Be Opiate Aware! Stay Safe!

Acute (short term) pain

Introduction

You have just been prescribed an opiate based medication for acute (short term) pain.  Opiates are the strongest pain killers we have available and can be very effective at treating acute, severe pain caused by injury, surgery or cancer but are not without risk.  This leaflet tells you all about opiates so you can get the most benefit from these drugs without exposing yourself to harm.

When & why we prescribe opiates

Opiates are usually our third line drug for treating pain and are typically added on top of paracetamol and an NSAID drug (eg: ibuprofen) if an NSAID is safe for you to take.  Opioids should rarely be prescribed as the only pain killer.

Opiates can be very useful after an injury such as a broken bone where we expect the pain to improve relatively quickly as the broken bone mends.  The opiate medication is unlikely to get you entirely pain free but does help reduce the intensity of the pain to a tolerable level.  You should take the minimum amount of opiate required to make your pain tolerable.

In contrast, opiates are not very good at treating chronic (long term) pain and can make pain worse in the long run if used for prolonged periods.

Sometimes we use opiates for conditions like back pain that can become chronic.  The opiates can be useful in the short term to help people with back pain get active and mobile (as this will help the pain) but if the back pain persists for more than a few weeks opiates are not an ideal medication to take.  If your pain is becoming chronic please discuss this with your doctor.

Side effects

When you first start taking opiate based medication some people get side effects such as:

• Feeling nauseous (sick) and sometimes vomiting
• Feeling dizzy
• Feeling sleepy or confused

These symptoms normally settle after a few days.  Other ongoing side effects of opiates include:

• Constipation that can require laxatives
• Itching
• Weight gain
• Lack of sex drive, irregular periods, reduced fertility, erection problems
• Increased levels of pain
• Difficulty breathing at night – particularly if you are overweight and suffer from a condition known as obstructive sleep apnoea

There is also an increasing awareness that people can die from opiate use.  This is not really a problem with weak opioids such as codeine on its own, but when more than one opiate is prescribed or when prescribed in higher doses or with other drugs that affect breathing like benzodiazepines and gabapentinoids (gabapentin and pregabalin) the risk is increased.

Driving

The law in the UK allows you to drive if you are taking prescribed opioid medicines in accordance with the instructions from your prescriber (including what your prescriber advises you about driving safely). You should never drive if you feel unsafe. Your ability to drive may be affected by other medicines you are taking in addition to opioids, whether you feel tired and by your pain. You are responsible for making sure you are safe on each occasion that you drive.

The law on drugs and driving in the UK changed in 2015. If your driving is impaired for any reason, including taking medicines, it is illegal to drive. It is also now illegal to drive when you are taking opioid medicines without them being prescribed, even if you are not impaired. Preparation for the new drug driving laws involved extensive scientific research to investigate what effect opioid drugs have on the ability to drive safely. We now know that if a person is taking more than 220mg of morphine a day they are likely to have a blood level of the medicine which impairs them nearly as much as someone who is over the legal limit of alcohol. All opioid medicines have the potential to impair driving and your prescriber will advise whether the dose of opioid you are taking is likely to impair you. If you are taking a high dose of opioid your prescriber will advise you that you are probably not safe to drive and will document this in your medical notes.

The doses of opioid medicine that are likely to affect your driving are quite high and are above the level that we know is safe and effective for pain treatment.

It is unsafe to drive in the first few days after starting an opioid and for a few days after dose change (up or down). Drinking alcohol reduces the amount of opioid medicine you can take and drive safely so do not drive if you have drunk alcohol and taken opioid medicines.

Alcohol & Opioid medication

Alcohol and opioids both can cause sleepiness and poor concentration. You should avoid alcohol completely when you first start on opioids or when your dose has just been increased. If you are taking opioids, you should avoid alcohol if you are going to drive or use tools or machines. When you get on a steady dose of opioid, you should be able to drink modest amounts of alcohol without getting any extra unusual effects.

The above driving and alcohol advice is quoted from the faculty of pain medicine https://www.rcoa.ac.uk/node/21136

Chronic pain and opiates

People with chronic pain are often desperate to seek a solution to that pain and will often take anything to try and help but taking opioids is often a bad option and this section explains why

Tolerance and increased pain

When an opioid medication is first started, or when the dose is increased, we typically get reduced pain levels for a few days to weeks.  However, during this time the body starts to produce more pain receptors in response to the opioid medication.  This increase in pain receptors is not an issue when we take opiates for short term pain like a broken bone of a short term flare in back pain because by the time our bodies have created more pain receptors the original pain we were taking the medication for has gone and we can reduce our opiate levels and get back to normal. (after a few weeks the extra pain receptors will have disappeared and our pain receptor levels will have normalised).  However when we use opiates for chronic pain the increase in the number of pain receptors means that after a few weeks we return to our old pain levels but on a higher and more harmful amount of medication!

Addiction

Opiate medication is addictive.   It is rare for someone with acute, short term pain to become addicted if they follow the prescribing advice and use the minimum amount of the drug required and start reducing the dose as the pain settles.  However, longer term use of opiates (over a few weeks) can lead to addiction.  People who are addicted may crave the drug, struggle to take the drug as prescribed and may over use it.   People with an opioid addiction may continue to take the drug even when they note the negative effect it has on their physical and mental health.

If you think you have an opiate addiction please speak to your doctor who can help you reduce your medication without unpleasant side effects.  We do not recommend stopping your opiates suddenly without medical advice

Side effects

Side effects have been described above but can often become worse the longer we take opioid medication.  If you are getting unpleasant side effects please speak to your GP.

Chronic pain is complex and often not helped by pain killers

Chronic pain is complicated and is often a result of many different factors combining to cause pain.  Some of these factors can be physical like an old injury but many of these factors causing chronic pain are related to psycho-social and emotional issues such as: Financial difficult; Inadequate housing; Family stress; Surviving previous abuse (eg: domestic violence, child hood abuse); Surviving a major trauma (eg: car crash, major surgery).

People with chronic pain may identify with more than one of the above issues and post traumatic stress disorder (PTSD) is commonly seen in our patients with chronic pain.  PTSD is characterised by flash backs or nightmares relating to the traumatic experience and /or a feeling of being constantly watchful or on-guard.

If you identify with any of these issues your GP can help and this help can be far more effective than any medication.