interventional pain practice.Key words: Opioid hyperalgesia, hyperalgesia, tolerance, NMDA receptor antagonists,NMDA receptor induced hyperalgesia, spinal dynorphin induced hyperalgesia, descendingfacilitation and hyperalgesia, buprenorphine and hyperalgesia, opioid detoxification, officebased detoxification, complications of opioid therapy