Treatment of side effects of opioids

Respiratory Depression:Clinically the most feared, and potentially life threatening complication of opioid administration. Fear of respiratory depression is one of the most frequent reasons for inadequate analgesia in sickle cell patients. Patients at risk include those with a history of sensitivity toward opioid effects, opioid naive, continuous infusions and smaller children. Those at risk may need continuous pulse oximetry. Treatment is with a titrated amount of naloxone to achieve a normal respiratory rate and not complete reversal of analgesia. This can be done by titrating naloxone doses of 1-5 mcg/kg while supporting oxygentaion and ventilation as needed. If the patient is in respiratory arrest 10 mcg/kg should be administered rapidly IV, with the understanding that it will most likely completely reverse the analgesia.

Nausea: Can be very debilitating and limit opioid dose. Treat aggressively with Metaclopramide, or Ondansetron. May need other agents as well ( promethazine, compazine, Diphenhydramine),

Pruritis: Can be worse than the pain itself. Opioid induced pruritis is very difficult to treat. Most efficacious is low dose opioid antagonist Naloxone or Nalbuphine. These must be used with caution as they can precipitate withdrawal. Also consider diphenhyramine. For extreme cases very low dose propofol in PCA form may be helpful.

Constipation: Aggressive maintanance of bowl function should be sought. This is to include Dolcusate, Metamucil, Senna, Dulcolax suppositories. Enemas should be used for refractory patients.

Somnolence: Usually not a major problem but in severe cases Ritalin, or methamphetamine in low doses has helped.

Sleep disturbance: Patients with insomnia have significantly increased pain scores. Opioids should be continued through the night. Sedatives should be used with caution in patients receiving high dose opioids because of additive effects on respiratory depression. Tricyclic antidepressants in low doses can be used as an aid to sleep.