OPIOIDS FOR PERSISTENT PAIN: INFORMATION FOR PATIENTS This leaflet aims to help you understand your pain, so that you can work with your health care team to self-manage your symptoms and improve your quality of life. In particular it provides information on a particular type of painkiller, called opioids, to help you decide if you wish to try them. ABOUT PAIN Pain can be divided into two types, Acute (short term) pain Persistent or Chronic (long term) pain. Both types of pain can be severe or mild and the main difference is how long you have had the pain. ACUTE PAIN Acute pain is usually short term and caused by an injury or painful event. The most common types are headaches, muscle pain following exercise, pain from a bone fracture or pain after an operation. Acute pain can be severe, but usually gets better within a few days or weeks. PERSISTENT OR CHRONIC PAIN Persistent pain sometimes begins with an injury, but doesn t get better as expected; often it is unclear why this pain continues. Common types of long term pain include; low back pain, pain related to arthritis and pain related to an injury to a nerve or other parts of the nervous system (neuropathic pain). Persistent pain is not usually a sign of on-going injury or damage, but can be associated with changes with the signalling in the nervous system and the way the brain interprets the pain, making the pain symptoms self-sustaining over a prolonged period. Pain is complicated and influenced by many factors, including; How you are feeling in general Your previous experience of pain This leaflet is available online at: http://www.wales.nhs.uk/sites3/page.cfm?orgid=814&pid=72052 Page 1 of 7
Your understanding of why you have pain and the worries you have about it How you deal with your pain and how it affects your life. When pain doesn t seem to get better it tends to cause a low mood, distress, tiredness and irritability. Your sleep may be affected and it can cause problems with daytime activities and moving around. Because of this it can affect relationships with family and friends. Free local courses are available to help you cope with these conditions (see page 7 of this leaflet). OPIOID TREATMENT FOR LONG TERM PAIN Opioids have been used for many years to treat pain and are considered to be some of the strongest painkillers available. They provide relief by blocking the transmission of pain signals. They include the weaker opioids such as; Codeine Dihydrocodeine Tramadol Sometimes the weak opioids are combined with paracetamol to make them work better. Stronger opioids include; Morphine Buprenorphine Oxycodone Fentanyl Acute pain is relatively easy to treat with the range of painkillers we have available and depending on how severe the pain is. Opioid medicines are used for a few days and the dose is reduced as the healing occurs. Persistent pain is more difficult to treat and it may not be possible to stop the pain completely. The usual painkillers, such as opioids, help less than a third of patients that try them. The aim of medication in persistent pain is to help reduce your pain symptoms enough to allow you to get on with your life and what you are able to do. Opiates are started as a trial and if they are not helpful in reducing pain then they will be discontinued. Higher doses of opioids are unlikely to give better pain relief and are associated with a number of adverse side effects. This leaflet is available online at: http://www.wales.nhs.uk/sites3/page.cfm?orgid=814&pid=72052 Page 2 of 7
Medicines work best if you combine them with regular activity and exercise and doing things that you find satisfying or enjoyable, such as work and study or social activities. Setting goals is an important way of seeing if medication is helping. Increasing physical fitness is also important to help you understand that physical activity does not necessarily cause further injury and is therefore safe. Slow release preparations are the best way to manage long term pain as they provide a steady level of medication throughout the day. These may take up to two days to work fully. Your clinician will slowly increase the dose to produce a noticeable benefit but without causing side effects, however it is not usual to get a complete eradication of pain. If pain is affecting your sleep opioids may help you recover your normal sleep pattern but they should not make you drowsy in the daytime. Fast acting opioid preparations are not useful for managing continuous pain as although they work quicker their effect only lasts three or four hours. You should always take the correct dose of the medication and if you feel this isn t enough, or that the side effects interfere with your life you must speak to your health care team. SIDE EFFECTS When you first start taking opioids you can get some side effects, which will usually stop after a few days. These include; Feeling dizzy Feeling sick (nausea) Being sick (vomiting) Feeling sleepy Feeling confused. Other medicines, such as anti-sickness tablets can be prescribed to help. Opioids can cause problems when you take them long term. These include, Constipation (you may need to be prescribed a laxative or have the medication changed) Itching Weight gain This leaflet is available online at: http://www.wales.nhs.uk/sites3/page.cfm?orgid=814&pid=72052 Page 3 of 7
