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Nutraceuticals, which are used as nutritional and health supplements, are naturally occurring products from plants or animals. These supple ments do not require the same study as drugs under federal Food and Drug Administration regulations. However, claims for the treatment of any disease states with these products cannot be made. The manufacturers are allowed to describe physiological actions of the products and market them on that basis.

In a US survey, one in four adults took at least one nutritional supplement; of the patients who took prescription medication, nearly half also took nutraceuticals (96a,96b). Many of these nutraceuticals have potent pharmacological effects from the natural products they contain. Therefore, before initiating any analgesic agents, an accurate nutraceutical history must be obtained from the patient to avoid inadvertent drug interactions or adverse effects.

Many herbals have properties that mimic nonsteroidal anti-inflammatory drugs (NSAIDs) and therefore can interfere with other NSAID analgesics by increasing the risk for side effects such as gastrointestinal irritation and bleeding. Other herbals, such as Angelica sinensis, have coumarin properties, which can complicate postoperative bleeding when NSAIDs are used or when spinal analgesia is contemplated.

Herbals not only have a pharmacological effect on the patient during pain management, but also may require scrutiny when preparing a patient for invasive procedures. Herbals such as St. John's wort can inhibit cytochrome P450 2D6 and 4AC and therefore alter analgesic metabolism (97). This metabolic step is essential in converting hydrocodone to the more active metabolite hydromorphone and codeine to morphine. It is less important in the metabolic conversion of oxycodone to oxymorphone because oxycodone is intrinsically active. Nutraceuticals containing ginkgo, ginseng, and garlic oils have platelet-inhibitory effects and therefore can cause bleeding when used with analgesics such as NSAIDs that also have platelet-inhibitory effects (98).

It is important to remember that these pharmacologically active herb-als are often hidden in proprietary combination products; it is essential for the clinician contemplating analgesic therapy of patients taking these combination nutritional health supplements to identify these active ingredients and their potential untoward effects. To complicate matters, these ingredients may not be listed by their common botanical names. Chinese names may be used for these herbal preparations imported from Asia. For example, Angelica sinensis can be called dang qui, dong quai, or tongkei. It has properties similar to the anticoagulant coumarin. Table 3

Table 1

Opiate Adverse Effects and Management

Adverse effect type Cause

Nausea and vomiting Opiate effect on chemotrigger zone.

Expected effect of all opioid analgesics. Patient-specific side effect.

Sedation Sedation is a common side effect of the opioid analgesics, especially in the elderly population. This is an expected side effect of opioid analgesics, but some opioid analgesics produce more sedation than others.

Constipation Opioid analgesics inhibit gastrointestinal propulsive peristalsis, but increase static tone of the gut, thereby causing constipation and cramping. This is especially true in the elderly population because of decreased activities, and bodily fluids.


Find alternative opioid analgesic for patient. Selection may depend on patient history or by trial and error. Anti-emetics can be used to treat this side effect, however, sedation and cognition can further be comprised by the anti-emetics in the vulnerable patient population. Anticholinergic anti-emetics can exacerbate constipation, and urinary retention effects of the opioid analgesics.

Morphine often produces sedation and cognitive impairment in the elderly population. Often, switching the patient to alternative opioid analgesics will reduce these side effects. Intravenous administration of opioid analgesics produce these side effects more frequently than by other routes because of high initial serum peak levels of the opioids produced by the intravenous route as compared to oral, intramuscular, subcutaneous, rectal, or transdermal routes.

Opioid analgesic-induced constipation needs to be treated aggressively in the elderly population to prevent impaction and bowel obstruction. Stool softeners alone do not work! Opioid-induced constipation must be treated with adequate hydration, along with stimulant laxatives such as senna, cascara, or bisacodyl. Osmotic laxatives such as magnesium sulfate or lactulose can

Hypotension oj Respiratory depression

Hypotension from opioid analgesics occurs frequently in postoperative patients, primarily due to volume depletion from surgery. In addition, general anesthetic agents can also sensitize the mast cell to release histamine when opioid analgesics are administered, which can also produce hypotention.

Respiratory depression is one of the critical side effects of opioid analgesics. Luckily, it does not occur too frequently. However, if patients are concurrently receiving sedatives such as benzodiazepines, or centrally mediated muscle relaxants, they might be at much higher risk of developing respiratory depression postoperatively.

also be considered, but in the elderly population the patient must be monitored for dehydration or magnesium accumulation.

