Opioid-Induced Hyperalgesia in the Perioperative Setting: Challenges for the Anesthesiologist and Prevention Strategies

Abstract

Opioid-induced hyperalgesia (OIH) is a paradoxical condition characterized by increased pain sensitivity following opioid administration and represents a major challenge in perioperative anesthetic management. Its occurrence is associated with increased postoperative pain, higher analgesic requirements, prolonged recovery, and a greater risk of persistent postoperative pain. This study aimed to review the main scientific evidence regarding the pathophysiological mechanisms, risk factors, clinical manifestations, and anesthetic strategies for preventing OIH. An integrative literature review was conducted using the PubMed/MEDLINE, Scopus, Web of Science, Embase, SciELO, and Virtual Health Library (VHL) databases. The analyzed studies demonstrated that N-methyl-D-aspartate (NMDA) receptor activation, central sensitization, and neuroinflammation are the main mechanisms involved in the development of OIH, with the use of potent opioids, particularly remifentanil and fentanyl, representing an important risk factor. Furthermore, multimodal analgesia, regional anesthesia, and adjuvant agents such as ketamine, intravenous lidocaine, and dexmedetomidine were shown to reduce postoperative pain intensity and opioid consumption. It is concluded that early recognition of OIH and the implementation of preventive anesthetic strategies are essential to optimize pain control, improve perioperative outcomes, and promote the rational use of opioids.