Why do Pain Physicians Not Routinely Use Mixed Opioids for the Prevention of Neuraxial Opioid-induced Pruritus?
Borja Mugabure Bujedo*
Identifiers and Pagination:Year: 2017
First Page: 14
Last Page: 21
Publisher Id: TOPAINJ-10-14
Article History:Received Date: 20/12/2016
Revision Received Date: 14/02/2017
Acceptance Date: 17/02/2017
Electronic publication date: 31/05/2017
Collection year: 2017
open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Pruritus is a very disturbing secondary effect that appears after epidural or intrathecal administration of opioid drugs, especially in the management of postoperative pain. It is induced by the activation of mu opioid receptors and it can often be even more unpleasant than the pain being treated.
A wide variety of drugs with different mechanisms of action have been used, aiming at the prevention of pruritus, with varying results. The aim of this comprehensive review letter is to summarize the current evidence of the available pharmacological options to either treat or prevent pruritus induced by spinal opioids.
The articles used in the review were found through a search in Medline, PubMed and Cochrane Library up to December 2016, using the keywords “Neuraxial opioids”, “Intrathecal morphine”, “Pruritus”, “Naloxone”, “Nalbuphine” and “Butorphanol”.
The most useful drugs act on the mu and kappa opioid receptors. They are either mu opioid antagonists, like intravenous naloxone, or mixed opioids mu antagonists/kappa agonists, such as intravenous nalbuphine and intravenous or epidural butorphanol, the latter being able also for maintaining the analgesia.
Both pruritus prevention and treatment remain a challenge in the treatment of patients receiving spinal opioids for postoperative pain. Recent findings suggest that mixed opioids must be added to evidence-based clinical guidelines for the management of pruritus induced by spinal opioids.