Global BulletinAll NewsFDA Approval AlertWomen in Oncology
Around the PracticeBetween the LinesFace OffFrom All AnglesMeeting of the MindsOncViewPodcastsTraining AcademyTreatment Algorithms with the Oncology BrothersVideos
Conferences
All JournalsEditorial BoardFor AuthorsYear in Review
Frontline ForumSatellite Sessions
CME/CE
Awareness MonthNurse Practitioners/Physician's AssistantsPartnersSponsoredSponsored Media
Career CenterSubscribe
Adverse Effects
Brain Cancer
Breast CancerBreast CancerBreast Cancer
Gastrointestinal CancerGastrointestinal CancerGastrointestinal CancerGastrointestinal CancerGastrointestinal CancerGastrointestinal Cancer
Genitourinary CancersGenitourinary CancersGenitourinary CancersGenitourinary Cancers
Gynecologic CancersGynecologic CancersGynecologic CancersGynecologic Cancers
Head & Neck Cancer
Hematologic OncologyHematologic OncologyHematologic OncologyHematologic Oncology
InfectionInfection
Leukemia
Lung CancerLung CancerLung Cancer
Lymphoma
Neuroendocrine Tumors
Oncology
Pediatric Cancers
Radiation Oncology
Sarcoma
Screening
Skin Cancer & Melanoma
Surgery
Thyroid Cancer
Spotlight -
  • Radiation Oncology
  • Surgery
Adverse Effects
Brain Cancer
Breast CancerBreast CancerBreast Cancer
Gastrointestinal CancerGastrointestinal CancerGastrointestinal CancerGastrointestinal CancerGastrointestinal CancerGastrointestinal Cancer
Genitourinary CancersGenitourinary CancersGenitourinary CancersGenitourinary Cancers
Gynecologic CancersGynecologic CancersGynecologic CancersGynecologic Cancers
Head & Neck Cancer
Hematologic OncologyHematologic OncologyHematologic OncologyHematologic Oncology
InfectionInfection
Leukemia
Lung CancerLung CancerLung Cancer
Lymphoma
Neuroendocrine Tumors
Oncology
Pediatric Cancers
Radiation Oncology
Sarcoma
Screening
Skin Cancer & Melanoma
Surgery
Thyroid Cancer
    • Conferences
    • CME/CE
    • Career Center
    • Subscribe
Advertisement

Neurotoxicity Related to High-Dose Opioid Therapy Can Be Managed

December 1, 1999
Publication
Article
Oncology NEWS InternationalOncology NEWS International Vol 5 No 10
Volume 5
Issue 10

EDMONTON, Alberta-Vigorous worldwide pain education efforts emphasizing undertreatment have resulted in a "very healthy increase" in the use of opioids around the world, including increases in dose and length of exposure, Eduardo Bruera, MD, of the University of Alberta and Edmonton General Hospital, said at a plenary session of the 8th World Congress on Pain.

EDMONTON, Alberta-Vigorous worldwide pain education efforts emphasizingundertreatment have resulted in a "very healthy increase"in the use of opioids around the world, including increases indose and length of exposure, Eduardo Bruera, MD, of the Universityof Alberta and Edmonton General Hospital, said at a plenary sessionof the 8th World Congress on Pain.

As a result of this increased usage, along with more and betterneuro-psychiatric assessments, a spectrum of neuropsychiatrictoxicities of opioids in cancer patients is emerging.

"It is no longer acceptable for patients on opioids to belying in bed, often confused. Clinicians are looking to improvecognitive and physical performance, and are more likely to identifyneuropsychiatric effects than before," Dr. Bruera said.

The patient population likely to receive massive opioid dosesfor long periods-patients with advanced cancer who may have lowcirculating albumin levels, low glomerular filtration rates, andprofound physical and mental fatigue-also helps to explain theincrease in reports of opioid neurotoxicity.

Delirium, myoclonus, grand mal seizures, and hyperalgesia haveall been reported in patients receiving strong opioids. Myoclonushas been seen in association with renal failure in patients receivinghigh opioid doses for prolonged periods, and may improve withopioid rotation, he said.

Delirium occurs more often in those on prolonged high-dose therapywho also have neuropathic pain, renal failure, and dehydration,and are using other psychoactive drugs.

Treatment Strategies

Possible strategies for treating opioid-associated neuropsychiatrictoxicity include opioid rotation, dose reduction, hydration, anduse of adjuvant therapies, Dr. Bruera said.

