Opioid-Induced Hyperalgesia


Opioid exposure causes rewiring in the central and peripheral nervous systems, increasing a patient’s sensitivity to painful stimuli and a worsening of their pain despite subsequent opioid increase. OIH is a form of opioid toxicity. OIH differs from Opioid Tolerance, which is a desensitization of the nervous system to a certain dose of opioid over time and requires dose increases to achieve symptom relief.

Risk Factors

  • High-dose opioids
  • Parenteral opioid administration

OIH can occur in any patient requiring opioids for symptom management, i.e. dyspnea, pain.


  • Worsening pain without evidence of disease progression
  • Pain occurs: in areas unaffected by disease progression; diffuse pain; allodynia
  • Pain worsens despite multi-fold opioid increases over a short period of time


  • *Critical*: Complete a thorough pain history and assessment.
  • Remember that more opioid will not help.
  • Provide a calm explanation to patient and family in distress. OIH can be mistaken for disease progression.
  • Ensure there is clear communication with care team about the management plan:
  1. Reduce the opioid dose by tapering off systematically (25-30% every 24 hours). Smaller reductions (i.e. 10-15%) are not useful.
  2. If possible, add in NMDA-receptor adjuvant medications (e.g. methadone, ketamine).
  3. Consider other adjuvant medications – steroids, NSAIDs, gabapentinoids, SNRI or TCA antidepressants or adjuvant therapies, like palliative radiation therapy.
  4. Consider non-tactile, non-pharmacologic management techniques as tolerated (i.e. distraction, meditation, breathing exercises, aromatherapy, Snozelin therapy, etc.).
  • Intermittent sedation or palliative sedation therapy may be warranted.
  • Continue to discuss goals of care with patient and family.

Adapted from Shobbrook, C. (2017). Opioid-Induced Hyperalgesia (OIH) [Presentation]

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  • Lee, M. et al (2011). A comprehensive review of opioid-induced hyperalgesia. Pain Physician. Mar-Apr;14(2), p 145-61.
  • Pasero, C. et al. (2012). Opioid Induced Hyperalgesia. Journal of PeriAnesthesia Nursing, 27(1), p 46-50. Available at www.jopan.org.