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Other Side Effects
Clinicians are often concerned that high doses of opioids used for palliation may harm or kill a patient, partially when doses are further increased to alleviate pain.21 This double effect of intended benefit and potential harm 390 is seen in the clinical situation when the intended treatment may have inextricably linked deleterious side effects. The administration of medication is always a risk-versus-benefit calculation. When the patient's death is imminent because of the progression of primary disease, an increased risk of earlier death counts little against the benefit of pain relief and painless death. The ethical duty to benefit the patient through relieving pain is by itself adequate to support increasing doses to alleviate pain, even if there might be life-shortening and expected side effects. Because many patients in the terminal phase have been receiving opioid pain medications for a significant period of time, the fear of shortening life by medication is usually unfounded. Respiratory depression is not often a significant limiting factor in pain management because, with repeated doses, tolerance develops to this effect, allowing for adequate pain treatment with escalating doses without respiratory compromise.164 The person dying from cancer should not be allowed to live out life with unrelieved pain because of fear of side effects; rather, appropriate, aggressive palliative support should be given.416 79
Opioids occasionally cause myoclonus, seizures, hallucinations,75 confusion, sexual dysfunction, sleep disturbances, and pruritus.465 Prolonged use is known to affect sexual function and libido in both men and women. Women experience amenorrhea and infertility, whereas men report an inability to attain or maintain an erection. Changes in serum testosterone and other sex hormones have been described and may be responsible for some of these effects.2
Urinary retention may also occur, especially with spinal opioids,102; 121; 343; 387 in men with prostatism, or in patients with pelvic tumors and bladder outlet obstruction. The management of urinary retention may include discontinuing adjuvant drugs with potentiating effects (e.g., tricyclic antidepressants) or changing to another opioid analgesic or route of administration. Diphenhydramine, an antihistamine, may reduce pruritus in some patients. The syndrome of the inappropriate secretion of antidiuretic hormone is a rare, often transitory, adverse effect of opioid drugs, most commonly reported with morphine and methadone; more often, it is a paraneoplastic complication.
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