Published courtesy of The Times where this article originally appeared in September 2019.
Closing the stable door after the horse has bolted is an occupational hazard in medicine where the risks of an intervention may only become apparent many years later. And the latest example is the use of opioid painkillers in long-term (chronic) pain. Once regarded as a useful ally when helping people with conditions like back pain, the recent increase in prescribing is now widely regarded as an indicator of poor practice.
Over the last few years doctors, particularly GPs, have been bombarded with warnings about excessive prescribing of opioids for long-term pain. The Scottish Intercollegiate Guidelines Network (the Scottish equivalent of Nice) has become the latest to join the fray by publishing new guidelines recommending much closer monitoring and follow-up of anyone prescribed these strong painkillers.
The opioid family includes codeine, tramadol and morphine and there has been a marked increase in both the amount and strength prescribed, with people in the UK now taking the equivalent of double the number they did just a decade ago. Perhaps more worrying is that this rise has been set against growing evidence that the drugs don’t work that well in long-term pain, and exact a considerable toll through side effects ranging from sedation, to addiction and overdose.
A recently convened expert working group from the UK’s Commission on Human Medicines will soon produce guidance – for both prescribers and patients – aimed at curbing “over-prescription and misuse of these medicines”. In the meantime, here are five things everyone taking an opioid painkillers should know.
- If you have been prescribed opioid drugs like codeine, tramadol or morphine for short-term pain (such as following an operation), or you have cancer or a life-threatening illness, then they are likely to help you. However, if you are taking them long term (12 weeks or more) for non-cancer type problems, like back pain or arthritis, then be aware that there is very little evidence that they work well for people like you, and lots to show they cause harm.
- If your painkillers are working well, and you are not troubled by side effects, then your prescription is likely to be appropriate. However, if you are still in pain despite high doses, they are not working and, rather than increase the dose as typically happens, you and your doctor should seriously consider reducing and stopping the medication and looking for an alternative. If you are on very high doses (the equivalent of 90mg of morphine a day according to the latest SIGN guidance – see sidebar) then there is a very good chance that your medicines are doing more harm than good.
- If you have just started taking a drug like codeine for a long-term problem and you don’t get any pain relief within the first few weeks despite being given a reasonable dose (up to 200mg codeine a day – the equivalent of 20mg of morphine), you probably never will. So be careful not to slip into the trap of taking ever higher doses of stronger drugs.
- Be aware of, and report any side effects. At the milder end of the spectrum, common problems include itching, constipation, sedation, reduced sex drive and inability to get an erection. At the other end, opioids are associated with an increased risk of falls, fractures, heart attacks and can be addictive (at least 1 in 10 people taking them are thought to be dependent on the drugs).
- Take them for the right reason. It is a difficult area to raise with patients but many people with long-term pain have complex psychological issues too. Often it is simply because they have been in such discomfort for so long, but problems like anxiety, depression, and past sexual and emotional abuse are all more common in those taking long-term opioids than the rest of the population. And using opioids to numb this sort of “pain” is not appropriate. There are better ways to help, with far fewer side effects.
You can read the new SIGN guidance on managing chronic pain at https://www.sign.ac.uk/assets/sign136_2019.pdf
- Codeine is the weakest of the commonly prescribed opioids, with morphine, diamorphine and fentanyl sitting at the strongest end of the spectrum
- Opioid pain killing properties vary from person to person but as a rough guide, 10mg of morphine is equivalent to 100mg of codeine, or 67mg of tramadol. For a more detailed list of equivalent doses visit https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware/structured-approach-to-prescribing/dose-equivalents-and-changing-opioids
- According to NHS guidance in my area, if you are taking a long-term opioid you should be followed-up, and the dose and strength reviewed, at least every 6 months.