Opioid Adverse Effect Management

Aka: Opioid Adverse Effect Management, Opioid Adverse Effect, Narcotic Side Effect, Opioid-Induced Nausea, Opioid-Induced Constipation

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II. Indications

  1. Cancer Pain Opioid
  2. Chronic Opioid

III. Approach: Pearls

  1. Many Opioid Adverse Effects are predictable and can be prophylaxed
  2. Consider Opioid intolerance as an opportunity to transition back to Non-Opioid Analgesics

IV. 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)
      3. Historically, Docusate (Colace) has been used with this combination, but unlikely to add benefit
  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)

V. 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 (ChemoreceptorTrigger 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)

VI. Adverse Effects: Miscellaneous

  1. Hypogonadism (86% of Chronic Opioid users)
    1. Reduces Testosterone and Estrogen levels
    2. Results in decreased libido, Erectile Dysfunction and irregular Menses
  2. Opioid Analgesic related confusion
    1. Methylphenidate reverses confusion
  3. Opioid reactions
    1. Typically not Allergic Reactions
    2. True Opioid anaphylactic reactions are rare (<1%)
      1. Avoid all Morphine analogs (e.g. Codeine) if opioid Anaphylaxis history
      2. Avoid semi-synthetics (e.g. Hydromorphone, Hydrocodone, Oxycodone) if opioid Anaphylaxis history
      3. Completely synthetic Opioids (e.g. Fentanyl, Methadone) are safe if opioid Anaphylaxis history
    3. Local histamine release is common at the Morphine injection site
      1. Presents at localized erythema and Urticaria, Flushing, itching, sweating
      2. Orthostatic Hypotension may occur
      3. More common with Morphine and Codeine than with more potent Opioids (Fentanyl, Hydrocodone)
  4. 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
    4. Consider alternative Opioid sparing agents in acute pain (e.g. Analgesic dose Ketamine)
  5. Serotonin Syndrome
    1. Synthetic Opioids (esp. Tramadol, Fentanyl, Methadone, Dextromethorphan) are frequent cause
  6. CNS and Respiratory Depression (high dose)
    1. See Opioid Overdose
    2. Risk of death
  7. Psychiatric effects (high dose)
    1. Nightmares
    2. Anxiety
    3. Dysphoria
    4. Major Depression

VII. References

  1. (2018) Presc Lett 25(8)

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