Can Opioid Useage Make People Hurt More?

Typically with opioid pain medications being prescribed the response is excellent pain relief. Side effects experienced may include tolerance, sedation, depression, and constipation. Fifteen percent of the US population experiences chronic pain, and doctors are prescribing narcotic medications much more often.

Is it possible for chronic opioid therapy to make patients worse? The answer is yes, and it is termed opioid-induced hyperalgesia (OIH). It is a paradoxical condition whereby patients become oversensitive to acute pain. There is a scarcity of literature on the subject of how often it occurs, what presents risk factors for its occurrence, and whether or not there is a dosing relationship for narcotics towards developing OIH.

Most importantly, no one accepted preventive strategies exist or exactly how it should be managed once OIH develops.

Opioid induced hyperalgesia is different than when a patient develops tolerance. With tolerance, the medication dose may just be increased for the desired effect. With OIH, this will not be the case since sensitization exists and increasing the medication dose would just make the pain worse.

A patient with OIH might actually become more sensitive to certain painful stimuli from the medication. The type of pain that the patient experiences may be the same as the underlying pain or quite possibly could be different than the original pain.

We don’t know why patients develop OIH exactly. There is some literature showing that a predisposing factor may be genetics, but it has not been explored in depth. There have been other studies showing an association between opioid metabolites and an increased sensitivity to pain (hyperalgesia).

Numerous observations have shown most often the OIH occurs with chronic opioid exposure. The main thing it needs to be differentiated from is simple tolerance or clinical worsening of the patient’s baseline pain with need for higher dosing.

Diffuse pain is typically produced with OIH, which quite often radiates to regions that were not painful before. OIH usually replicates opioid withdrawal with some of its symptoms along with increased pain. Along with that, if the person is dealing with tolerance, a higher dose would reduce the pain. This is not seen with OIH, in fact, the pain would probably get worse.

Treatment of OIH can be time-consuming, perplexing, and stressful for both the physician and patient. Rotating to a different opiate class may help. Trying non-opioid medications and decreasing opiate dosing is often helpful, along with administering interventional pain treatments to reduce the need for medications or eliminate the need altogether.

If these options are not possible or do not help sufficiently, the following may be attempted:

1. Attempt combination therapy with Cox-2 NSAID medications

2. Utilize a class of medications called NMDA receptor antagonists

3. Increase the opioid dose to see if it works, and the patient is dealing with tolerance rather than OIH.

4. Use opioids like methadone or buprenorphine which have properties with the potential to prevent or reduce OIH.

Opioid induced hyperalgesia should be placed into the mix as a potential diagnosis if chronic opioid treatment is failing. It is becoming more prevelant as the sheer numbers of patients in the US receiving chronic pain medication has risen exponentially over the past decade.

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