Opioid uses and risks – what students need to know
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Opioid uses and risks – what students need to know

Jennifer Trueland Health journalist

The medications are useful for managing acute pain but be mindful of risks, including the potential for addiction

Opioids are medications that help to reduce pain. ‘They work by replicating our natural endorphins – the natural pain-relieving chemicals that are produced in our body,’ says clinical matron for cancer services at Royal Devon University Healthcare NHS Foundation Trust Rhea Crighton.

Nursing Standard. 37, 9, 71-72. doi: 10.7748/ns.37.9.71.s22

Published: 31 August 2022

‘They work centrally – on the brain and spinal cord area – as well as peripherally, such as in the gut, which is why you can get side effects like constipation and nausea.’

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Picture credit: iStock

Which medications are opioids?

Opioid medications include dihydrocodeine, codeine, tramadol, morphine, and fentanyl.

‘I describe them as morphine-like medications because every patient knows what morphine is,’ says Jigna Shah, a clinical nurse specialist at the London Complex Mesh Centre at University College London Hospitals NHS Foundation Trust and a former pain management nurse specialist.

‘Even milder opioids, like codeine and dihydrocodeine, break down into morphine in the body, giving the effects of morphine,’ she says.

How are opioids administered?

Opioids can be administered in the following forms:

  • » Oral (including buccal tablets that are rubbed into the cheek and sublingual tablets which are placed under the tongue).

  • » Liquids.

  • » Lozenges.

  • » Transdermal, through skin patches.

  • » Subcutaneous injections.

  • » Intravenous.

‘Oral would be the first port of call’ says Ms Crighton. ‘It’s easiest for the patient as they can take it themselves. But if they aren’t able to tolerate anything by mouth, or if they are being sick or have swallowing difficulties, you can consider other routes, such as buccal or sublingual.’

This would also be the case for patients with an ileus or intestinal obstruction.

‘If you can’t use those routes, or the drug doesn’t have these routes, you can use a subcutaneous injection but only for small amounts of liquid or it can be quite sore for the patient,’ says Ms Crighton.

The intravenous route tends only to be used for acute pain, usually in a hospital setting where people can be monitored, she adds, while transdermal is not appropriate in the acute setting or for acute pain as skin patches can take 72 hours to act and the drug can remain in the body for 72 hours after the patch is removed.

‘Transdermal is appropriate when the pain is constant and you want the patient to have something consistent in the background, being released over 24 hours,’ says Ms Crighton.

Signs of opioid addiction

  • » Craving the medicine

  • » Feeling the need to take more than prescribed or instructed on the pack

  • » Feeling the need to take additional medicines containing opioids or other pain relief to achieve the same result

  • » Taking opioid medicines for other reasons than pain, such as to stay calm or help you sleep

  • » Withdrawal side effects – such as shivers, diarrhoea, nausea and body aches

Source: MHRA tinyurl.com/MHRA-opioid-risk

When should opioids be used – and when not?

‘Opioids are useful for managing acute postoperative pain or for procedural pain – such as insertion of a chest drain or a biopsy,’ says Felicia Cox, nurse consultant and head of pain services at the Royal Brompton and Harefield hospitals and co-ordinator of the Pain Nurse Network. ‘They can also be used for shortness of breath for patients who have long-term respiratory disease, such as chronic obstructive pulmonary disease, because they can relieve anxiety and that sensation of breathlessness.’

Opioids are also used for cancer pain and pain experienced towards or at the end of life.

‘Opioids should be used for controlling acute pain, so after surgery or any other trauma, but also for pain management when pain is moderate to severe,’ says Ms Shah. ‘You wouldn’t jump to morphine as a first line if someone has mild pain.’

Opioids are not appropriate for every pain, says Ms Crighton. ‘If it’s inflammatory pain, opioids wouldn’t necessarily do a lot, so you’d be better off having an anti-inflammatory drug,’ she says.

