4.2. Central nervous system and psychiatric effects
Drowsiness and sedation are very common side-effects of opioids. Patients may feel confused and their ability to think clearly, impaired; high doses of opioids increase the risk of delirium. Dizziness is also a frequent side effect. Mood alteration with opioids can range from euphoria and elation to dysphoria (unease and unhappiness). CNS adverse effects generally settle as tolerance develops.
Hyperalgesia—increased sensitivity to pain—can follow long-term use of high doses of an opioid. Rarely, convulsions occur with excessive doses (see Overdose), but with some opioids they may occur with therapeutic doses.
Factors which increase risk
Drowsiness and confusion may increase with increasing dose of opioid. These effects also increase if an opioid is taken with medicines with similar side effects, such as antimuscarinic (anticholinergic) medicines. Patients with dementia are at greater risk of worsening cognitive impairment. Opioids should be used with care in patients susceptible to convulsions or those with head injuries.
While the dose of opioid should be adequate, an excessive dose or very rapid dose escalation should be avoided to reduce the risk of CNS effects such as drowsiness and confusion.
CNS side effects of opioids generally diminish without specific treatment. Additional drugs to counteract CNS side effects can be considered, but they may complicate therapy and there are no licensed medicines for this purpose.
What would be your advice on driving for a patient prescribed 5-days’ supply of an opioid for postoperative pain? How might this advice differ for a patient treated for 6 months with a steady dose of transdermal opioid patches?
Opioids cause drowsiness and can affect psychomotor performance: ability to drive or undertake skilled tasks, including reaction time, may be affected on starting opioid treatment or when the dose is increased. However, tolerance develops to these effects of opioids. In those on prolonged treatment and on a stable opioid dose, the effect on psychomotor function may be much diminished.
Patients just prescribed an opioid or whose opioid dose is not stable should be warned not to drive or take on tasks that call for fine psychomotor skills. When opioid treatment persists and there has been no change to the dose, the patient can drive provided that psychomotor or cognitive ability is not impaired and the patient is not taking other substances (eg alcohol) or medicines that can affect the ability to drive.
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