Opioids
Opioids
Opioids
Introduction to opioids
Opioids are commonly used in the context of pain and palliative care.
Junior doctors will often be asked prescribe these drugs and whether it is starting a patient on it for the
first time, or writing up an admitting drug chart it is helpful to understand a bit more about opioids and
what adverse effects to look out for.
Pharmacology of opioids
Types of Opioids
o Natural opiates: codeine, morphine
o Semi-synthetic opioids: oxycodone, hydrocodone, diamorphine, buprenorphine
o Synthetic opioids: methadone, fentanyl
Morphine Metabolism
o Opiates are predominantly metabolised by the liver where they undergoes 1st pass metabolism
o 2 main metabolites are M3G and M6G (morphine-3 or 6-glucononide)
o Well tolerated in patients with mild to moderate hepatic impairment
o Morphine metabolites are then excreted by the kidneys
Caution in patients with renal impairment as the metabolite will not be excrete as fast
leading to risk of overdose over time
Prescribing opioids
Cautions with morphine (i.e. you can still prescribe it but be aware of how its effect might be different)
Caution in patients with renal and hepatic impairment (not excreted so quickly – more risk of overdose)
Caution in the elderly (tend to need lower doses, more inclined to become delirious with opiates)
Caution in inflammatory bowel disorders (may increase complication rate including toxic megacolon)
Caution in obstructive airways disease (can lead to respiratory depression, risking CO2 retention)
Caution in epilepsy (may lower the seizure threshold - uncommon)
Side effects of morphine
Once started on an opioid remember to regularly review for common side effects which include the list
below (the * indicates toxicity: immediately review and discussion with specialist palliative care team)
Constipation and nausea
Dry mouth
Confusion*
Drowsiness *
Myoclonus *
Hallucinations *
Pinpoint pupils * (can be present in chronic opioid use)
Respiratory depression if severe (RR<8) *
Severe pain:
o Morphine Sulphate IR (oramorph) 5mg 4-6 hourly regularly (i.e. QDS or six times per day)
AND
o Morphine Sulphate IR (oramorph) 5mg PRN max 2 hourly
NB. if starting a regular opioid remember to start a laxative (e.g. Macrogol I sachet BD orally)
Toxicity
This is quite commonly seen in the acute hospital setting or on the wards. The basic steps in management
are the same but they differ slightly in naloxone dosing:
2. Opioid toxicity in patients who are not on regular long term opioids
Assess from an ABCD perspective as above
Stop any opioids that have been recently started – remember to look for any new patches
If there is evidence of reduced GCS and respiratory depression (see above) you will need to give naloxone
to reverse the toxic effects
o The dose of naloxone recommended by the BNF for patients not on long-term opiates is 400
micrograms to 2mg via intravenous injection
o If there is no response, the initial 400mcg dose can be repeated at intervals of two to three
minutes to a maximum of 10mg