Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition _ ________________
PROTECTING AGAINST OPIOID-INDUCED ADVERSE EVENTS
NALOXONE FOR OPIOID OVERDOSE Naloxone (e.g., Narcan) is an opioid antagonist that quickly reverses the effects of opioid overdose. Naloxone is increasingly available to first responders, patients, and friends and family members of those prescribed opioids, and a generic formulation of nasal-spray naloxone was approved by the FDA in April 2019 [62]. Primary care providers should prescribe naloxone to patients at risk of overdose, including those: • With renal or hepatic dysfunction • Taking opioid doses >50 MMED • Co-prescribed benzodiazepines or other sedating medications • With a history of overdose or OUD • Starting treatment for opioid use disorder
Prophylaxis for constipation (the most common opioid- induced adverse event) has been facilitated by the approval of methylnaltrexone subcutaneous administration and naloxegol oral administration for patients with chronic noncancer pain. Other, less expensive medications like senna and docusate are also effective to guard against constipation (Table 4). Both male and female patients on long-term opioid therapy are at risk for hypogonadism; thus current guidelines suggest that the endocrine function of all patients should be assessed at the start of long-term opioid therapy and at least annually thereafter.
RECOMMENDATIONS FOR PREVENTING OR TREATING OPIOID-INDUCED SIDE EFFECTS
Constipation
Methylnaltrexone or naloxegol Prophylactic mild peristaltic stimulant (e.g., bisacodyl or senna) If no bowel movement for 48 hours, increase dose of bowel stimulant If no bowel movement for 72 hours, perform rectal exam If not impacted, provide additional therapy (suppository, enema, magnesium citrate, etc.)
Nausea or vomiting
Consider prophylactic antiemetic therapy Add or increase non-opioid pain control agents (e.g., acetaminophen) If analgesia is satisfactory, decrease dose by 25% Treat based on cause
Sedation
Determine whether sedation is due to the opioid—if so, lower opioid dose immediately Eliminate nonessential CNS depressants (such as benzodiazepines) Reduce dose by 20-30% Add or increase nonopioid or nonsedating adjuvant for additional pain relief (such as NSAID or acetaminophen) so the opioid can be reduced Change opioid Prescribe naloxone
Pruritus
Consider treatment with antihistamines Change opioid Evaluate underlying cause Eliminate nonessential CNS acting medications
Hallucination or dysphoria
Sexual dysfunction Reduce dose
Testosterone replacement therapy may be helpful (for men) Erection-enhancing medications (e.g., sildenafil)
Source: [61]
Table 4
16
MDUT1125
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