A number of researchers have rotated between morphine and hydro-morphone(Dilaudid), and "this is probably a sensible approach sinceboth are agonists and both are given every 4 hours by mouth andother routes of administration," he said. Other drugs suchas fentanyl (Sub-limaze) and sufentanil (Sufenta) can also besubstituted for morphine.

Several studies, although mostly with small numbers of patients,have reported significant improvement in patients with hyperexcitabilitysyndromes after rotation from a number of different opioids toan equianalgesic dose of a number of other opioids, Dr. Bruerasaid. Such rotations usually resulted in a final dose reduction.

The problem, he said, is "how do we rotate?" More dataare needed on the dose ratios of commonly used opioids, he said,adding that some studies suggest that the ratio will change accordingto the patient's previous opioid exposure.

Dose reductions may also be possible by recognizing the circadianmodulation in dose requirements, he said. In one study, in whichpatients receiving regular opioid doses every 4 hours were alsoallowed to take an extra dose at any time, the extra dose requirementat night was approximately half that needed during the daytime.

In a study of psychostimulation after an increase in opioid dose,cognitive assessment significantly improved on methylphenidate(Ritalin) vs placebo, and more patients preferred the psychoactiveagent. This suggests, Dr. Bruera said, that some psychostim-ulantscould be used to reverse the cognitive effects of high opioiddoses.

Although a large number of other drugs have been suggested foruse in managing hyperexcitability effects, including baclofen,valproic acid (Depakene), midazolam (Versed), and lorazepam (Ativan),"there have been few controlled trials, and such treatmentis not likely to deal with the underlying problem, only with themanifestations," he said.

Dr. Bruera concluded that perhaps "we will have to add toour message for increased opioid use a cautionary note that, insome cases, massive opioid doses can result in neuropsychiatrictoxicity; our education programs should emphasize not just under-treatmentbut also the aspects of inappropriate treatment."

Articles in this issue

Anesthetic Interventions Rise When Anesthesiologists Join the Pain Team
Worldwide UN Survey Shows Many Impediments to Morphine Availability
Case-Based Pain Curriculum Used in Canadian Schools
Effective Physician and Patient Communication Is Essential in Palliative Care
Withdrawal Syndrome After Stopping Opioids Is Not Evidence of Drug Dependence, WHO Committee Says
Brief Pain Inventory and Faces Scale Perform Well in a Group of Low-Income, Primarily Black Cancer Patients
Whole-Body Vibration Within Specified Frequency Range May Provide Pain Relief
Pain Descriptions May Predict Presence of Neuropathic Pain
Neurotoxicity Related to High-Dose Opioid Therapy Can Be Managed
Epidural Morphine Relieves Pain in Advanced Cancer, But May Not Influence Quality of Life
Dr. Payne Urges Strategies to Overcome Barriers to Use of Cancer Pain Guidelines
Program Trains Community Opinion Leaders in Principles of Pain Control
Postmarketing Surveillance for Drug Abuse Supports Nonscheduled Status of Tramadol
Consider Quality of Life and Patient Preference When Choosing Pain Relief
Patients' Pain Anxiety Levels Vary Depending on the Type of Pain, the Patient's Gender, and Pain Duration
Recent Videos
A machine learning method for scoring tumor-infiltrating lymphocytes may address variability in pathologist measurements.
Clinical trials in small cell lung cancer appear to be more “pragmatic” with their inclusion criteria than before, according to Anne Chiang, MD, PhD.
Related Content
Advertisement

Laser vision correction. A patient and team of surgeons in the operating room during ophthalmic surgery. Eyelid speculum. Lasik treatment.| Image Credit: © romaset-stock.adobe.com

Brachytherapy/Vitrectomy, Silicone Oil Confer Positive Uveal Melanoma DMFS

Ariana Pelosci
September 28th 2025
Article

An 80% disease metastasis-free survival rate occurred in those with uveal melanoma who received a brachytherapy plaque with vitrectomy and silicone oil.


Prospective data observed with the gemcitabine intravesical system may be superior to prior reports of other therapies in BCG-unresponsive NMIBC.

Gemcitabine Intravesical System Offers Tremendous Benefits in NMIBC

Gary Steinberg, MD
September 29th 2025
Podcast

Prospective data observed with the gemcitabine intravesical system may be superior to prior reports of other therapies in BCG-unresponsive NMIBC.


