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Submitted by Dr S. Patel on 10 July 2019
An open and fallen bottle of pills spilt on the table

Opioids are essential to pain management in patients with chronic and severe pain. Since they are narcotic medications and have side-effects, it is important for patients and caregivers to be aware of the type of Opioid that has been prescribed and possible adverse reactions. Excerpted from Indian Primer of Palliative Care by Pallium India. 

Opioids are a class of drugs that are used in pain management in patients with chronic and debilitating pain. They work by binding to opioid receptors in the nerve cells thus relieving pain.

The World Health Organization classifies Opioids as weak or strong. Here is a generic list of both that is actively used by doctors to manage severe pain which is not resolved by over-the-counter drugs.

WEAK

STRONG

Codeine
Tramadol

Morphine
Fentanyl
Pethidine
Oxycodone
Hydromophone
Methadone

Weak or mild opioids are widely available and often in combination with paracetamol. Most of these drugs are offered as oral pills. Fentanyl is available in a patch which allows slow release of medication through the skin. Opioid drugs are available on prescription only because they have the potential to cause dependence, addiction and overdose incidents.

Management of Opioid side-effects

Since opioids are narcotic medications, side-effects can be grave if not used correctly. These side-effects should be recognized and addressed right away by the family members or care providers. Make sure you inform your doctor about all adverse effects cause by the pain management drugs. Do not stop taking medication abruptly without consulting your doctor to avoid having withdrawal symptoms.

Below are listed the common side-effects and few tips on how patients and their care providers can manage them at home.

Common Side effects

Management at home

Constipation

Increase fluid and fiber intake. Stool softeners/ laxatives/ lubricant (liquid paraffin)/ are to be used. Bulk-forming laxatives are unsuitable for opioid-induced constipation.

Nausea and vomiting

Usually resolves in a week. Prophylactically anti-emetics can be given for first 3 days of opioid therapy.

Sleepiness and tiredness

Usually resolves in a week. Ask your doctor about dose reduction.

Dry mouth

Mouth care is essential, gargle with soda bicarbonate several times a day.

Urinary hesitancy

Use the restroom to empty the bladder when possible. Avoid excess fluid intake 2-3 hours before bedtime.

Itching

Keep skin moist with moisturisers. Aloe vera helps reduce itching and redness and gives a cooling effect. Use Anti-histamines if required.

Opioid Tolerance vs Dependence vs Addiction

When taken regularly, the effects of the same amount of drug can reduce overtime. The body develops tolerance for that specific drug dosage such that larger amount is required to achieve the same pain relief. When opioids are used repeatedly and over a long period of time, tolerance is likely to develop.

Use of opioids over an extended period of time can make the body become accustomed to it, thus causing dependence. In such situations, any sudden break in use of the drug can lead to withdrawal symptoms such as diarrhea, nausea, vomiting, anxiety, low moods, irritability, pain etc.

If opioid consumption becomes a compulsive behavior despite its negative effects on the body, it is called Addiction. Addiction is rarely seen in chronic pain patients and mostly prevalent in recreational opioid users.

In cancer, patients often develop tolerance to opioid medication requiring higher and higher doses for their pain relief. This leads to dependence due to chronic use, but rarely do patients become addicted.

In cancer, patients often develop tolerance to opioid medication requiring higher and higher doses for their pain relief. This in addition leads to dependence due to chronic use, but rarely do patients become addicted.

Signs of Opioid overdose

An overdose can be life-threatening and is a medical emergency! The symptoms of overdose are undue drowsiness, vomiting, confusion, myoclonus( involuntary muscle spasm), delirium and hallucinations. Patients may have pin point pupils with morphine overdose. Contrary to popular belief, respiratory depression is not common with oral morphine unless there is a deliberate or accidental overdose. Adequate hydration is important for managing states of overdose. Seek medical attention immediately if you notice any signs of an overdose.

Myths and facts about Morphine

Fearing addiction and unwanted side-effects, strong opioids such as morphine are not readily welcome into the treatment plan for patients in India. World over, morphine is widely used to manage pain. Pallium India explores these common myths about morphine and presents the facts.

MYTHS

FACTS

Respiratory depression is common with regular use of step 3 drugs.

Respiratory depression is very rare if the analgesic dose is appropriately titrated for pain relief.

All patients on morphine become addicted to them.

The chance of addiction with good monitoring is low.

It should be used for managing pain only in terminal illness.

Choosing the drug should be based on severity of pain and not on the stage of the disease.

Step 3 drugs are expensive drugs.

Morphine and methadone are among the least expensive medicines. Transdermal fentanyl is expensive.

The therapeutic range is narrow and toxic effects occur within the therapeutic range.

Oral formulations of morphine have wide range of therapeutic efficacy and do not have ceiling effect. The dose may be gradually increased and individualized.

Citations:

  1. Rajagopal MR, Vallath N, Mathews L, Rajashree KC. Watson M (ed). An Indian Primer of Palliative Care. 2017.
  2. Morgan MM and MacDonald C. Analysis of opioid efficacy, tolerance, addiction and dependence from cell culture to human. Br J Pharmacol. 2011 Oct; 164(4): 1322–1334.