Russell Portenoy, MD is Executive Director of the MJHS Institute for Innovation in Palliative Care and Chief Medical Officer of MJHS Hospice and Palliative Care. He is a Professor of Neurology and Family and Social Medicine at the Albert Einstein College of Medicine. Prior to joining MJHS, Dr. Portenoy was founding Chairman of the Department of Pain Medicine and Palliative Care and the Gerald J. Friedman Chair in Pain Medicine and Palliative Care at Beth Israel Medical Center, New York. Dr. Portenoy is past-president of the American Academy of Hospice and Palliative Medicine and past-president of the American Pain Society. He previously chaired the American Board of Hospice and Palliative Medicine. In 2013, Dr. Portenoy was elected one of 30 “Visionaries” in palliative care by the membership of the American Academy of Hospice and Palliative Medicine. He has received the 2015 Galen Miller Leadership Award of the National Hospice and Palliative Care Organization and the 2016 Ventafridda Award of the European Association for Palliative care. He is a past recipient of the Lifetime Achievement Award and the National Leadership Award of the American Academy of Hospice and Palliative Medicine, has received both the Wilbert Fordyce Award for Lifetime Excellence in Clinical Investigation and the Distinguished Service Award from the American Pain Society, and was given the Founder’s Award by the American Academy of Pain Medicine. Dr. Portenoy has been Editor in Chief of the Journal of Pain and Symptom Management for three decades, co-edits the Oxford Textbook of Palliative Medicine, and is editor for the palliative care section of The Oncologist. He has written, co-authored, or edited 21 books and more than 525 papers and book chapters on topics in pain and symptom management, opioid pharmacotherapy, and palliative care.
Side Effects and Drug Abuse: Managing Opioid Risk
Opioid risk comprises side effects and substance abuse outcomes. The most common side effects are gastrointestinal and neurological; less common are itch, urinary retention, sleep-disordered breathing, and QTc prolongation (methadone). Conventional treatments for constipation include bulk laxatives, osmotic laxatives, stool softeners, and stimulants. Newer therapies include probiotics, peripherally-acting opioid antagonists (e.g., methylnaltrexone and naloxegol) and chloride channel stimulants (e.g., linaclotide and lupiprostone). Treatment of constipation remains empirical. Somnolence/mental clouding may be treated in the appropriate setting; there are limited data supporting stimulants (e.g., methylphenidate or modafinil). Neuroendocrine effects are prevalent and hypogonadism deserves treatment in highly selected cases. Opioid-induced itch occurs infrequently, and there are no evidence-based therapies. Drugs used empirically include H1 antagonists, H2 antagonists, 5HT3 antagonists, SSRIs, mirtazapine, and the gabapentinoids. Opioid-induced sleep disordered breathing can be a significant concern in some patients, and when appropriate, a sleep apnea syndrome should be managed. Guidelines for managing QTc prolongation during methadone therapy have been proposed; most important, treatment is typically withheld if the QTc is >500ms. All opioids are potentially abusable and palliative care specialists should be able to recognize, assess, and manage drug abuse phenomena. Physical dependence (the potential for abstinence) and tolerance (declining drug effect induced by exposure to the drug) are physiologic outcomes and uncommonly pose clinical problems. Drug abuse is an imprecise term referring to any drug use outside of socially accepted norms, and addiction is a complex disease, defined in various ways. Defined as as a primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations, addiction is characterized behaviorally by the “4 C’s”: craving, compulsive use, loss of control, and continued use despite harm. Drug abuse and addiction can be recognized if clinicians monitor drug-related behaviors. Aberrant drug-related behaviors are those that raise concerns about abuse, addiction or diversion. The term, pseudoaddiction, implies that aberrant behaviors reflect desperation about pain. Diversion is a legal term indicating transfer of a controlled drug to the illicit marketplace. To manage these outcomes in the medically ill, a “universal precautions” approach can be recommended. This 5-step approach includes assessing and stratifying risk, choosing to prescribe or not to prescribe, monitoring adherence to minimize risk, monitoring drug-related behaviors over time, and responding appropriately to aberrant drug-related behavior. When aberrant behavior noted, the clinician should assess and diagnose it, and then change therapy to minimize future harms.
