Indian Journal of Palliative Care
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Table of Contents 
Year : 2015  |  Volume : 21  |  Issue : 1  |  Page : 82-84

Is mechanism and symptom-based analgesia an answer to opioid-Induced hyperalgesia?

1 Department of Medical Intensive Care Unit and Pain, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
2 Employee's State Insurance Hospital, Okhla, Delhi, India

Date of Web Publication28-Jan-2015

Correspondence Address:
Mayank Gupta
Department of Medical Intensive Care Unit and Pain, Rajiv Gandhi Cancer Institute and Research Centre, Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1075.150196

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 » Abstract 

"Cancer Pain" and "Pain in cancer patient" are not synonymous. Opioid-induced Hyperalgesia (OIH) is a paradoxical state of nociceptive sensitization caused by exposure to opioids. Neuropathic pain is only partially responsive to opioids; injudicious increase in dose of opioids in neuropathic pain may not only result in inadequate pain relief but also OIH. Majority of literature on OIH is in non-cancer pain with systemic use of opioids. We describe the development and successful treatment of OIH in a 55-year-old male patient with Small cell Carcinoma Lung. Opioid tapering, rotation, systemic desensitization helps in combatting OIH. The use of anti-neuropathic adjuvant analgesics helps not only in preventing and treating OIH but also in understanding putative mechanisms underlying neuropathic pain and OIH.

Keywords: Mechanism based, opioid induced hyperalgesia, opioids

How to cite this article:
Gupta M, Gupta P. Is mechanism and symptom-based analgesia an answer to opioid-Induced hyperalgesia?. Indian J Palliat Care 2015;21:82-4

How to cite this URL:
Gupta M, Gupta P. Is mechanism and symptom-based analgesia an answer to opioid-Induced hyperalgesia?. Indian J Palliat Care [serial online] 2015 [cited 2020 Nov 25];21:82-4. Available from:

 » Introduction Top

Pain is the most common and multifactorial symptom of cancer. Opioids are considered as the cornerstone of cancer pain management. Opioid Induced Hyperalgesia (OIH) is a paradoxical state of nociceptive sensitization caused by exposure to opioids. [1] The incidence, predisposing factors and underlying mechanisms remain largely unknown. [1],[2],[3],[4] Neuropathic pain is only partially responsive to opioids; [5] injudicious increase in dose of opioids in neuropathic pain may result in OIH. Adjuvant analgesics by supplementing analgesia and avoiding injudicious increases in opioid doses not only herald OIH but also prove to be a valuable treatment tool in OIH. In literature, OIH has mostly been described in non-cancer pain with systemic use of opioids.

 » Case report Top

A 55-year-old male known case of metastatic small cell carcinoma lung was admitted for severe pain over right buttock with pain and tingling sensation in right leg and sole. Whole body 18F fluorodeoxyglucose (FDG) positron emission tomography computer tomography (PET-CT) scan depicted hypermetabolic lytic/sclerotic lesions in multiple skeletal regions including cervico-dorso-lumbar vertebrae and bilateral pelvic bones. Magnetic resonance imaging (MRI) spine revealed multiple areas of marrow signal alteration suggesting metastasis in almost all the visualized vertebrae. Ventral epidural soft tissue was seen at right S1 compressing right traversing nerve root.

Patient was prescribed Tablet Morphine sulphate Immediate Release (IR) 10 mg 4 hourly, injection diclofenac 50 mg intravenous (iv) tds and injection zoledronic acid iv every 4 weeks for persistent back pain. Morphine was escalated to 15 mg followed by 20 mg4 hourly and SOS over 48 hours in view of unremitting pain. Despite increase in morphine dosage, pain increased both in intensity and distribution. Patient developed pain, burning, and tingling sensation in bilateral legs which used to increase 30 minutes to an hour after ingestion of oral morphine. The patient was referred to our pain clinic. A complete history and physical examination including neurological and musculoskeletal examination was performed. Patient had sharp, shooting pain in right buttock radiating to right lower limb till sole of the foot (S1 radiculopathy) and burning pain in bilateral lower limbs with a 10-point visual analogue score (VAS) of 9/10 with a minimum VAS of 8/10. Pain was neuropathic in nature (Pain Detect Tool score of 19). Examination revealed bony tenderness present over multiple dorso-lumbar spinous processes and right sacral region and allodynia in bilateral lower limbs.Rest of the neurological examination was normal except for the right side ankle reflex which was absent. Tablet Morphine was tapered to 10 mg 4 hourly and 10 mg SOS, Buprenorphine patch 20 μg/hour was applied and Inj Dexamethasone 8 mg intravenously BD was started to reduce the edema.However, patient refused to take oral morphine due to increased pain and burning sensation associated with its consumption. Injection Tramadol 50 mg intravenous TDS was started to tackle ongoing pain. Injection Lignocaine 3 mg/kilogram body weight (BW) and injection ketamine 0.2 mg/kilogram BW diluted in 100 ml normal saline was given intravenous slowly over 1 hour consecutively for 3 days, under electrocardiography (ECG), Noninvasive blood pressure (NIBP) and Pulse oximeter (SPO 2 )monitoring. The patient did not develop side-effect other than mild dizziness and demonstrated reduction in pain and burning sensation after each infusion; however, the effect was short lived. Analgesia was supplemented with Tablet Etorocoxib (Cox-2 inhibitor) 60 mg BD and injection Paracetamol 1 gram iv TDS. Tablet Gabapentin-NT 1 tablet HS was started and escalated gradually to BD and then TDS to tackle neuropathic component. Radiotherapy to the lumbosacral region was started and continued for 5 days. Patient's intensity of pain decreased to 1/10, allodynia and hyperalgesia decreased. Over next few days Nucoxia and tramadol were stopped, inj Paracetamol converted to tablet paracetamol 1 gram TDS. The analgesia was maintained successfully and patient discharged on Buprenorphine patch 20 μg/hour and tablet Gabapentin-NT TDS.

