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Constipation and hyperalgesia: case report A 66-year-old woman developed constipation during treatment with oxycodone, and she developed hyperalgesia during treatment with oxycodone and methadone for chronic pain [durations of treatments to reactions onsets not stated]. The woman was hospitalised in October 2018 to undergo elective orthopedic spinal surgery for post-traumatic kyphosis. She had injured her back after falling down a flight of stairs in October 2015, which had further aggravated by a recurrent fall in January 2016. Her falls caused an L2 compression fracture, which progressed to L2 vertebra collapse with kyphosis and spinal stenosis. She reported nociceptive lower back pain, which gradually worsened. Between January 2016 and October 2018, she transitioned from not using any opioid medications to consuming oxycodone 70mg daily (oxycodone 30mg controlled release, twice daily, with additional oxycodone 10mg immediate release as required). She subsequently developed constipation secondary to oxycodone. The woman regularly required laxatives [specific drugs not stated] for constipation. Also, there were concerns regarding opioidinduced hyperalgesia, given her progressive pain in spite of increasing oxycodone doses prior to hospitalisation. She underwent surgery under general anaesthesia on the day of admission, without complications. She received multiple medications through her hospital stay, and oxycodone was continued throughout the perioperative phase. Her back pain persisted after her surgery, which necessitated escalation of opioid doses. The pain was functionally debilitating, and it interfered with ambulation and self-care. She required oxycodone 135–205mg daily (30mg extended release, three times daily, with supplemental immediate-release doses as required). Since increasing doses of oxycodone resulted only in a partial effect, she started receiving oral methadone 5mg three times daily on post-operative day 9 (POD 9). Regular doses of extended release oxycodone were discontinued, while she continued receiving immediate-release oxycodone 5–10mg every 3 hours as required. On POD 13, the dose of methadone was titrated to 8mg three times daily. She continued receiving oxycodone 60–80mg daily alongside methadone 24mg daily. The Complex Pain and Addiction Consult Service was consulted due to the escalating opioid use and poorly controlled postoperative pain. Due to the concerns regarding opioid-induced hyperalgesia, a transition from oxycodone and methadone to buprenorphine/naloxone was decided, using a rapid microdosing induction (off-label use). On POD 21, the dose of methadone was decreased to 6mg three times daily, to reduce the risk of precipitated opioid withdrawal with buprenorphine/naloxone induction, and on POD 22, she started receiving a rapid, 3-day microdosing titration of buprenorphine/naloxone. She received sublingual buprenorphine/naloxone tablet 0.25mg/0.0625mg every 3 hours for eight doses, followed by 0.5mg/0.125mg every 3 hours for eight doses, and 1mg/0.25mg every 3 hours for ei