Managing pain

Opioids in palliative care: 5 tips for reducing side effects

Nausea and sedation are common, but physicians should also be alert to complications like opioid-induced neurotoxicity.


Hospice patients who take opioid medications for pain commonly experience nausea, constipation, sedation. The possibility of these side effects means physicians need to be extra vigilant when using opioids as part of palliative care, according to Gerald Turgeon, DO, a hospice and palliative care specialist who’s medical director of Treasure Coast Hospice in Fort Pierce, Florida.

Dr. Turgeon recently discussed common side effects of opioids and how to treat them during a presentation at OMED 2015 in Orlando. Here are five key takeaways.

1. Sedation often resolves after several days.

Patients who are just starting to take opioids can show signs of sedation, Dr. Turgeon said, noting it’s especially common with morphine. Patients usually develop a tolerance within several days. Physicians can address the problem by reducing the opioid dose or giving the patient a stimulant such as methylphenidate or modafinil for about a week.

2. Constipation is a ‘nearly universal’ side effect.

All patients who are prescribed opioids should have protocols in place to ward off constipation. “This is something you have to constantly be questioning patients about,” Dr. Turgeon noted. “Many times they are embarrassed and won’t offer the information.”

3. Use caution with patients who have kidney or liver problems.

For patients with liver dysfunction or failure, Dr. Turgeon said, codeine is not recommended. Fentanyl is the safest option, since it has no active metabolites. Morphine, oxycodone, hydrocodone and hydromorphone should be used with caution.

Patients with renal dysfunction or failure should not take codeine or morphine, Dr. Turegon said. Fentanyl and methadone are the safest options, while oxycodone and hydromorphine should be used with caution.

4. Nausea and vomiting aren’t uncommon.

Dr. Turgeon estimated that one-third of patients taking opioids experience nausea or vomiting. He recommends using haloperidol to combat these side effects; metoclopramide, compazine and chlorpromazine are also options.

5. Opioid-induced neurotoxcitiy is a dangerous and frequently missed side effect.

Opioid-induced neurotoxicity is a risk for patients who’ve been taking high doses of opioids or who’ve just had a large increase in dosage. Dehydration, advanced age and renal failure are also risk factors. The condition is marked by agitation, seizures, and myoclonus, or muscle spasms.

“If the patient develops myoclonus, it’s a red flag to be very cautious and look for alternatives to the opioid they’re taking,” Dr. Turgeon explained. “Opioid-induced neurotoxicity is missed a lot, even by doctors who do a lot of hospice work. But if you keep escalating the opioid dose for these patients, they can die sooner than they would have otherwise.”

Patients with opioid-induced neurotoxicity should be given benzodiazepines to calm the central nervous system and switched to methadone or fentanyl in place of the opioid that triggered the problem. The current opioid should be stopped, not tapered. If there’s no alternative opioid, scale back to 25% of the current dose.

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