DRUG TREATMENT - Opioids - General Info
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A general strategy to minimize adverse effects:
1. Adverse effects can usually be minimized through the use of low starting doses, slow titration rates, prophylactic and symptomatic treatments, and specific patient education provided at initiation of therapy.
2. Symptomatic treatment should be augmented with slow dosage titration, dose modification, and/or opioid rotation to minimize the adverse effects as follows:
Constipation:
4. Initial bowel regimens should generally consist of a bowel stimulant and a stool softener as well as general measures, such as increased fluid intake, increased dietary fiber, and adequate exercise.
5. Routinely initiate a stimulant-based bowel regimen at commencement of chronic opioid therapy.
6. If the initial regimen is inadequate, mild hyperosmotic, saline, and emollient laxatives may be added.
7. If possible, reduce or discontinue other drugs that may cause or contribute to constipation.
8. Bulk-producing laxatives, such as psyllium and polycarbophil, are not recommended and are relatively contraindicated as they may exacerbate constipation and lead to intestinal obstruction in patients with poor fluid intake.
9. Assess patients for constipation symptoms at every office visit.
Nausea and vomiting:
10. Consider prophylactic antiemetic therapy at initiation of therapy.
11. Rule out other causes of nausea, and/or treat based on cause including
12. Rule out an allergic reaction.
13. Itching may resolve spontaneously despite continuation of opioid therapy. If the itching does not spontaneously resolve, consider treatment with antihistamines.
Sedation:
14. Rule out other causes.
15. Reduce dose (with or without addition of a co-analgesic). Excessive sedation within the first few days of initiating opioids may require temporarily holding one or two doses and restarting at a lower dose to prevent respiratory depression.
16. Add or increase non-opioid or non-sedating adjuvant for additional pain relief so that the opioid can be reduced.
17. If the above measures fail to relieve sedation adequately, consider rotating to another opioid agent.
18. Consider adding caffeine or a prescription psychostimulant medication.
Confusion or Minor deterioration of cognitive function:
19. Rule out other causes.
20. Consider reducing or stopping (tapering) the dose.
21. Add or increase non-opioid or non-sedating adjuvant for additional pain relief so that the opioid can be reduced.
22. Rotate opioid agent.
23. If patient continues to deteriorate during titration phase and presents with symptoms of delirium, opioid therapy should be discontinued.
24. If patient develops increased confusion or major cognitive changes (delirium) during the maintenance phase, consider hospitalization to investigate the cause and to continue treatment safely.
1. Adverse effects can usually be minimized through the use of low starting doses, slow titration rates, prophylactic and symptomatic treatments, and specific patient education provided at initiation of therapy.
2. Symptomatic treatment should be augmented with slow dosage titration, dose modification, and/or opioid rotation to minimize the adverse effects as follows:
- Titrate slowly, temporarily reducing or holding doses if necessary, or modify the dosage regimen to allow the patient to develop tolerance to the adverse effects
- If these measures fail to minimize the adverse effects, consider rotating to another opioid agent
Constipation:
4. Initial bowel regimens should generally consist of a bowel stimulant and a stool softener as well as general measures, such as increased fluid intake, increased dietary fiber, and adequate exercise.
5. Routinely initiate a stimulant-based bowel regimen at commencement of chronic opioid therapy.
6. If the initial regimen is inadequate, mild hyperosmotic, saline, and emollient laxatives may be added.
7. If possible, reduce or discontinue other drugs that may cause or contribute to constipation.
8. Bulk-producing laxatives, such as psyllium and polycarbophil, are not recommended and are relatively contraindicated as they may exacerbate constipation and lead to intestinal obstruction in patients with poor fluid intake.
9. Assess patients for constipation symptoms at every office visit.
Nausea and vomiting:
10. Consider prophylactic antiemetic therapy at initiation of therapy.
11. Rule out other causes of nausea, and/or treat based on cause including
- Stimulation of chemoreceptor trigger zone: dopamine or serotonin antagonist
- Slowed GI motility: metoclopramide
- Nausea associated with motion: dimenhydrinate or scopolamine.
12. Rule out an allergic reaction.
13. Itching may resolve spontaneously despite continuation of opioid therapy. If the itching does not spontaneously resolve, consider treatment with antihistamines.
Sedation:
14. Rule out other causes.
15. Reduce dose (with or without addition of a co-analgesic). Excessive sedation within the first few days of initiating opioids may require temporarily holding one or two doses and restarting at a lower dose to prevent respiratory depression.
16. Add or increase non-opioid or non-sedating adjuvant for additional pain relief so that the opioid can be reduced.
17. If the above measures fail to relieve sedation adequately, consider rotating to another opioid agent.
18. Consider adding caffeine or a prescription psychostimulant medication.
Confusion or Minor deterioration of cognitive function:
19. Rule out other causes.
20. Consider reducing or stopping (tapering) the dose.
21. Add or increase non-opioid or non-sedating adjuvant for additional pain relief so that the opioid can be reduced.
22. Rotate opioid agent.
23. If patient continues to deteriorate during titration phase and presents with symptoms of delirium, opioid therapy should be discontinued.
24. If patient develops increased confusion or major cognitive changes (delirium) during the maintenance phase, consider hospitalization to investigate the cause and to continue treatment safely.