DRUG TREATMENT - Opioid Complications
Complex Persistent Opioid Dependence” (CPOD)
--Insistence/Need to continue opioids or increase opioid dose for pain despite caution regarding:
  • Minimal or no efficacy
  • Complex behavioral and social patterns around opioids (what is characterized as opioid seeking, misuse/abuse, etc.)
  • Safety issues
  • Increased “opioid related morbidity and mortality”
  • Increased psychiatric morbidity
  • Increased overall morbidity and mortality
--Treatment possibilities with primary focus on dependence (dependence is the main driver of pain), noting that abstinence oriented treatment (taper) often worsens the situation
  • Medication treatment of dependence
  • Buprenorphine is a useful agent in this setting.
​Checkout below a marvelous discussion on CPOD and approach to its management.
​Impaired Respiration:
  • Respiratory depression is the chief hazard of all opioid preparations. Respiratory depression occurs most frequently in the elderly and debilitated patients as well as in those suffering from conditions accompanied by hypoxia or hypercapnia when even moderate therapeutic doses may dangerously decrease pulmonary ventilation.
  • Opioids should be used with extreme caution in patients with chronic obstructive pulmonary disease or cor pulmonale, and in patients having a substantially decreased respiratory reserve, hypoxia, hypercapnia, or pre-existing respiratory depression. 
Drug Interactions:
  • The concomitant use of other central nervous system depressants including sedatives or hypnotics, general anesthetics, phenothiazines, tranquilizers and alcohol may produce additive depressant effects. Respiratory depression, hypotension and profound sedation or coma may occur. When such combined therapy is contemplated, the dose of one or both agents should be reduced. 
  • Opioid analgesics may enhance the neuromuscular blocking action of skeletal muscle relaxants and produce an increased degree of respiratory depression.
Opioid OD Antidote (naloxone):
  • The pure opioid antagonist naloxone, is a specific antidote against respiratory depression which results from opioid overdose. 
  • Dose (usually 0.4 to 2 mg) should be administered intravenously (intranasal route may also be effective); 
  • Because duration of action is relatively short, the patient must be carefully monitored until spontaneous respiration is reliably re-established. If the response to naloxone is suboptimal or not sustained, additional naloxone may be administered, as needed, or given by continuous infusion to maintain alertness and respiratory function.
  • Naloxone should not be administered in the absence of clinically significant respiratory or circulatory depression secondary to morphine overdose. 
  • Naloxone should be administered cautiously to persons who are known, or suspected to be physically dependent on morphine sulfate extended-release tablets. In such cases, an abrupt or complete reversal of narcotic effects may precipitate an acute abstinence syndrome.
Acute Abstinence Syndrome (withdrawal):
  • The opioid agonist abstinence syndrome is characterized by some or all of the following: restlessness, lacrimation, rhinorrhea, yawning, perspiration, gooseflesh, restless sleep or “yen” and mydriasis during the first 24 hours. 
  • These symptoms often increase in severity and over the next 72 hours may be accompanied by increasing irritability, anxiety, weakness, twitching and spasms of muscles; kicking movements; severe backache, abdominal and leg pains; abdominal and muscle cramps; hot and cold flashes, insomnia, nausea, anorexia, vomiting, intestinal spasm, diarrhea; coryza and repetitive sneezing; increase in body temperature, blood pressure, respiratory rate and heart rate. Because of excessive loss of fluids through sweating, vomiting and diarrhea, there is usually marked weight loss, dehydration, ketosis, and disturbances in acid-base balance. Cardiovascular collapse can occur. 
  • Without treatment most observable symptoms disappear in 5 to 14 days; however, there appears to be a phase of secondary or chronic abstinence which may last for 2 to 6 months characterized by insomnia, irritability, and muscular aches.