What are the side effects of chronic opioid (narcotic analgesic) use?

From the Guidelines

Chronic opioid use is associated with several side effects, including constipation, nausea, sedation, respiratory depression, and the development of tolerance and physical dependence, and should be prescribed at the lowest effective dose with regular reassessment of benefits versus risks. The most common side effects of chronic opioid use include constipation, which affects nearly all chronic opioid users, and can be managed with a prophylactic bowel regimen including stool softeners like docusate sodium (100mg twice daily) and stimulant laxatives such as senna (8.6mg daily to twice daily) 1. Nausea typically improves after 1-2 weeks of use, but can be managed with antiemetics like ondansetron 4mg every 6-8 hours as needed. Sedation also usually improves with continued use, but patients should avoid driving or operating machinery until this side effect subsides. Respiratory depression is most concerning during initiation and dose increases, requiring careful monitoring. Long-term use leads to tolerance, where increasing doses are needed for the same effect, and physical dependence, where abrupt discontinuation causes withdrawal symptoms.

Some key points to consider when prescribing opioids for chronic pain include:

• The risks of opioid addiction, which can be increased by factors such as current or past substance-use disorders, psychiatric comorbidities, and family history of these disorders 1
• The importance of regular reassessment of benefits versus risks, and consideration of alternative treatments such as non-opioid pain medications and non-pharmacologic treatments 1
• The need for careful monitoring of patients on chronic opioid therapy, including regular checks for signs of addiction and overdose 1
• The potential for rotation between different opioids to help manage tolerance, but this should be done with caution and under close medical supervision 1

It's also important to note that the development of addiction to opioids is a complex process that involves multiple neurobiological mechanisms, including learning and conditioning, and can be influenced by a range of factors, including genetic predisposition, environmental factors, and individual characteristics 1. Therefore, a comprehensive approach to pain management that takes into account the individual patient's needs and circumstances is essential to minimize the risks associated with chronic opioid use.

From the FDA Drug Label

The potential for these risks should not, however, prevent the prescribing of buprenorphine hydrochloride for the proper management of pain in any given patient Patients at increased risk may be prescribed opioids such as buprenorphine hydrochloride, but use in such patients necessitates intensive counseling about the risks and proper use of buprenorphine hydrochloride along with frequent reevaluation for signs of addiction, abuse, and misuse. Life-Threatening Respiratory Depression Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended. Opioids can cause sleep-related breathing disorders including central sleep apnea (CSA) and sleep-related hypoxemia. Opioid-Induced Hyperalgesia (OIH) occurs when an opioid analgesic paradoxically causes an increase in pain, or an increase in sensitivity to pain.

Chronic Opioid Use Side Effects include:

• Life-threatening respiratory depression
• Sleep-related breathing disorders such as central sleep apnea (CSA) and sleep-related hypoxemia
• Opioid-induced hyperalgesia (increased sensitivity to pain)
• Addiction, abuse, and misuse These side effects can occur with the use of opioids like buprenorphine hydrochloride, even when used as recommended 2.

From the Research

Chronic Opioid Use and Side Effects

• Chronic opioid use can lead to various side effects, including constipation, which should be monitored and managed appropriately, including discontinuation of opioids when indicated 3.
• Long-term opioid therapy should be provided only to patients with proven medical necessity and stability, with improvement in pain and function, independently or in conjunction with other modalities of treatments in low doses with appropriate adherence monitoring and understanding of adverse events 3.
• Opioid use, abuse, and adverse consequences, including death, have escalated at an alarming rate since the 1990s, highlighting the need for responsible opioid prescribing and monitoring 3.

Monitoring and Management

• Monitoring for adherence, abuse, and noncompliance by urine drug testing (UDT) and prescription drug monitoring programs (PDMPs) is essential in managing chronic opioid use 3.
• Patients on methadone should be monitored with an electrocardiogram periodically, and those on long-acting or high-dose opioids should be closely monitored for side effects and adherence 3.
• A comprehensive assessment and documentation, including screening for opioid abuse, should be conducted before initiating opioid therapy 3.

Treatment and Rehabilitation

• Medications such as methadone, buprenorphine, and naltrexone have been demonstrated to be effective for opioid use disorder (OUD) treatment 4, 5.
• Treatment with methadone and buprenorphine has the additional risk of diversion and misuse of medication, highlighting the need for close monitoring and adherence management 5.
• New depot and implant formulations of buprenorphine and naltrexone have been developed to address issues of safety and problems of poor treatment adherence 5.

Screening Tools and Adherence

• Various screening tools are available to monitor opioid adherence, but there is a paucity of literature on their use in pain medicine, and no single best tool has been identified for universal application 6.
• Prospective comparative studies of screening tools are needed to identify the most effective tools for monitoring opioid adherence in chronic non-cancer pain patients 6.