The Lived Experience of Talquetamab Therapy in a Patient With Multiple Myeloma

The Lived Experience of Talquetamab Therapy in a Patient With Multiple Myeloma

ONCOLOGY Staff
September 27th 2025
Article

Karen Kehl shares her decade-long journey with multiple myeloma, discussing treatment options and the impact of bispecific antibodies like talquetamab with Binod Dhakal, MD.


Experts discuss key considerations for applying ctDNA to clinical practice, such as distinguishing between tumor-informed and tumor-uninformed testing.

Diving Into the Practical Applications of ctDNA in Oncology Care

Manojkumar Bupathi, MD, MS;Benjamin Garmezy, MD;Arnab Basu, MBBS, MPH, FACP
September 25th 2025
Podcast

Experts discuss key considerations for applying ctDNA to clinical practice, such as distinguishing between tumor-informed and tumor-uninformed testing.


Data from KOMET-001 support ziftomenib as a new potential option for patients with relapsed/refractory NPM1-mutated acute myeloid leukemia.

Ziftomenib Shows Significant Benefit in Relapsed/Refractory NPM1+ AML

Russ Conroy
September 26th 2025
Article

Data from KOMET-001 support ziftomenib as a new potential option for patients with relapsed/refractory NPM1-mutated acute myeloid leukemia.


Following over a decade of oversight, no cases of Torsades de pointes or unexplained sudden deaths were reported among US patients who received vandetanib in REMS assessments.

FDA Drops REMS Requirement for Vandetanib in Medullary Thyroid Cancer

Tim Cortese
September 26th 2025
Article

Physicians are no longer required to have special certification to administer vandetanib to patients with medullary thyroid cancer.

Related Content
Advertisement

Laser vision correction. A patient and team of surgeons in the operating room during ophthalmic surgery. Eyelid speculum. Lasik treatment.| Image Credit: © romaset-stock.adobe.com

Brachytherapy/Vitrectomy, Silicone Oil Confer Positive Uveal Melanoma DMFS

Ariana Pelosci
September 28th 2025
Article

An 80% disease metastasis-free survival rate occurred in those with uveal melanoma who received a brachytherapy plaque with vitrectomy and silicone oil.


Prospective data observed with the gemcitabine intravesical system may be superior to prior reports of other therapies in BCG-unresponsive NMIBC.

Gemcitabine Intravesical System Offers Tremendous Benefits in NMIBC

Gary Steinberg, MD
September 29th 2025
Podcast

Prospective data observed with the gemcitabine intravesical system may be superior to prior reports of other therapies in BCG-unresponsive NMIBC.


The Lived Experience of Talquetamab Therapy in a Patient With Multiple Myeloma

The Lived Experience of Talquetamab Therapy in a Patient With Multiple Myeloma

ONCOLOGY Staff
September 27th 2025
Article

Karen Kehl shares her decade-long journey with multiple myeloma, discussing treatment options and the impact of bispecific antibodies like talquetamab with Binod Dhakal, MD.


Experts discuss key considerations for applying ctDNA to clinical practice, such as distinguishing between tumor-informed and tumor-uninformed testing.

Diving Into the Practical Applications of ctDNA in Oncology Care

Manojkumar Bupathi, MD, MS;Benjamin Garmezy, MD;Arnab Basu, MBBS, MPH, FACP
September 25th 2025
Podcast

Experts discuss key considerations for applying ctDNA to clinical practice, such as distinguishing between tumor-informed and tumor-uninformed testing.


Data from KOMET-001 support ziftomenib as a new potential option for patients with relapsed/refractory NPM1-mutated acute myeloid leukemia.

Ziftomenib Shows Significant Benefit in Relapsed/Refractory NPM1+ AML

Russ Conroy
September 26th 2025
Article

Data from KOMET-001 support ziftomenib as a new potential option for patients with relapsed/refractory NPM1-mutated acute myeloid leukemia.


Following over a decade of oversight, no cases of Torsades de pointes or unexplained sudden deaths were reported among US patients who received vandetanib in REMS assessments.

FDA Drops REMS Requirement for Vandetanib in Medullary Thyroid Cancer

Tim Cortese
September 26th 2025
Article

Physicians are no longer required to have special certification to administer vandetanib to patients with medullary thyroid cancer.

Advertisement
About
Advertise
CureToday.com
OncLive.com
OncNursingNews.com
TargetedOnc.com
Editorial
Contact
Terms and Conditions
Privacy
Do Not Sell My Personal Information
Contact Info

2 Commerce Drive
Cranbury, NJ 08512

609-716-7777

© 2025 MJH Life Sciences

All rights reserved.