 » Discussion Top

OIH is diagnosed when increase in opioid doses causes escalating pain intensity or distribution or both. [3] There may be associated allodynia or hyperalgesia which may be so severe that even non painful stimulus such as touching, clothing, pressure, or heat produces excruciating pain. Its diagnosis may be confounded by factors such as worsening pain pathology or opioid tolerance; which unlike OIH usually respond to increase in opioid dosage. Neuroplastic changes such as upregulation of N Methy D Aspartate (NMDA) receptors, windup, descending pain facilitation, enhanced production, and decreased breakdown of excitatory neurotransmitters have been postulated as the underlying mechanisms of OIH.[2],[3] Ketamine, a NMDA receptor antagonist, in subanaesthetic doses suppresses NMDA receptor mediated neuronal plasticity and its clinical correlates such as allodynia and hyperalgesia. [1],[6] Lidocaine, a local anesthetic and Na channel blocker is effective in a number of neuropathic pain conditions. [7] Cycloxegenase-2 (COX-2) selective antagonists inhibit spinal release of excitatory neurotransmitters (glutamate), prostaglandins, and may partially reverse OIH. Buprenorphine due to its action as kappa antagonist- and voltage-gated Na channel blocker has been found to be useful in neuropathic pain and hyperalgesia. [8],[9],[10] Tramadol likely due to its inhibitory action on serotonin and norepinephrine reuptake is useful in neuropathic pain. [11],[12] Systemic desensitization with Injection lignocaine, ketamine, and opioid rotation, helped in reversing OIH. These in combination with COX-2 inhibitors, acetaminophen, gabapentin, and nortryptiline helped in controlling pain by the time palliative radiotherapy reduced the mass effect. Accurate determination of pain generating mechanism is complex but essential for a rational analgesic therapy. A top-down approach in delineating neuropathic pain mechanism may prove to be a daunting task because of heterogeneity of pathophysiologic mechanisms in different pain states but also in different patients. In such a scenario, a bottom-up approach of selecting anti-neuropathic medications based on patients symptomatology may prove not only gratifying but also in understanding putative neuropathic mechanism involved in that patient.It is important not to have a tunnel vision when treating a patient with cancer pain.The diagnosis of neuropathic pains though not a deterrant but warrants judicious use of opioids along with co-analgesics. Tailoring analgesic prescription to algesic mechanism, repeated assessment to evaluate analgesic effectiveness, side-effects, and continued search for pain generating mechanism are the analgesic pillars, importance of whom cannot be emphasized enough.

 » References Top

Chu LF, Angst MS, Clark D. Opioid-induced hyperalgesia in humans: Molecular mechanisms and clinical considerations. Clin J Pain 2008;24:479-96.  Back to cited text no. 1
Mitra S. Opioid-induced hyperalgesia: Pathophysiology and clinical implications. J Opioid Manag 2008;4:123-30.  Back to cited text no. 2
Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician 2011;14:145-61.  Back to cited text no. 3
Pasero C, McCaffery M. Opioid-Induced hyperalgesia. J Perianesth Nurs 2012;27:46-50.  Back to cited text no. 4
Mercadante S, Gebbia V, David F, Aielli F, Verna L, Casuccio A, et al. Tools for identifying cancer pain of predominantly neuropathic origin and opioid responsiveness in cancer patients. J Pain 2009;10:594-600.  Back to cited text no. 5
Ramaasubbu C, Gupta A. Pharmacological treatment of opioid-induced hyperalgesia: A review of the evidence. J Pain Palliat Care Pharmacother 2011;25:219-230.  Back to cited text no. 6
Mao J, Chen LL. Systemic lidocaine for neuropathic pain relief. Pain 2000;87:7-17.  Back to cited text no. 7
Johnson RE, Fudala PJ, Payne R. Buprenorphine: Considerations for pain management. J Pain Symptom Manage 2005;29:297-326.  Back to cited text no. 8
Koppert W, Ihmsen H, Korber N, Wehrfritz A, Sittl R, Schmelz M, et al. Different profiles of buprenorphine-induced analgesia and antihyperalgesia in a human pain model. Pain 2005;118:15-22.  Back to cited text no. 9
Leffler A, Frank G, Kistner K, Niedermirtl F, Koppert W, Reeh PW, et al. Local anesthetic-like inhibition of voltage-gated Na (+) channels by the partial μ-opioid receptor agonist buprenorphine. Anesthesiology 2012;116:1335-46.  Back to cited text no. 10
Grond S, Sablotzki A. Clinical pharmacology of tramadol. Clin Pharmacokinet 2004;43:879-923.  Back to cited text no. 11
Arbaiza D, Vidal O. Tramadol in the treatment of neuropathic cancer pain: A double-blind, placebo-controlled study. Clin Drug Investig 2007;27:75-83.  Back to cited text no. 12


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