This patient is a chronic opioid user. Patients develop tolerance to most opioid adverse effects except constipation and miosis.
Patients with chronic pain frequently require opioids to adequately control their pain. Side effects of opioid therapy include nausea, vomiting, constipation, respiratory depression, and miosis. Over time, tolerance develops to most of the side effects of opioids, however tolerance does not develop to constipation or miosis.
Berland and Rogers discuss the use of opioids for chronic pain. They note that there has been a sharp increase in opioid prescriptions for chronic nonterminal pain, and that the potential for harm is high. They recommend the use of long-acting forms of opioids because these have lower abuse potential.
Nalamachu et al. conducted a case series to examine the feasibility of a extended release formulation of hydromorphone for patients with chronic neuropathic pain. They noted that patients were able to achieve adequate analgesia with a once daily dosing regimen, and that the most common toxicities were dizziness, headache, and nausea.
Figure A is an image of an abdominal radiograph with severe constipation, note the balls of stool in the rectum, as well as in the left upper quadrant. Illustration A is an example of a patient with opiate-induced miosis.
Answer 1: While respiratory depression is a common toxicity of acute opioid toxicity, tolerance develops to this effect, and patients on chronic opioids typically do not have respiratory depression.
Answers 2, 3 and 5: Rhinorrhea, sweating and diarrhea are all symptoms of opioid withdrawal. Since this patient is currently taking his medicine, we have no reason to belief that he is in active withdrawal.
Berland D, Rodgers P. Rational use of opioids for management of chronic nonterminal pain. Am Fam Physician. 2012 Aug 1;86(3):252-8. Review. PubMed PMID: 22962988
PMID:22962988 (Link to Abstract)
Nalamachu S, Ruck D, Nalamasu R, Fasbinder S, Bansal R. Open-label study to evaluate the efficacy and safety of extended-release hydromorphone in patients with chronic neuropathic pain. J Opioid Manag. 2013 Jan-Feb;9(1):43-9. doi: 10.5055/jom.2013.0146. PubMed PMID: 23709303.
PMID:23709303 (Link to Abstract)