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In clinical medicine, the conditions that demand our greatest attention are those that are common, serious or treatable. Opioid-induced neurotoxicity (OIN) satisfies all three criteria. Yet OIN, as a toxicity cluster, remains inadequately researched. The rapid review by Le Bihan and colleagues synthesises the evidence for OIN in the palliative care population.1 It reveals the extent of what we still do not know: OIN is inadequately acknowledged, inconsistently measured and under-researched. Part of the problem is that OIN frequently presents like disease progression or natural dying, especially with sedation and hypoactive delirium, leading to missed or delayed OIN recognition.2