The appropriate treatment of postoperative hypotension from opioid analgesic is not by withholding the opioid analgesic, but rather by making sure the patient is adequately hydrated. However, elderly patients need to be monitored very closely to avoid inadvertently volume overloading the patient. Always remember, treat the patient and not the symptoms!

Respiratory depression from opioid analgesics most often occur because the patient has been given too large of a bolus dose of opioid analgesic at once by the intravenous route or because the patient is receiving multiple central nervous system depressants in addition to the opioid analgesics. Respiratory depression can be reduced or prevented by careful patient assessment and therapeutic planning. All analgesic regimens should be tailored to the individual patient. The one size fits all approached should be avoided in pain management. The use of shorter acting opioid analgesic preparations should be encouraged when initiating analgesic therapy. Once the patient is stabilized, he or she can be converted to a longer acting preparation.

Table 2

Common Antihistamine-Antiemetics






Hydroxyzine Promethazine Metoclopramide Prochlorperazine

10-25 mg every 6 hours 25 mg every 6 hours 10 mg every 6 hours 5-10 mg every 6 hours


25 mg every 6 hours 12.5 mg every 6 hours

NA 10 mg every 6 hours

25 mg every 6 hours 5-10 mg every 6 hours

12.5-25 mg every 6 hours 12.5-25 mg every 6 hours 10 mg every 6 hours 5-10 mg ever 6 hours

NA, not applicable; P.R., Per Rectum.

Table 3

Pharmacological Activities of Selected Herbals and Nutraceuticals

Common name

Scientific name


Angelica: dong quai (root of A. sinensis); bai zi (root of A. dahurica); du huo (root of A. pubescens)

Anise: aniseed; sweet cumin

Arnica: leopard's bane; mountain tobacco; mountain snuff; wolf's bane

Asafoetida: asafetida; asafoetida; devil's dung; gum asafetida

Black cohosh


Boldo: boldus; boldoa; boldea

Borage seed oil


Capsicum: cayenne pepper; red pepper; African chillies; green pepper

Angelica sinensis

Pimpinella anisum Arnica montana

Ferula assafoetida Cimicifuga racemosa

Peumus boldus Borago officinalis

Capsicum frutescens; C. annuum

Contains coumarin derivatives; increases PT/INR, APTT; potential bleeding risk

Potential bleeding risk (has coumarin derivatives; antiplatelet effect) Potential bleeding risk (has coumarin derivatives; antiplatelet effect)

Potential bleeding risk (has coumarin derivatives; antiplatelet effect) Decreases blood pressure; inhibits platelet aggregation because of salicylate content Potential bleeding risk (has coumarin derivatives; antiplatelet effect) Cytoprotective and anti-inflammatory actions Potential bleeding risk (has coumarin derivatives; antiplatelet effect) Potential increased risk of bleeding Irritant and analgesic; used in self-defense sprays and in pain treatments for postsurgical neuralgia, shingles, and the like

Discontinue 2 weeks before surgery


Table 3 (continued)

Common name

Scientific name

Celery: celery seed; celery seed oil Apium graveolens Chamomile Matricaria chamomilla

Clove: caryophyllus

Eugenia caryophyllata

Danshen: danshen, tan-shen, tzu tan-ken (roots of purple sage); hung ken (red roots); shu-wei ts'ao (rat-tail grass); ch'ih shen (scarlet sage); pin-ma ts'ao (horse-racing grass) Devil's claw

Salvia miltiorrhiza

Harpagophytum procumbens

Echinacea: purple cone flower root

Ephedra: ma huang; herbal ecstasy; natural ecstasy; cloud 9; ultimate xphoria


Echinacea angustifolia DC;

Rudbeckia; Brauneria Ephedra major Host; E. vulgaris; E. atlissima; and so on

Trigonella foenum-graecum


Potential bleeding risk (has coumarin derivatives; antiplatelet effect) Potential bleeding risk (has coumarin derivatives; antiplatelet effect); confusion or sedation Inhibition of platelet aggregation and antithrombotic activity Positive inotropic, antiplatelet, coronary arterial vasodilatory effects; possesses ATIII-like activity and promotes fibrinolysis

Possesses anti-inflammatory activity; reduces blood pressure, decreases heart rate, and slows antiarrhythmic activities in animal studies

Immunosupression; activation of cell-mediated immunity

Increases heart rate and blood pressure through indirect sympathomimetic effect

Potential bleeding risk (has coumarin derivatives; antiplatelet effect)

