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Welcome to the PERT Advisor. This online forum is provided by the PERT Program to give nurses and nursing aides the opportunity to ask questions about providing end-of-life care. Answers will be provided by a collaboration of PERT Program faculty and staff 
with expertise on the pertinent topic.Scroll down to read questions and answers that have already been posted, or click on the button to the right to submit your own question.
 The PERT Advisor is intended for educational and support purposes only. Information about the diagnosis and treatment of medical conditions should not substitute for necessary consultations with a qualified medical professional. Biliary Spasms and Opioids 
Can biliary spasms be caused by opioids given as conscious sedation? Can they be experienced as similar to the acute pain of a gall bladder attack?
Yes, biliary tract function can be affected by opioids and yes, biliary spasms can cause acute pain. The PERT Advisor previously discussed this phenomenon when we addressed the topic of Opioids and Gallstones.
For more in-depth information on the relationship between biliary spasms and opioids, we turned to Anna Du Pen, ARNP, MN, nurse practitioner and pain specialist at Swedish Medical Center. She responded with the following information: For practical purposes experts agree that opioids should be avoided in patients with active biliary pathology as they can clearly exacerbate the underlying problem. This particular question refers to opioids being given as conscious sedation. It is important to point out that conscious sedation generally is achieved by using benzodiazepines such as Midazolam (Versed®) which provide a more dependable, predictable level of conscious sedation. All of the currently available mu opioids (for example, morphine, hydromorphone, and oxycodone) can cause biliary spasm. Low dose mu opioid antagonists such as naloxone (Narcan®) have been used to reverse opioid-induced biliary spasm.¹,² More recently novel peripheral opioid antagonists have been introduced that block the peripheral action of opioids without affecting centrally-mediated analgesia.³ These agents (methylnaltrexone, alvimopan) have been shown to reverse opioid-induced bowel symptoms, maintaining very low plasma levels, without antagonizing centrally mediated opioid effects.4,5 In the future, these agents may have a therapeutic role in opioid-induced biliary spasm. Additionally there is evidence for a significant role for the kappa opioid receptor in visceral afferent pathways. Recently asimadoline (a kappa agonist) was demonstrated to reduce colonic distension and postprandial symptoms in healthy subjects by acting primarily on peripheral afferent pathways.6 Modulation of peripheral kappa pathways may be another target of future research in this area.
Pain Hypersensitivity and Allodynia
What is the etiology of total body pain hypersensitivity? I read an article describing a phenomenon where persons living with controlled chronic pain begin to experience widespread bodily pain unrelated to new disease or trauma. It was suggested that pain signals were creating new pathways and firing widely and randomly causing significant distress in other areas of the body. Can you explain that further?
We asked Gordon Irving, MD, and Director of Swedish Pain Services to briefly discuss the question of total body hypersensitivity. The following response is based on his comments: Allodynia is a term used to describe a heightened painful experience to normally non-painful stimuli, such as the brushing of cloth against skin, alterations in temperature, presence of wind, or gentle pressure. Allodynia generally occurs peripherally, and is therefore limited in its distribution. For example, a limb or digit can become extremely allodynic when affected by reflex sympathetic dystrophy (RSD) or complex regional pain syndrome (CRPS), diabetic neuropathy or post-herpetic neuralgia. Hyperalgesia is described as an increased response to a painful stimulus. Where a pinprick may be considered painful, it will cause excruciating pain in a person with hyperalgesia. Total body hypersensitivity (aka central pain) has its origin in the central nervous system and is likely related to altered processing in the brain. One or several of the brain's 13 "processing centers" is impacted and subsequently causes hyperexcitability and misfiring of nerve signals all over the body. As Dr. Irving says, "the exact cause of this type of experience is a million dollar question." It's quite clear however, that it originates centrally. Toxins, stress, or other environmental factors are not thought to be primary causes of this phenomenon. There is some evidence for the role of opioid metabolites in the development of central pain. There are case studies in humans that indicate opioid metabolites [e.g. morphine-3-glucuronide (M3G)] may cause hyperalgesia and allodynia in rare instances with extremely high doses of morphine. Animal studies have shown a correlation between the presence of metabolites and the presence of neurotoxic symptoms, but the role of metabolites is not clearly understood and remains controversial.
Opioids and Gallstones I have a resident who is on OxyContin® with good relief for pain related to spinal compression fractures. She recently experienced severe abdominal pain from a gallstone and severe UTI. Prior to going to the hospital, she was given parenteral morphine with no relief of her acute pain. During her hospital stay the gallstone was presumed to have passed, she received antibiotic therapy for the UTI and her pain ultimately subsided. She declined surgical intervention though there remain small stones in her gallbladder.
Upon return to our facility, her physician stated a reluctance to have morphine available for acute pain, since it can increase the possibility of biliary spasm. Is this true of all opioids or just morphine? Can she stay on OxyContin®? Can we give the morphine if it happens again?
It is true that morphine and other opioids increase the tone of the biliary tract, which can result in biliary spasms, or colic. According to Clinical Pharmacology, an online pharmacological reference, opioids also may increase plasma amylase and lipase concentrations to 2–15 times the normal values. For this reason, it is recommended that morphine and other opioids be used cautiously in patients with biliary tract disease or undergoing biliary tract surgery.We asked Jon Younger, MD and Anna Du Pen, ARNP, MN to comment on your question. Their responses follow: Dr. Younger: Gallstones are not an absolute contraindication to the use of opioids. If the patient has pancreatitis related to gallstones, or ongoing gallstone-related pain made worse by the use of opioids, then opioids should not be used. Testing alkaline phosphatase and pancreatic enzymes with the onset of abdominal pain may help determine the cause and if opioids should be used. Also checking the same labs after the use of opioids if the pain persists or worsens may be helpful. If her pain is related to gallstones, especially if there are felt to be stones in the bile duct, an Endoscopic Retrograde Cholangiopancreatography (ERCP) with sphincterotomy may be an alternative to a cholecystectomy. Anna Du Pen: I agree. I would consider a short course of higher dose NSAID to help with acute pain and do some opioid dose sparing. Clinical Pharmacology Copyright ©2003 Tampa, FL: Gold Standard Multimedia |
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