Opioids in managing pain for people with advanced disease

What are opioids?

Opioids are a group of medicines that have been used for many years to provide pain relief by imitating the body’s natural pain relievers. They are used when the pain is moderate to severe after an operation or accident. They are also used at different stages in the course of an illness.

Examples of weak opioids include:

• codeine
• dihydrocodeine
• tramadol.

Sometimes these are combined with paracetamol to make them work better. They include co-codamol (codeine and paracetamol) and co-dydramol (dihydrocodeine and paracetamol).

Stronger opioid drugs include:

• morphine
• oxycodone
• buprenorphine
• fentanyl
• diamorphine
• methadone.

Morphine is the most widely used strong opioid. Other strong opioids are prescribed for people who cannot tolerate Morphine or who cannot take tablets easily or reliably.

What are strong opioids used for?

They are prescribed when pain is severe and not helped by other medications. They may also be prescribed to help manage breathlessness. You will be able to take strong opioids for as long as you need to; the effects do not wear off over time and the dose can be increased if needed.

Does taking strong opioids mean I am seriously ill?

Strong opioids are used for pain which can happen at different stages in the course of a disease, and it does not necessarily mean you are close to the end of your life. They are used when pain is severe, and they aim to help you live as comfortable as possible. Many people find they sleep better and have less pain. You may find you have a renewed interest in food, and life generally.

Will strong opioids take my pain away completely?

The aim is to manage your pain as effectively as possible however opioids may not provide complete relief. Certain pains can be harder to control, such as pain relating to damaged bones and nerves. With these pains, you may need to have other medicines in addition to, or instead of, strong opioids.

How to take opioids

The most common strong opioid is Morphine which is usually prescribed in a form that you can take by mouth, such as tablets, capsules, liquid or powder.

There are two types of Morphine – short acting and long acting. The short acting form takes 30 minutes to work and relieves pain for up to four hours. It may be given regularly, every four to six hours. Extra doses can be used to control breakthrough pain (pain that returns between your regular doses) as it works quickly. The long-acting form (often called modified or sustained release) is taken every 12 hours to control pain that is constantly present (background pain).

It is common to be started on a short acting strong opioid every four hours and switched to the long-acting preparation twice a day (e.g. 8am and 8pm) once the correct dose has been established. Often the dose needs to be adjusted before your pain will be adequately controlled. You should be reviewed soon after starting the medication to monitor the effects and you will be told the plan for this by the doctor or nurse prescribing the strong opioid for you.

Oxycodone is also available in a short acting and a long-acting form and is prescribed and used in the same way as Morphine.

If you are started on a pain-relieving patch, such as Fentanyl or Buprenorphine, it is likely you will be offered short acting Morphine or Oxycodone in case you have breakthrough pain.

Name of long acting opioid you have been prescribed:
When to take it / dose to take:

Name of short acting opioid you have been prescribed:
When to take it / dose to take:

What to do if you miss a dose

Take the dose you missed as soon as you remember and then take the next dose at the usual time. Do not take a double dose to make up for the missed one. If you are sick and bring up your medicine, take the dose as soon as you feel able to.

What to do if you get pain between regular doses of painkillers

If the pain is mild, Paracetamol may help (remember that a maximum of eight 500mg tablets may be taken in 24 hours). If it is more severe, you should take a dose of your short acting opioid. If you require more than 3 extra doses in a 24-hour period, tell your doctor or nurse.

Some people find doing certain things, for example, having a bath or a dressing change brings on the pain. Your doctor or nurse may suggest that you take a dose of your short acting pain killer about half an hour before these activities.

Side effects

The most common side effects include:

• Constipation - this is a very common side effect, and you should be prescribed a laxative to take regularly. It is important to drink plenty of fluids
• Sickness - some patients feel sick when they first start an opioid. Your doctor or nurse prescriber may need to give you some anti-sickness medication for a few days just in case.
• Sleepiness - this is common when you first start to take strong opioids or when the dose is increased and should improve after a few days. If sleepiness persists beyond a few days let your doctor or nurse know
• Others - less common side effects include itching, change in taste and difficulty passing urine. If you experience any of these side effects, please tell your health care professional

How will I know if strong opioids are not going to work for all my pain?

You may still have pain despite taking bigger doses of opioids, and may feel unwell in one of more of the following ways:

• more sleepy than usual
• feeling sick more often
• feeling restless or twitchy
• having bad dreams, or hallucinations
• itching

Don’t worry if this happens. Tell your doctor or nurse, who may reduce that amount of strong opioid you are taking and suggest some other treatments to help the pain.

Will I become addicted?

Many people are frightened they will become addicted to strong pain killers, this is not the case. If you no longer need Morphine to control your symptoms, your doctor will reduce the dose gradually.

Driving

UK law allows you to drive if you are taking opioid medicines according to the advice of your prescriber or leaflet in the package, and your driving skills should not be impaired. However, you are responsible for making sure you are fit to drive.

Because opioid medicines can make you feel sleepy, you should not drive or operate machinery until you see how it affects you as your reactions and alertness will be affected. You should only consider driving regularly if you are confident that your concentration is not impaired.

You should not drive if your dose is changed, or you feel unsafe. You do not have to inform the DVLA that you are starting an opioid, however there may be other information about your illness the DVLA needs to know.

Drinking alcohol

You can still enjoy a small glass of wine or spirits. It is best to avoid more than this amount of alcohol as you may become too drowsy.

Storing painkillers at home

Store your medicines in the original, labelled container from the pharmacy and only remove the dose you need each time. Keep them out of sight and reach of children. Medicines should be stored in a dry, clean place at room temperature.

Always return any unused medicines to your pharmacist, who can dispose of them safely. It is useful to do this anytime your medication is changed, so that you only have the medications you are taking currently to avoid getting confused. Do not dispose of unwanted medicines by putting them down the toilet or the sink.

Who to contact if you have any concerns or questions

Phone your specialist nurse or GP. It is a good idea to write down the contact numbers and keep them somewhere you can easily find them. If you think there is something seriously wrong, phone 999.