Concern with use longer than 8 weeks (chronic Risk of ventricular arrythmias with halothane; discontinue 24 hours before surgery

Feverfew: featherfew; altamisa; bachelor's button; featherfoil; febrifuge plant; midsummer daisy; nosebleed; Santa Maria; wild chamomile; wild quinine


Garlic: allium; stinking rose; rustic treacle; nectar of the gods; camphore of the poor; poor man's treacle


Ginkgo: maidenhair tree; kew tree

Ginseng (Panax): American, Korean (red), and Chinese

Goat's rue: French lilac; Italian fitch

Goldenseal: eye balm; eye root; ground raspberry; Indian dye; jaundice root; orange root

Horse chestnut: chestnut; California buckeye; Ohio buckeye; buckeye

Tanacetum parthenium

Linum usitatissimum Allium sativum

Zingiber officinale

Ginkgo biloba Eleutherococcus senticosus

Galega officinalis (family

Leguminosae) Hydrastis canadensis

Aesculus hippocastanum L. (horse chestnut); A. californica Nutt. (California buckeye); A. glabra Willd. (Ohio buckeye)

Inhibitor of prostaglandin synthesis (in vitro)

Decreases platelet aggregation

Inhibits platelet aggregation (may be Discontinue 7 days before irreversible); increases fibrinolysis; surgery antihypertensive activities

Antiemetic; inhibits thromboxane synthetase activity (in vitro), hence may inhibit platelet function

Inhibits platelet-activating factor Discontinue at least 36

hours before surgery

Causes hypoglycemia; inhibits platelet Discontinue 7 days before aggregation (may be irreversible); surgery increases PT/PTT; causes sedation or confusion

Potential bleeding risk (has coumarin derivatives; antiplatelet effect)

Antagonizes heparin

Potential bleeding risk (has coumarin derivatives; antiplatelet effect)


Table 3 (continued)

Common name

Kava kava: awa; intoxicating pepper; kawa Licorice

Lovage root: maggi plant; smellage

Meadowsweet ulmaria L. Milkweed ¡^ Onion



Quassia Red clover Rue SamE

Scientific name

Piper mythysticum Glycyrrhiza glabra

Levisticum officinale

Filipéndula ulmaria; Spiraea

Asclepias Allium cepa

Petroselinum crispum; P. hártense;

P. sativum Passiflora spp.; P. incarnata

Pier asma excelsa; Quassia amara

Trifolium pratense

Ruta graveolens; R. montana;

R. bracteosa L. s-Adenosyl methionine


Causes sedation, anxiolysis; increases sedative effects Causes hypertension; disrupts corticosteroid metabolism; potential bleeding risk (has coumarin derivatives ; antiplatelet effect) Potential bleeding risk (has coumarin derivatives; antiplatelet effect) Potential bleeding risk (has coumarin derivatives; antiplatelet effect) Arrythmias (contain cardioglycosibe) Potential bleeding risk (has coumarin derivatives; antiplatelet effect) Potential bleeding risk (has coumarin derivatives; antiplatelet effect) Potential bleeding risk (has coumarin derivatives; antiplatelet effect); causes sedation or confusion Potential bleeding risk (has coumarin derivatives; antiplatelet effect) Potential bleeding risk (has coumarin derivatives; antiplatelet effect) Potentially increases risk of bleeding

Blocks platelet aggregation in vitro

Discontinue at least 24 hours before surgery


St. John's wort: amber; goat weed; hardhay; hypericum; Klamatheweed Sweet clover Turmeric

Valerian: all heal; garden heliotrope;

vandal root Wild lettuce

Willow (bark)

Scutellaria laterifolia Hypericum perforatum

Melilotus officinalis Curcuma longa Valeriana officinalis

Lactuca virosa; L. sativa var. capitata

Salix alba; S. purpurea; S. fragilis

Causes sedation or confusion Inhibits neurotransmitter reuptake; inhibits P450 enzymes

Potential for bleeding (has coumarin derivatives) Potentially increases risk of bleeding Causes sedation

Causes a hallucinogenic effect

Potential bleeding risk (has coumarin derivatives; antiplatelet effect)

Discontinue 5 days before surgery

Source: From refs. 97-103.

NA, not applicable; PT/INR, prothrombin time/international normalized ratio; PT/PTT, prothrombin time/partial thromboplastin time.

lists herbals and nutraceuticals that require special attention when used perioperatively or with other medications.

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Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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    Are nutraceuticals an opioid?
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