Opioid Induced Hyperalgesia with Intrathecal Infusion of High‐Dose Fentanyl

Abstract

Introduction Despite being reported since 1943 as well as being the subject of a large body of literature since that time, no consensus has been reached regarding the etiology of opioid induced hyperalgesia (OIH). It is often described as a paradoxical increased pain response to noxious stimuli due to increased sensitization or an acute tolerance to opioids. Case We report the case of a 60 year old patient on chronic Intrathecal combined fentanyl and Bupivacaine who had worsening pain with increasing doses and improved after weaning off intrathecal opioids. Conclusion OIH has been described in various settings including patients on methadone maintenance therapy, perioperative opioid administration, cancer patients on opioids, and healthy volunteers who are acutely exposed to opioids, including high dose intrathecal opioids such as Morphine and Sufentanil. To our knowledge, no cases of opioid induced hyperalgesia was previously reported in the case of intrathecal Fentanyl.

Opioid-induced Hyperalgesia in Patients With Chronic Pain

“…None of the authors used experimental nociceptive tests to diagnose OIH. In 69 cases (96%), the patients experienced refractory pain despite an increase in opioid dose; in 24 cases (33%), the pain was diffuse or clearly extended to other anatomic areas in the absence of disease progression,16–29 and in 20 cases (27.7%), diffuse allodynia was observed 17,20,21,26,27,30–42. An association of 2 of these symptoms was reported in 24 cases (33%)16,18,21,23–26,29–31,33–38,40,42 and an association of all 3 symptoms was observed in 8 cases (11%) 17,20,26–28,42…”

“…Symptoms of withdrawal were checked in only 9 cases, and were found in only 1 of these cases. Symptoms of opioid toxicity were reported in 3 cases, all on very high doses of opioids: 2988, 8000, and 28,600 mg per day 19,40,52. The most frequent manisfestations described were myoclonus, agitation, hallucinations, delirium, and leg movements.…”

“…None of the authors used experimental nociceptive tests to diagnose OIH. In 69 cases (96%), the patients experienced refractory pain despite an increase in opioid dose; in 24 cases (33%), the pain was diffuse or clearly extended to other anatomic areas in the absence of disease progression, [16][17][18][19][20][21][22][23][24][25][26][27][28][29] and in 20 cases (27.7%), diffuse allodynia was observed. 17,20,21,26,27,[30][31][32][33][34][35][36][37][38][39][40][41][42] An association of 2 of these symptoms was reported in 24 cases (33%) 16,18,21,[23][24][25][26][29][30][31][33][34][35][36][37][38]…”

A single dose of ketamine relieves fentanyl-induced-hyperalgesia by reducing inflammation initiated by the TLR4/NF-κB pathway in rat spinal cord neurons

“…Fentanyl has been widely used perioperatively as an analgesic since it was first synthesized in 1960. However, the use of high-dose fentanyl can induce hyperalgesia simultaneously from several hours to a few days after infusion (1)(2)(3)(4). Fentanyl-induced hyperalgesia (FIH) decreases patients' quality of life and requires larger doses of fentanyl for pain relief, which increases adverse reactions such as nausea, vomiting, and respiratory depression.…”

Opioid-induced hyperalgesia after implantation of intrathecal morphine pump: a case report

“…Opioid-induced hyperalgesia (OIH), an uncommon phenomenon observed in patients receiving opioid therapy, occurs after patients use various opioid medications such as remifentanil, fentanyl, sufentanil, and oxycodone [4][5][6][7]. Di-Sungryul Yoon, et al: Opioid-induced hyperalgesia after intrathecal morphine pump 48 www.embse.org verse routes of administration such as oral, intravenous (IV), epidural, and IT are associated with OIH.…”