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Opioid-induced Hyperalgesia — SCE Medical Oncology MCQ

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HardSupportive & Palliative OncologyOpioid-induced HyperalgesiaSCE Medical Oncology

A 58-year-old woman with cancer is on long-term opioids and develops opioid-induced hyperalgesia (OIH). She reports increasing pain despite escalating morphine doses, with generalised hyperalgesia (allodynia on examination). What is the key management principle?

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Correct answer: A — Opioid-induced hyperalgesia requires REDUCING or rotating the opioid (not increasing) — the opioid itself is causing increased pain sensitivity through central sensitisation mechanisms; adjuvant analgesics and opioid rotation are the key interventions

OIH is a paradoxical state where opioids cause increased pain sensitivity rather than analgesia. Features: generalised hyperalgesia/allodynia (not limited to the cancer site), escalating opioid requirements without improvement, pain quality change (diffuse, poorly localised). Mechanism: NMDA receptor upregulation, dynorphin system activation, glial cell activation. Management: opioid rotation (to different receptor profile), dose reduction, addition of NMDA antagonists (ketamine, methadone — which has intrinsic NMDA antagonist activity), and adjuvant analgesics.

Reference: NICE CG140; ESMO Pain Management; Palliative Care Formulary; Chu et al Pain 2008