Adam Clements, DO; Ben Kaster, MD, MPH; Phillip Hartfield, MD
WMJ. 2025;124(5):489-491.
ABSTRACT
Introduction: Opioid-induced hyperalgesia (OIH) is a paradoxical increase in pain sensitivity in patients receiving chronic opioid therapy. Many patients with OIH may be labeled incorrectly as drug-seeking or addicted. Common management strategies include opioid rotation, dose reduction, and use of N-methyl-D-aspartate receptor antagonists and/or nonsteroidal anti-inflammatory drug. However, evidence supporting these interventions is limited.
Case presentation: We report the case of a 57-year-old woman with metastatic endometrial cancer, previously treated with hysterectomy, chemotherapy, and pelvic radiation, who was receiving hospice care. Despite escalating opioid doses (240 morphine milligram equivalents daily), her pain worsened. She was discharged from hospice for opioid overuse and referred to our addiction clinic. OIH, rather than opioid use disorder, was suspected as the primary barrier to pain relief. Using a microdosing strategy, we transitioned her to buprenorphine, resulting in significant pain reduction and improved quality of life.
Discussion: Buprenorphine is an opioid widely used for the treatment of opioid use disorder, and emerging evidence supports its role in chronic pain management. However, its ability to treat OIH has not been well described. This case suggests that buprenorphine may be effective for patients with opioid tolerance and hyperalgesia and underscores the importance of considering alternative diagnoses in those who are diagnosed with opioid use disorder.
Conclusions: Buprenorphine may offer a safe and effective option for managing OIH in patients with chronic pain and high-dose opioid exposure. Further research is needed to clarify its role in treating OIH and to guide clinical practice.