Opioid induced hyperalgesia

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We have all seen it.

The patient has a pain response completely disproportionate to the stimulus. An absolutely agonizing sprained ankle. A blood pressure cuff causing 10/10 pain.

Look up the patients history, and sure enough, multiple visits for pain. Dental pain, strained back, headaches, sprains, etc. Often these folks will have a history of complaints with no objective findings, and have subjective symptoms that can be relieved by mind altering drugs. Multiple prescriptions for narcotics.

It is easy to write this off as Drug Seeking Behavior. (I actually think this is a ridiculous term, but that is a different subject) Turns out there is a growingly accepted explanation for the phenomena.

It has become obvious to me over the years that treating minor injuries with narcotics is a truly bad idea. I am very active, and no stranger to injury, yet somehow I manage without narcotics. And, I see the phenomenon of increasing visits once we start giving narcs. It feels to me, like we are writing off these folks, taking the easy way out. Doctors regularly give narcotics to patients that they would never allow for their own family, given the same condition.

It turns out my anecdotal observations are backed by science. Who knew? While the phenomenon is obvious to many, I did not realize, until recently, that it had a name and scientific evidence.

Opioid-induced hyperalgesia (OIH) refers to a phenomenon whereby opioid administration results in a lowering of pain threshold, clinically manifest as apparent opioid tolerance, worsening pain despite accelerating opioid doses, and abnormal pain symptoms such as allodynia.

If, as a nurse with a 2 year degree, this is obvious to me, it has got to be obvious to the docs that contribute to this problem. But, as long as we use The Customer Service Model in healthca.re, it seems unlikely to change. What are the chances that somebody complains about being given percocet for a sprained wrist? But, untreated pain....

For anyone interested, lots of info a quick Google search away.

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Specializes in Emergency & Trauma/Adult ICU.

Current US culture, the regulatory environment (CMS and JCAHO) and the healthcare industry itself have created an expectation of the absence of pain or other inconvenient symptomatology.

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Specializes in Critical Care, Education.

Wow! Great catch. I am going to share this information with all my clinical educators.

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Specializes in ICU, LTACH, Internal Medicine.

Actually, this phenomenon is known for quite some time. And, yes, it is not drug seeking behavior. These folks, like people with fibromyalgia, really feel that 10/10 pain from BP cuff. It was confirmed by functional PET scans multiple times. The theory says that the pain is central and probably caused by de-regulation of thalamic opioid and opioid-like receptors (pretty much like excessive sugar intake can eventually decrease sensitivity of insulin receptors and lead to DM type II). This thing has a lot in common with FM, "irritable bowel syndrome" and diabetic chronic pain and is treated the same ways with addition of very, very slow withdrawal of all opioids and alcohol.

With all that being said: does anybody actually tells patients (or witness such talks) that surgeries, labor, etc. are NOT supposed to be absolutely pain-free? I was told more than once in that "natural labor class" (in hospital, mind you) about labor pains "just a bit worse than period cramps", and more about "almost pain-free" surgeries before that and after. If patients are said so, why shouldn't they believe that?

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Specializes in ICU, telemetry, LTAC.

I am one of the nurses who tells people they are not supposed to be "pain free" at all times. I tell preops they are going to have pain, but we will try for taking the edge off. I tell postops it's supposed to hurt. I tell chronics you aren't supposed to feel "good" after you take pain meds, the best you should hope for is neutral and the ability to function. If you feel really good, you took too much. I preach biofeedback till I am blue in the face, people do not want to listen. I can't make a dent in this problem, but I take my own advice, and I guess that's the best I can do, is to keep working, and to keep talking in case someone accidentally listens.

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I also tell my post ops that they are going to have pain. I tell them that we hope their pain medication will keep their pain level below a 5, but that it can not take it all away. I have found our plastics docs to be the least forthcoming about pain expectations and our orthos and general surgeons to be the most direct. I also deal with several docs who seem to be in complete denial that their surgical procedures can cause pain so they refuse to give scripts. They make me the saddest.

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Actually, this phenomenon is known for quite some time. And, yes, it is not drug seeking behavior. These folks, like people with fibromyalgia, really feel that 10/10 pain from BP cuff. It was confirmed by functional PET scans multiple times. The theory says that the pain is central and probably caused by de-regulation of thalamic opioid and opioid-like receptors (pretty much like excessive sugar intake can eventually decrease sensitivity of insulin receptors and lead to DM type II). This thing has a lot in common with FM, "irritable bowel syndrome" and diabetic chronic pain and is treated the same ways with addition of very, very slow withdrawal of all opioids and alcohol.

