Opioid Adverse Effect Management

1. See Also
   1. Opioid
   2. Bowel Regimen in Chronic Narcotic Use
   3. Narcotic Overdose
2. Indications
   1. Cancer Pain Opioid
   2. Chronic Opioid
3. Pearls
   1. Many Opioid adverse effects are predictable and can be prophylaxed
4. Adverse Effects: Constipation
   1. Begin Bowel regime concurrently with Narcotics
      1. See Bowel Regimen in Chronic Narcotic Use
      2. Sample protocol
         1. Polyethylene glycol solution (Miralax) and
         2. Peristaltic stimulant (senna alkaloid) with or without Docusate (Colace)
   2. Consider other Constipation Causes
      1. See Constipation in Cancer
   3. Precautions
      1. Fecal Impaction may present as overflow Diarrhea
      2. Regular stooling for comfort should still be maintained even as intake decreases
      3. Reevaluate Anticholinergic Medications that further provoke Constipation
   4. Refractory cases in cancer patients
      1. Methylnatrexone (Relistor)
5. Adverse Effects: Nausea or Vomiting
   1. See Nausea in Cancer
   2. Types
      1. Initial Nausea when starting medication
         1. Consider Antiemetic for first 3-5 days
      2. Persistent Nausea on starting Opioid (Chemoreceptor trigger zone stimulation)
   3. Antiemetics
      1. 5-HT3 Receptor Antagonist (e.g. Ondansetron or Zofran)
      2. Phenothiazines (e.g. Prochlorperazine)
      3. Dimenhydrinate (Dramamine)
      4. Metoclopramide (Reglan)
6. Adverse Effects: Miscellaneous
   1. Reverse Narcotic Analgesic related confusion
      1. Methylphenidate
   2. Opioid reactions
      1. Typically not Allergic Reactions
      2. Local histamine release is common at the morphine injection site
         1. Presents at localized erythema and Urticaria
   3. Opioid induced neuroexcitation (Opioid Toxicity response)
      1. May present as hyperalgesia, Delirium. or Myoclonus
      2. Masquerades as increasing pain and common mistaken approach is to increase Opioid dose
      3. Management strategy is to decrease the Opioid dosing or rotate Opioids