Management of opioid related side effects

Most common side effects are predictable consequences of opioid pharmacological actions and include nausea, vomiting, constipation, pruritus, dizziness, dry mouth and sedation

• Opioid-associated side effects should be anticipated and appropriate counselling about common side effects and their management should be provided to patients before the first prescription.
• Tolerance to many side effects usually occurs within the first few days of initiating treatment; however, unlike other side effects pruritus and constipation tend to persist throughout treatment.
• Common gastrointestinal side effects should be predicted, and prophylactic treatments considered if appropriate.
• A small supply of an anti-emetic (e.g., cyclizine, prochlorperazine) may be beneficial when providing the initial prescription of an opioid.
• Encouraging the patient to drink lots of fluid, and to eat additional fruit and fibre may minimise constipation, however a combination of stool softener (e.g., docusate sodium) and a stimulant laxative (e.g., senna or bisacodyl) is often necessary.
• Peripherally restricted opioid antagonists (such as oral naloxegol, oral prolonged release naloxone in combination with prolonged release oxycodone, and subcutaneous methylnaltrexone) have modest benefit for improving constipation when compared with placebo, however there are many fewer data compared with regular optimal laxative therapy and lifestyle advice. These products have a limited place in the management of opioid induced bowel symptoms and constipation after an adequate trial of other options.
• Central side effects, such as drowsiness and dizziness, also tend to improve gradually after opioid initiation, however patients should be counselled about the possible effects on driving and other skilled tasks involving co-ordination and concentration when initiating or increasing an opioid dose.
• Patients should be warned of the likelihood of enhanced effects and risks associated with concomitant use of other medicines and substances with sedative properties, including alcohol.

Further Reading

• The National Institude for Health and Care Excellence (NICE). Naldemedine for treating opioid-induced constipation. Technology appraisal guidance [TA651], 2020.
• Chey WD, Webster L, Sostek M, et al. Naloxegol for Opioid-Induced Constipation in Patients with Noncancer Pain.  New England Journal of Medicine 2014; 370: 2387-2396.
• Simpson K, Leyendecker P, Hopp M, et al. Fixed-ratio combination oxycodone/naloxone compared with oxycodone alone for the relief of opioid-induced constipation in moderate-to-severe noncancer pain. Current Medical Research and Opinion 2008; 24:  3503-3512.
• Twycross R, Sykes N, Mihalyo M, et al. Stimulant laxatives and opioid-induced constipation. Journal of Pain and Symptom Management. 2012; 43: 306-13.
• Anastassopoulos KP, Chow W, Tapia CI, et al. Economic study on the impact of side effects in patients taking oxycodone controlled release for noncancer pain. Journal of Managed Care Pharmacy 2012; 18: 615-26.
• Annemanns L. Pharmacoeconomic impact of adverse events of long-term opioid treatment for the management of persistent pain. Clinical Drug Investigation 2011; 31: 73-86.