With all that being said: does anybody actually tells patients (or witness such talks) that surgeries, labor, etc. are NOT supposed to be absolutely pain-free? I was told more than once in that "natural labor class" (in hospital, mind you) about labor pains "just a bit worse than period cramps", and more about "almost pain-free" surgeries before that and after. If patients are said so, why shouldn't they believe that?

I look at a lot of charts of a lot of patients who get a lot of narcotics. I have seen a lot of obscure diagnoses. I have never- not once- seen mention of OIH. I see evidence of it frequently.

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Looks like (after a quick review of the scholarly articles available) it's been known since at least 1994

http://www.sciencedirect.com/science/article/pii/0304395994900841

I would imagine you'd never see it in a chart. It isn't something the medical profession really discusses, much less diagnoses and charts. I'd imagine most diagnostic protocols are 1) costly (PET scans aren't cheap from what I hear) and 2) not covered by insurance.

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Specializes in Emergency/ICU.

This is why it is becoming problematic for people to use the ED as their "Dr's Office." Many of my patients do, and, from what I've seen, a visit to the ED for a minor issue often equates to overtreatment: unnecesssary radiation and strong narcotics. This is not to fault the ordering physician, they are covering their rear just in case the person is that 1 in 1,000,000 who is sicker than they appear.

I often put Dilaudid into a bag of NS and let it drip in slow (over a half hour) for fear of creating a "Dilaudid monster." You guys have seen the monster, have you not? A patient comes in for nonspecific abdominal pain and they get a mg of Dilaudid IV push and BAM, 30 minutes later they are asking for more, and again and again and again.

Then on subsequent visits for minor ailments, a headache, for example, they expect Dilaudid and report continued pain until they get it and the cycle begins again. I don't believe they intended to be drug seeking originally, but we trained them to equate pain with the reward of euphoria and a momentary abscence of pain. Many of my patients become angry when I suggest Tylenol or Motrin because they have been trained to expect narcotics because they are in the ED.

I believe overtreatment contributes to the problem of hyperalgesia. I hate pain and always seek to treat it appropriately, but for questionable pts, I'm hanging my Dilaudid in NS because I'm not looking to contribute to this problem.

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Specializes in ICU, LTACH, Internal Medicine.

...3) patient with OIH has to either continue to take opioids, or accept the fact of living with significant pain for months and longer. The vast majority of them chooses "just taking my pain pills"; 4) accepting client with OIH as a patient, doctor has a choice: to get time-consuming, difficult, probably non-compliant patient who, in addition to all that, can successfully sue the doctor at every moment because "poor pain management" and for whose treatment there are no clear guidelines, or just continue to write scripts and keep everybody happy.

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...3) patient with OIH has to either continue to take opioids, or accept the fact of living with significant pain for months and longer. The vast majority of them chooses "just taking my pain pills"; 4) accepting client with OIH as a patient, doctor has a choice: to get time-consuming, difficult, probably non-compliant patient who, in addition to all that, can successfully sue the doctor at every moment because "poor pain management" and for whose treatment there are no clear guidelines, or just continue to write scripts and keep everybody happy.

Excellent additional points. Overall, it isn't to the monetary/legal benefit of the physician/insurance company OR to the physical benefit of the patient (at least initially) to diganose OIH.

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Specializes in CVICU.

If, as a nurse with a 2 year degree, this is obvious to me, it has got to be obvious to the docs that contribute to this problem.

You say this as though docs want to be licensed drug dealers. Trust me, they don't. Physicians constantly tell stories about administrators routinely chiding them for not "controlling patient's pain more effectively" i.e. give the drug seekers in the ER what they want so they'll give good Press Ganey responses. We have allowed extortionists like JAACHO and Press Ganey to hold healthcare hostage which is just as much our fault. Our current associations that we continue to give our money to (ENA, AACN, etc) are apparently not doing an effective job of lobbying or acting in our best interests, so maybe it's time to start sending our money to organizations that actually do something to help nurses and healthcare as a whole break free from these sanctioned extortionists.

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