Are we still scratching the surface? A case of intractable pruritus following systemic opioid analgesia

Authors

  • Dana Tarcatu, MD
  • Cristina Tamasdan, MD
  • Natalie Moryl, MD
  • Eugenie Obbens, MD, PhD

DOI:

https://doi.org/10.5055/jom.2007.0055

Keywords:

pruritus, systemic opioids, opioid rotation

Abstract

This article describes a case of severe opioid-induced pruritus following systemic morphine administration. Symptoms did not resolve after administration of antihistamines or rotation to fentanyl or hydromorphone, but oral oxycodone and small-dose intravenous naloxone did alleviate the patient’s itching. The pathogenesis of opioidinduced pruritus and the rationale for opioid rotation are briefly discussed. Current and possible future therapeutic options are mentioned.

Author Biographies

Dana Tarcatu, MD

Fellow, Pain and Palliative Care, Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York.

Cristina Tamasdan, MD

Fellow, Pain and Palliative Care, Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York.

Natalie Moryl, MD

Attending, Pain and Palliative Care, Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York.

Eugenie Obbens, MD, PhD

Acting Chief, Pain and Palliative Care, Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York.

References

Ballantyne JC, Loach AB, Carr DB: The incidence of pruritus after epidural morphine. Anaesthesia. 1989; 44(10): 863.

Woodham M: Pruritus with sublingual buprenorphine. Anaesthesia. 1988; 43(9): 806-807.

Katcher J, Walsh D: Opioid-induced itching: Morphine sulfate and hydromorphone hydrochloride. J Pain Symptom Manage. 1999; 17(1): 70-72.

Ballantyne JC, Loach AB, Carr DB: Itching after epidural and spinal opiates. Pain. 1988; 33(2): 149-160.

Andrew D, Schmelz M, Ballantyne JC: Itch—mechanisms and mediators. In Dostrovsky JO, Carr DB, Koltzenburg M (eds.): Proceedings of the 10th World Congress on Pain: Progress in Pain Research and Management. Seattle: IASP Press, 2003, pp. 213-226.

Atanassoff PG, Brull SJ, Zhang J, et al.: Enhancement of experimental pruritus and mechanically evoked dysesthesiae with local anesthesia. Somatosens Mot Res. 1999; 16(4): 291-298.

Ko MC, Song MS, Edwards T, et al.: The role of central p opioid receptors in opioid-induced itch in primates. J Pharmacol Exp Ther. 2004; 310(1): 169-176.

Schmidt R, Schmelz M, Forster C, et al.: Novel classes of responsive and unresponsive C nociceptors in human skin. J Neurosci. 1995; 15(1 Pt 1): 333-341.

Weidner C, Klede M, Rukwied R, et al.: Acute effects of substance P and calcitonin gene-related peptide in human skin—a micro-dialysis study. J Invest Dermatol. 2000; 115(6): 1015-1020.

Heyer G, Dotzer M, Diepgen TL, et al.: Opiate and H1 antagonist effects on histamine induced pruritus and alloknesis. Pain. 1997; 73(2): 239-243.

Satoh M, Minami M: Molecular pharmacology of the opioid receptors. Pharmacol Ther. 1995; 68(3): 343-364.

Fine PG, Portenoy RK: A Clinical Guide to Opioid Analgesia. New York: McGraw-Hill, 2004.

Dunteman E, Karanicolas M: Transnasal butorphanol for the treatment of opioid-induced pruritus unresponsive to antihista-mines. J Pain Symptom Manage. 1996; 12(4): 255-260.

Twycross R, Greaves MW, Handwerker H, et al.: Itch: Scratching more than the surface. QJM. 2003; 96(1): 7-26.

McQuay H: Opioids in pain management. Lancet. 1999; 353(9171): 2229-2232.

Poyhia R, Kalso EA: Antinociceptive effects and central nervous system depression caused by oxycodone and morphine in rats. Pharmacol Toxicol. 1992; 70(2): 125-130.

Wang SC: Emetic and antiemetic drugs. In Roots W, Hoffmann F (eds.): Physiological Pharmacology. New York: Academic Press, 1965, pp. 255-328.

Ko MC, Lee H, Song MS, et al.: Activation of kappa-opioid receptors inhibits pruritus evoked by subcutaneous or intrathecal administration of morphine in monkeys. J Pharmacol Exp Ther. 2003; 305(1): 173-179.

Kumagai H, Utsumi J: Endogenous opioid system in uraemic patients. Br J Clin Pharmacol. Abstracts of the Joint Meeting of the Seventh World Conference on Clinical Pharmacology and Therapeutics IUPHAR—Division of Clinical Pharmacology and the Fourth Congress of the European Association for Pharmacology and Therapeutics. 2000; 282.

Okano K, Togashi Y: Anti-pruritic effect of opioid kappa receptor agonist TRK-820. Br J Clin Pha-rmacol. Abstracts of the Joint Meeting of the Seventh World Conference on Clinical Pharmacology and Therapeutics IUPHAR—Division of Clinical Pharmacology and the Fourth Congress of the European Association for Pharmacology and Therapeutics. 2000; 283.

Lugo RA, Kern SE: The pharmacokinetics of oxycodone. J Pain Palliat Care Pharmacother. 2004; 18(4): 17-30.

Poyhia R, Vainio A, Kalso E: A review of oxycodone’s clinical pharmacokinetics and pharmacodynamics. J Pain Symptom Manage. 1993; 8: 63-67.

Lalovic B, Kharasch E, Hoffer C, et al.: Pharmacokinetics and pharmacodynamics of oral oxycodone in healthy human subjects: Role of circulating active metabolites. Clin Pharmacol Ther. 2006; 79(5): 461-479.

Mercadante S: Opioid rotation for cancer pain: Rationale and clinical aspects. Ca,ncer. 1999; 86(9): 1856-1866.

Gaveriaux-Ruff C, Kieffer BL: Opioid receptors: Gene structure and function. In Stein C (ed.): Opioids in Pain Control: Basic and Clinical Aspects. Cambridge, England: Cambridge University Press, 1999, pp. 1-20.

Knapp RJ, Porreca F, Burks TF, et al.: Mediation of analgesia by multiple opioid receptors. In Hill CS, Fields WS (eds.): Advances in Pain Research and Therapy. New York: Raven Press, 1989, pp. 247-289.

Kalso E, Vainio A: Morphine and oxycodone hydrochloride in the management of cancer pain. Clin Phatma-col Ther. 1990; 47(5): 639-646.

Ikoma A, Steinhoff M, Stander S, et al.: The neurobiology of itch. Nat Rev Neurosci. 2006; 7(7): 535-547.

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Published

05/01/2007

How to Cite

Tarcatu, MD, D., C. Tamasdan, MD, N. Moryl, MD, and E. Obbens, MD, PhD. “Are We Still Scratching the Surface? A Case of Intractable Pruritus Following Systemic Opioid Analgesia”. Journal of Opioid Management, vol. 3, no. 3, May 2007, pp. 167-70, doi:10.5055/jom.2007.0055.

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Section

Case Studies