Decrease in immunity Changes in hormone levels leading to side effects that include a lack of sex drive, irregular periods, reduced fertility and erectile dysfunction (an inability to keep an erection) Increased pain (hyperalgesia) Difficulty breathing at night (Difficulty breathing at night is common if you are overweight and if you snore heavily. If you have a condition called obstructive sleep apnoea it may not be safe to take opioids). WHY DON T MY PAINKILLERS WORK? This is commonly asked, but there is no easy answer. Persistent pain arises from many different mechanisms and most types of medication only works on one of these. Some pain does not respond to any medicine. Also your body can get used to painkiller, such as opioids so that you need take more to get the same effect. This is called building up tolerance. DEPENDENCY AND ADDICTION Over time the body can develop dependency. This means that if you stop taking the drugs suddenly or reduce the dose too quickly you can develop symptoms of withdrawal. The symptoms include; Tiredness Sweating A runny nose Stomach cramp Diarrhoea Aching muscles ADDICTION to opioids is rare, but people can, Feel of out of control about how much medicine they take or how often they take it Develop a craving for the drug Continue to take the drug even when it has a negative effect on their physical or mental health. Addiction is more common in those who have been addicted to other opioids or alcohol previously or those with severe depression or anxiety. This leaflet is available online at: http://www.wales.nhs.uk/sites3/page.cfm?orgid=814&pid=72052 Page 4 of 7
IS IT SAFE TO DRIVE ON OPIOIDS? The law in the UK allows you to drive if you are taking opioids, but you should not drive if you feel unsafe to do so opioids are more likely to make you unsafe to drive for the first few days after starting to take them or after a dose change (up or down). Your ability to drive may also 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 Driver and Vehicle Licensing Authority (DVLA) website can provides further guidance on driving whilst taking prescription medicines https://www.gov.uk/drug-driving-law IS IT SAFE TO DRINK ALCOHOL WITH OPIOIDS? Alcohol and opioids together cause sleepiness and poor concentration. You should avoid alcohol completely when you first start on opioids or when your dose is increased. You should also avoid this combination completely if you are going to drive or operate machinery. When you get on a steady dose you should be able to drink within safe limits. UNDERSTANDING NEUROPATHIC PAIN Your clinician may mention that you have neuropathic pain. This is another type of persistent pain associated with injury to the nerve endings or the nervous system. Types of neuropathic pain include; Sciatica (leg pain) following a disc prolapse, Nerve injury following spinal surgery, Pain after infections like shingles or HIV/AIDS, Pain associated with diabetes, Pain after an amputation (phantom limb pain), Pain associated with multiple sclerosis or stroke. Neuropathic pain is usually severe and unpleasant. Opiates are much less effective in neuropathic pain. Other medicines are available although they are similarly not very effective and may only work in a small proportion of patients. Other non-medicine treatments may be suggested, such as TENS machines (electrical stimulations), acupuncture, Cognitive Behavioural Therapy (CBT), meditation and mindfulness. This leaflet is available online at: http://www.wales.nhs.uk/sites3/page.cfm?orgid=814&pid=72052 Page 5 of 7
OTHER IMPORTANT INFORMATION You also must let the health care team know if you are; Allergic to any medication Taking any other medication from the chemist or any herbal preparations Pregnant or breastfeeding or if you are planning to become pregnant Have a kidney problem You have a background of excessive alcohol use, recreational drug use or addiction to prescribed or bought medication. COURSES AND SELF HELP GUIDES ACTIVATE YOUR LIFE available across Gwent; a free 4 week course to help you deal with emotional issues, low self-esteem, low self-confidence, stress and panic, unwanted habits or a lack of motivation. http://www.wales.nhs.uk/sitesplus/866/page/87366 EPPCYMRU a free 6 week health and wellbeing course, providing tools and techniques to help you recognise and manage symptoms, develop relationships and develop new skills and knowledge to improve you quality of life. Tel: 01443 233514 or email: info@eppwales.org STRESS CONTROL available across Gwent; a free 6 week course to explain how to control your thoughts, actions, body, panic and sleep http://www.wales.nhs.uk/sitesplus/866/page/87366 PAIN TOOLKIT an online guide to learning and understanding how to self-manage your pain using 12 tools and videos http://www.paintoolkit.org/tools ARTHRITIS RESEARCH UK a complete online guide to living with arthritis, providing tips and information on lifestyle and living, medication and exercise. http://www.arthritisresearchuk.org/arthritis-information.aspx PAIN CONCERN a charity funded organisation that provides a telephone help-line and support and information on pain and self-management, including on line videos by patients on how they manage their pain. This leaflet is available online at: http://www.wales.nhs.uk/sites3/page.cfm?orgid=814&pid=72052 Page 6 of 7
Tel: 0300 123 0789 or email help@painconcern.org.uk. http://painconcern.org.uk/ HOW WE DEVELOPED THIS INFORMATION The following resources were used to write this leaflet The British Pain Society leaflet: Opioids for persistent pain; information for patients (January 2010) Opioids Aware 2016: Faculty of Pain Medicine www.fpm.ac.uk/faculty-of-pain-medicine/opoids-aware The British Pain Society has been helped substantially by patient organisations and individual service users who have commented on and contributed to the information in this document. This leaflet is available online at: http://www.wales.nhs.uk/sites3/page.cfm?orgid=814&pid=72052 Page 7 of 7