For neuropathic or nerve pain, some opioids such as tramadol can have an effect, but it is better to try other options, like low-dose antidepressants or gabapentinoids, adds Ms Crighton.

She recommends basing the decision on whether to initiate or stop opioids on how well a patient is functioning, as well as the patient’s assessment of their pain. That means looking at whether the opioid is helping the patient to be able to do things like walk, sleep and eat, and to do things important to them, such as going to work.

Some opioids will not be effective for everyone, adds Ms Cox. ‘You need certain chemicals in your liver to break down morphine and codeine into suitable analgesic agents,’ she says. ‘Around 10% of the population doesn’t have that enzyme – it varies by ethnicity – so not everyone gets good pain relief from codeine and morphine.’ Switching to another opioid can sometimes be the answer, she says.

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Opioids are used for cancer pain and pain experienced towards or at the end of life

Picture credit: iStock

Side effects of opioids

Side effects are common with opioid therapy. The most common include:

  • » Nausea

  • » Vomiting

  • » Constipation

  • » Pruritus (itchy skin)

  • » Dry mouth

  • » Drowsiness

With the exception of constipation and itching, most side effects improve shortly after initiation of treatment or following an intended dose increase.

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Opioids also have an effect on respiratory physiology, causing irregular respiratory pauses that can lead to erratic breathing and variability in respiratory rate. Some people also experience respiratory depression. This is mostly a concern in acute pain management where patients have not developed tolerance to opioids. For persistent pain, respiratory depression is most likely to be a problem if there has been a large – often unintended – dose increase or changes in the formulation of the drug or route of administration.

Patients can also develop a tolerance to opioids, which is why it is important to titrate or alter the dose.

Source: Faculty of Pain Medicine of the Royal College of Anaesthetists tinyurl.com/opioids-effects

Are opioids good for long-term pain relief?

‘There isn’t a huge amount of evidence for the use of opioids for long-term pain,’ says Ms Crighton. ‘Apart from in palliative care or patients with cancer pain, people may be on opioids for a long time if they are having ongoing treatment that is causing severe pain that affects their ability to function.’

Opioids do not tend to be indicated for ongoing treatment of non-malignant (non-cancer) pain, such as arthritis, fibromyalgia or back pain, she adds.

‘There is evidence that taking opioids long-term can actually increase your pain level – you develop what’s called opioid-induced hyperalgesia, which basically means that the more you take opioids, the more pain you get,’ Ms Crighton says,

Initiating opioids in general practice for a long-term condition should be done with great care, says Ms Cox. ‘It’s only suitable for a small proportion of patients. You would have a time-limited trial of six weeks or so, and you would want the patient to report and demonstrate an improvement in function,’ she says. ‘If they don’t report an improvement in function or pain relief, the opioids are not working and the trial should be stopped.’

Opioids: resources

  • » Opioids Aware from the Faculty of Pain Medicine has information on best practice, understanding pain and pain medicines, and clinical use of opioids fpm.ac.uk/opioids-aware

  • » Live Well with Pain has resources for health professionals and patients, including an opioid zone with information on starting an opioid prescription and reviewing prescribed opioids livewellwithpain.co.uk

  • » The Pain Toolkit has useful information for people living with persistent pain and the healthcare teams supporting them, including advice on self-management of pain, workshops and webinars paintoolkit.org

Are opioid medications dangerous?

Opioids have a serious risk of addiction, particularly with long-term use, says the Medicines and Healthcare products Regulatory Agency. A study in the Journal of the Royal Society of Medicine, published in February, shows that opioid-related hospitalisations in England increased by 48.9% between 2008 and 2018 – from 10,805 admissions to 16,091.

The authors say that although hospitalisation and mortality rates are less pronounced than other countries – there are approximately 130 deaths due to opioids each day in the US – opioid use as an ‘increasing public health concern in England’.

Ms Crighton says it is difficult to say how much of a problem it is because official figures do not differentiate between people who become addicted after being prescribed opioids, and those who get them by other routes.

Read this article in full at rcni.com/students-opioids

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