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Opioid-Induced Tolerance and Opioid-Induced Hyperalgesia in Critical Illness

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Opioid Use in Critical Care

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Abstract

Opioids are the most commonly used analgesics to treat pain in critically ill patients but carry a significant risk for many adverse effects, contributing to problematic long-term use. Long-term opioid use leads to tolerance (i.e., less susceptibility to the analgesic effects of the opioid, which can result in a need for higher and more frequent doses to achieve the same analgesic effect), opioid-withdrawal symptoms during weaning and may contribute to the development of opioid-induced hyperalgesia, a paradoxical hypersensitivity to pain. Hyperalgesia is particularly problematic as pain persists, yet further opioid prescribing is largely futile. Both opioid tolerance (OT) and opioid-induced hyperalgesia (OIH) can contribute to both poorly controlled pain and dose escalation. OT can develop with opioid exposure during a variety of acute and chronic disease states; the magnitude, however, often appears exaggerated in critically ill patients. The development of OT and OIH in critically ill patients is due in part to the large doses of opioids needed to control pain as well as the duration of administration. However, the inflammatory response seen in critically ill or injured patients also plays an important role in tolerance and OIH. Critical care clinicians have not typically been overly concerned about OT and OIH instead focusing their attention on management of acute life-threatening conditions. However, a growing body of evidence suggests long-term harms may be associated with prolonged opioid exposure during this critical illness. It is crucial for the critical care practitioner not only to be aware of the issues of tolerance, addiction and withdrawal, but also to have knowledge of the possibility for OIH. By improving understanding of the underlying mechanisms and diagnosis, it may be possible to develop strategies to better manage pain associated with critical illness and injury, to improve efficacy and safety of opioid use, and to minimize long-term harms.

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Author information

Authors and Affiliations

  1. Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA

    Edward A. Bittner & Rachel Steinhorn

  2. Harvard Medical School, Boston, MA, USA

    Edward A. Bittner, Rachel Steinhorn & J. A. Jeevendra Martyn

  3. Shriners Hospitals for Children, Boston, MA, USA

    J. A. Jeevendra Martyn

  4. Massachusetts General Hospital, Boston, MA, USA

    J. A. Jeevendra Martyn

Authors
  1. Edward A. Bittner
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  2. Rachel Steinhorn
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  3. J. A. Jeevendra Martyn
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Corresponding author

Correspondence to Edward A. Bittner .

Editor information

Editors and Affiliations

  1. Professor of Surgery and Neurosurgery, Perelman School of Medicine Clinical Associate, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA

    Jose L. Pascual

  2. Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Timothy G. Gaulton

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Bittner, E.A., Steinhorn, R., Jeevendra Martyn, J.A. (2021). Opioid-Induced Tolerance and Opioid-Induced Hyperalgesia in Critical Illness. In: Pascual, J.L., Gaulton, T.G. (eds) Opioid Use in Critical Care. Springer, Cham. https://doi.org/10.1007/978-3-030-77399-1_8

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  • DOI: https://doi.org/10.1007/978-3-030-77399-1_8

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-77398-4

  • Online ISBN: 978-3-030-77399-1

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