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The mechanisms by which opioids cause these adverse effects are not always completely understood.

Sex, race, and increasing age are all factors shown to influence the development of adverse effects.4 Reductions in renal function associated with aging may lead to accumulation of opioids and their metabolites.5 To reduce the risk of developing adverse effects, downward dose adjustments or prolonging the opioid interval should be anticipated for persons older than 70 years.16 The EAPC working group identified four general approaches to consider when encountering adverse effects caused by opioids: dose reduction of systemic opioid, symptomatic management of the adverse effect, opioid rotation, and switching the route of systemic administration.3If pain is well controlled, small reductions in the dose of opioid may help resolve the adverse effect while maintaining pain control.3 Addition of nonopioid analgesics, use of adjuvant agents (e.g., tricyclic antidepressants), or treatments directed toward the source of pain are all options for providing a synergistic approach to pain management.3Opioids have subtle differences in binding to the mu, kappa, and sigma receptors; the clinical effects can vary from one agent to another.78 Opioid rotation is a concept in which one opioid is exchanged for another to improve pain control or manage certain adverse effects.

However, one common approach is the scheduled use of senna with or without a stool softener.13 If patients do not have an adequate response, a trial of an osmotic agent (e.g., sorbitol) may be used. Addition of ultralow dose naloxone to postoperative morphine PCA: unchanged analgesia and opioid requirements but decreased incidence of opioid side effects.

Bulk-forming laxatives also are an option, although these agents require adequate fluid intake that may not be appropriate in all patient populations.19 Periodic use of saline laxatives or administration of suppositories or enemas may be needed. Agents used for diarrhea, constipation, and inflammatory bowel disease; agents used for biliary and pancreatic disease.

Antipsychotics are inexpensive agents that block dopamine receptors within the CTZ.14 Haloperidol (Haldol) and prochlorperazine (Compazine) are considered first-line options, primarily based on expert opinion.310 Adverse effects such as akathisia, dystonic reactions, sedation, and orthostatic hypotension may occur with antipsychotic use.

In addition, evaluation of consensus guidelines and various working groups providing expert opinion were used in developing this review.

Few randomized comparative studies have evaluated the safety and effectiveness of various treatment regimens to manage adverse effects of opioids.

Physicians should minimize the development of constipation using prophylactic measures.

Monotherapy with stool softeners often is not effective; a stool softener combined with a stimulant laxative is preferred.

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