Opioid induced hyperalgesia

Nurses General Nursing

Published

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.

Specializes in Critical Care.
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.

How can you put dilaudid in a normal saline bag when it is supposed to be given IV push, sounds like your administering the med wrong and could get in trouble for that.

my concern would be leaving the patient with the narcotic hanging. i have had patients ask me to put their pain med in the syringe on the secondary line on the iv pump so it could run slowly but I've always refused. I have other patients and I can't just stand there for 20 minutes watching it infuse. I'm not turning my back on some narcotics that I'm not certain were administered to the patient himself.

I guess a happy medium would be diluting Dilaudid in 10 mL NS, regardless of whether the patient has just a saline lock or has fluids going. And push that syringe VERY slow, as in more than 2 minutes. I think I'll start doing that.

Specializes in ICU, LTACH, Internal Medicine.
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. .

They don't, but every minute of their residency training and their subsequent practice push them to do just that. They're trained - or rather programmed, to "address" every "problem" they can think of in every single "case" in the most quick, effective and insurance-correct way, with as little time sacrifice as possible. They're afraid of lawsuits, taught to follow specialty "guidelines" without ever thinking of analyzing. The level of statistical literacy required by USMLE (the infamous "steps" exam) is well below "elementary statistics", let alone statistical analysis (that's one reason why so many doctors don't like alternative therapies - they just can't analyze evidence and simply dismiss it all as "anecdotal") . And in majority of cases doctors cannot safely - from legal point of view - recommend or prescribe any kind of complementary therapy within their scope of practice. And last but not least - they hate to see patients' sufferings, just like we do. They want to help.

There are currently dozens of common medical conditions which can, and in many cases probably should, be at least attempted to be treated without pharmacological interventions, and for which there are high-quality evidence of alternative therapies being equally "safe and effective" comparing with drugs. But all that costs money, takes valuable doctor's time and often leaves the patient wrestling with symptoms for months instead of quick and effective "help". Doctors don't like it at all - and they just do what they can do. Many of them are aware of the results. But that's sick reality of modern American healthcare.

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.

I agree. And that is exactly why I am surprised that this diagnosis isn't used. The docs I work with are decent people who see lives destroyed by narcotics on a regular basis.

When a person walks in on a sprained ankle and state that there is 9/10 pain, there are two possibilities:

1- The pt is telling the truth. They are in agonizing pain completely disproportionate to the injury. The only way this could be, is if their pain sensing mechanism was disrupted. Taking hx into account, the most reasonable dx is OIH. Narcotics would be contra-indicated.

2- Pt is lying about their pain. Narcotics would be contra-indicated.

It seems like an obvious and easy out.

Specializes in ICU, LTACH, Internal Medicine.

When a person walks in on a sprained ankle and state that there is 9/10 pain, there are two possibilities:

1- The pt is telling the truth. They are in agonizing pain completely disproportionate to the injury. The only way this could be, is if their pain sensing mechanism was disrupted. Taking hx into account, the most reasonable dx is OIH. Narcotics would be contra-indicated.

2- Pt is lying about their pain. Narcotics would be contra-indicated.

It seems like an obvious and easy out.

3- patient has no idea what 10/10 pain level means. Sorry, we don't live in the world where kids were whipped on regular basis, girls burned their fingers by live coals and babies were born "the way God made it". Unless patient had "pain experience" of some sort, there's no way to explain it. Whatever it is in reality, this pain is 10/10 for him, it is felt like it, and his/her brain reacts appropriately. No way to check it, either - even if you do fPET scan right them and there, it will show features of "excruciating pain".

4- this is not just plain sprain. It can be nerve trauma, bleeding into joint, fracture, etc. A doctor or mid-level provider is needed to figure it out, and the patient has the 10/10 pain in the meantime.

5- even if it is OIH, opioids are not contraindicated. Only things like extended-release or high-peak forms (like Opana or fentanyl lollipops) are truly contraindicated.

6- patient has contraindications to NSAIDs (which are more suitable for pain control in cases like simple sprain); patient needs good pain control because he has to walk/drive to work and his boss will fire him if he misses another day; patient lives alone in 2-level house and has no means to pay for home care; hospital has no anesthesiologist/CRNA who knows how to perform prolonged nerve block; patient has no means to pay for the block and return in hospital in 3 days for control.

