Local and National NHS policies including Public Health England and the Faculty of Pain Medicine advise there is little evidence that opioids (morphine based pain killers, like codeine, tramadol, oxycodone) are helpful for long term pain and intermittent use may be of higher benefit.
Like other opioids, codeine is associated with possible dependence and addiction and should only be continued where there is a clear benefit. Codeine and co-codamol are widely prescribed in Devon and data suggests that there is a greater number of high quantity prescriptions for codeine in comparison with areas nationally.
NHS Devon has recommended that we reduce codeine and co-codamol prescriptions to smaller quantities to ensure that use is safe and appropriate. “The lowest effective dose for the shortest period of time” and that we encourage patients to use nondrug measures to help manage their pain, such as those in the resources below.
Opioids 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. The role of opioids in chronic pain is less clear and there is now emerging evidence that, for most people, they are not effective for chronic pain. This leaflet tells you all about opioids so you can get the most benefit from these drugs without exposing yourself to harm.
Opioids 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.
Opioids 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. In contrast, opioids are not very good at treating chronic (long term) pain and can make pain worse in the long run if used for prolonged periods. Over the past 20 years there has been increasing use of opioids for chronic pain but it is only in the past few years we have realised that opioid medication is often so ineffective at treating chronic pain and so potentially harmful.
We find that many of our chronic pain patients are so desperate for a solution to their pain that they will try anything though – even potentially harmful drugs such as opioids. This information leaflet is designed to help you understand the risks and benefits of opioid medication and make an informed decision as to whether you want to continue taking it at your current level or reduce the dose with the help of your GP.
Want to reduce your opioid medication or other pain meds?
If you are taking regular opioids or other pain killers and you want to stop them we can help! Please do not stop any of your medications suddenly without seeking medical advice as this could cause side effects and make you feel unwell. A slow and controlled reduction in your medication could be very sensible and your GP can support you to do this.
When you first start reducing your opioid medication you may experience a small increase in your chronic pain – but as the opioid levels in your system reduce your body will adjust by reducing the number of pain receptors and your pain will come back down to the previous levels. If you have reduced the dose a little too fast you may also feel tired, sweaty, get a runny nose, diarrhoea and stomach cramps but these withdrawal symptoms settle after a few days or you could go back on an intermediate dose between your original dose and the new dose.
A few weeks after the dose reductions you are likely to notice yourself feeling better with a clearer head, less dizziness and less muddled thinking. Your pain may be no better on the reduced dose but certainly after a few weeks it should be no worse either and you will have reduced the severity of side effects you are getting.
The route to resolving your pain is more complex and requires a detailed review of your life looking for any stressors that may be contributing to your pain and treating any emotional or psychological health problems that are an issue for you. Your GP can help in this area.
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.
Side effects
When you first start taking opioid based medication some people get side effects such as:
These symptoms normally settle after a few days. Other ongoing side effects of opioids include
There is also an increasing awareness that people can die from opioid use. This is not really a problem with weak opioids such as codeine on its own, but when more than one opioid 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.
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 opioids for short term pain like a broken bone or 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 opioid 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 opioids 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
Opioid 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 opioids (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 opioid addiction please speak to your doctor who can help you reduce your medication without unpleasant side effects. We do not recommend stopping your opioids suddenly without medical advice
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
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.
Chronic Pain Management Resources
Arthritis Research UK Leaflet on Fibromylagia
https://www.versusarthritis.org/about-arthritis/conditions/fibromyalgia
(or PDF version https://www.versusarthritis.org/media/24901/fibromyalgia-information-booklet-july2021.pdf)
Tame The Beast
ReConnect2Life is an interactive programme to help you look at your pain and how it affects you
https://www.torbayandsouthdevon.nhs.uk/services/pain-service/reconnect2life/
Live Well With Pain
https://livewellwithpain.co.uk/
body reprogramming
https://www.plymouthhospitals.nhs.uk/body-reprogramming
Health Talk Chronic Pain
https://healthtalk.org/chronic-pain/overview
British Pain Society
https://www.britishpainsociety.org/people-with-pain/
Help With Sleep