Opioid risk assessment in palliative medicine

Abstract

Palliation of severe pain at the end of life is probably the most widely accepted indication for chronic opioid therapy. At increased doses, adverse effects of opioids may limit or interfere with the benefits of treatment. Careful screening and follow-up will allow risk factors to be recognized and addressed when possible. The use of adjunctive treatments for pain may reduce opioid requirements and yield better outcomes.

Opioid risk assessment in palliative medicine

“…Te side efects that carry the greatest risk include central nervous system toxicity (sedation, cognitive impairment, and increased risk of falls), addiction, constipation, and respiratory depression. 12 Medical risks. Opioid-induced sedation is considered an adverse efect in most situations because of its often signifcant impairment of patient function.…”

“…Sedation risks are increased when patients have underlying risk factors for falls or unsteadiness, such as advanced age or cognitive impairment. 12 Patients older than 60 years who are on daily opioid therapy have a signifcantly increased risk of fall and fracture. Patients taking higher doses (>50 mg morphine equivalents/day) are twice as likely to sustain a fracture compared with those who are no longer taking opioids.…”

“…Use of concurrent sedating medications should be carefully monitored, and lowest dose or alternate therapy should be used whenever possible. 12 Opioid-induced respiratory depression is closely related to sedation and is defned as decreased ventilation after use of opioid medications. Opioid-induced sedation typically precedes opioid-induced respiratory depression and exists on the same clinical spectrum.…”

“…Patients on multiple sedating medications, with underlying respiratory disease, or on very high doses of opioids should be monitored closely as they can be considered high-risk patients. 12,16 Opioid-induced constipation is an adverse efect of opioids for which tolerance does not develop. It is experienced by almost all patients because of the mu-agonist efects of opioids in the gut.…”

“…17 Like other opioid adverse efects, concurrent use of additional medications, such as anticholinergics and chemotherapy agents, can have an additive efect on constipation. 12 Te stool habits in any patient on opioid medications, regardless of dose or length of treatment, should be carefully monitored. Bowel management regimens should be initiated simultaneously with opioid therapy.…”