Add to that simple human wish to alleviate the poor guy's sufferings ASAP and you'll get the picture.

If only we were dealing with the system where the same patient could spend next 72 hours at home doing RICE, if he had preventive care 20 years ago so that his kidneys were in better shape and he could take NSAIDS, if he could get good explanation of the reasons why Vicodin isn't the right thing for him and get couple of visits of home care aide, the whole thing would look different.

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3- patient has no idea what 10/10 pain level means. Sorry, we don't live in the world where kids were whipped on regular basis, girls burned their fingers by live coals and babies were born "the way God made it". Unless patient had "pain experience" of some sort, there's no way to explain it. Whatever it is in reality, this pain is 10/10 for him, it is felt like it, and his/her brain reacts appropriately. No way to check it, either - even if you do fPET scan right them and there, it will show features of "excruciating pain".

4- this is not just plain sprain. It can be nerve trauma, bleeding into joint, fracture, etc. A doctor or mid-level provider is needed to figure it out, and the patient has the 10/10 pain in the meantime.

5- even if it is OIH, opioids are not contraindicated. Only things like extended-release or high-peak forms (like Opana or fentanyl lollipops) are truly contraindicated.

6- patient has contraindications to NSAIDs (which are more suitable for pain control in cases like simple sprain); patient needs good pain control because he has to walk/drive to work and his boss will fire him if he misses another day; patient lives alone in 2-level house and has no means to pay for home care; hospital has no anesthesiologist/CRNA who knows how to perform prolonged nerve block; patient has no means to pay for the block and return in hospital in 3 days for control.

Add to that simple human wish to alleviate the poor guy's sufferings ASAP and you'll get the picture.

If only we were dealing with the system where the same patient could spend next 72 hours at home doing RICE, if he had preventive care 20 years ago so that his kidneys were in better shape and he could take NSAIDS, if he could get good explanation of the reasons why Vicodin isn't the right thing for him and get couple of visits of home care aide, the whole thing would look different.

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You make some great points, which are applicable to the patient you portray. A guy with a somewhat obscure injury that would respond to an intervention if his provider had the skill, and he had the money. He has a job he needs to go to, and his lack of preventative care resulted in kidney problems, so he can't take NSAIDS. He can't afford to miss work, so he can't RICE. He does, however, have a job that can be safely done while on narcotics.

The pt's are I deal with are a little different.

3. True, we are sheltered from true pain. But- referring to a sprain on which you can walk, talk, and eat as the "worst pain imaginable" means that you must have a really limited imagination.

4. True- outliers exist. But, when they become the norm, something is off. having severe pain with no objective findings happens. When it happens 3 times in 3 months with 3 different complaints, the prudent healthcare provider should look at all possibilities and the risk/benefit of any treatment.

5- This is interesting. I have only read a few articles on OIH. I didn't pick up on this. Short term narcotics are not a factor?

6- Contraindications? The contraindications I see are an allergy to any analgesic that is not a drug of abuse. I have actually had pt's tell me that they are allergic to plain tylenol, but can take vicodin.

As far as giving somebody narcotics so they can drive to work? Seems a bit risky, but not an issue for most of the folks I deal with in this condition. They don't work.

My interest in OIH comes from my observations that often, people who use a lot of narcotics experience pain differently than the rest of us. Of course there are people who lie to get high. What is more interesting to me is the pt who appears to be in genuine pain, without what appears to be a significant mechanism.

I have a theory with no scientific validity based only on anecdotal observation. Some people, when exposed to narcotics develop a need for narcotics. This need develops irrespective of whether the drugs are prescribed or not.

The body/mind is an amazing combination. The very fact that placebos often work as well as actual medications is a testament to the ability of the body and mind to work together. When I see a narcotic user in severe pain despite a trivial mechanism, I believe the pain is real. I believe that the body produces this response to meet its need for narcotics.

This is very different from OIH. But, reading about OIH is the first I have been exposed to any literature discussing the fact that narcotic users can experience pain differently from non narcotic users.

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