8S/e of opiatesconstipation, nausea, somnolence, itching, dizziness, vomitingTolerance to SE usually occurs within few days,Constipation & itching tend to persistManage with antiemetics (cyclizine), aperients (movicol), antihistaminesRespiratory depression only likely with major changes in dose, formulation or route.Accidental overdose is most likely causeCaution if >1 sedative drug or other disorders of respiratory control ( eg OSA)
9Long-term adverse effects Endocrine impairment in both men and womenHypothalamic-pituitary pituitary-adrenal/ gonadal axis suppression leading to amenorrhoea, infertility, reduced libido, infertility, depression, erectile dysfunction.Immunological effects- in animals, effects on antimicrobial response and tumour surveillance.Opioid induced hyperalgesia - reduce dose, change preparationPregnancy & neonatal effects
10Stopping strong opioid medication Large differences between individuals in susceptibility to, and severity of, withdrawal syndromeSymptoms last up to 72hrs following reduction/withdrawal.Incremental dose reductions 10% -25% depending on patient response and bear in mind half life of preparation
11Recommendations 1:Useful analgesia in the short and medium term. No data to support longer term use.Useful in neuropathic pain too.Complete relief of pain is rarely achieved. The goal should be to reduce pain sufficiently to facilitate engagement with rehabilitation and the restoration of useful function. Use as part of a wider management plan to reduce disability and improve QOL.
12Recommendations 280% of patients taking opioids experience at least one adverse effect. Discuss before treatment! DO NOT USE in pregnancy / children and use with caution in Elderly.Resp. depression commoner if elderly/coprescription / comorbidity e.g. OSA.Withdrawl symptoms – yawning, sweating abdo cramps common with abrupt withdrawl even short courses of tramadol.
13Recommendations 3Educate re long term effects of opioids, particularly in relation to endocrine and immune function. Warn re Steroid induced Hyperalgesia.Do not use as first lineConsider carefully the decision to start long term therapy and make arrangements for long-term monitoring and follow-up.Use modified release opioids for long term use
14Recommendations 4Avoid driving at the start of opioid therapy and following major dose changes. Patients responsibility to advise the DVLA that they are taking opioid medication.Addiction is characterised by impaired control over use, craving and continued use despite harm.