Opioids for Acute Pain Relief

What is acute pain?

There are several types of pain. Acute pain is pain that occurs immediately on or after a physical injury or surgery. It provides the body with a warning signal, that something is wrong. It is important to manage acute pain properly to avoid it developing into long-term chronic pain.

Acute pain can be experienced after an operation, one off accidents or sports injuries and usually gets better quickly over a few days or weeks.

What is an opioid?

Opioids are morphine like medications used to relieve acute, severe pain. Opioids should be used in the smallest dose for the shortest period of time and usually only need to be given for a few days to relieve acute pain following surgery or severe injury. Opioids help to reduce severe pain to a level where you can move, deep breathe and cough comfortably.

Opioids are often given with regular paracetamol. You may also be advised to take non-steroidal-anti-inflammatory (NSAIDs) medication such as ibuprofen or naproxen (as long as you do not have a history of stomach ulcers, aspirin sensitive asthma or poor kidney function). Paracetamol and NSAIDs can reduce the overall amount of opioid needed and should be taken regularly while you are experiencing acute pain.

Immediate release opioids taken by mouth

Morphine Sulphate solution 10mg in 5ml (Oramorph®) or Oxycodone liquid 5mg in 5ml (OxyNorm® Shortec®) are all types of immediate release opioids. The opioid liquid should take about 20 minutes to start working and the relief can last around 4 hours.

Immediate release morphine also comes in tablet form known as Sevredol®, while immediate release oxycodone comes in capsule form known as Shortec®. Both medications take about 30 to 60 minutes to start working and the relief can last around 4 hours.

As your pain improves you should increase the time between each dose of the opioid medication then over a few days stop taking it.

Modified release (slow release) opioids taken by mouth

Generally it is recommended that slow release opioids are not used for acute pain relief. Occasionally, for some patients the doctor may consider it appropriate to use this type of opioid.

Modified release (MR) opioids are types of pain relief medication taken by mouth that work slowly over 12 hours; they are taken twice a day.

Examples of MR opioids are: Morphine Sulphate tablet (MST®), Zomorph®, Filnarine ®SR, Morphgesic®SR, Oxycodone MR, Oxycontin®, Longtec®.

If you have been prescribed MR opioids you will be given a small supply (no more than a week) to take home when discharged. You will be given advice on how to take this medication and when to stop.

You may be stepped down to a weaker opioid such as codeine, by your GP, to help wean you off the MR opioids.

Other opioids

These are all pain relief medications used to treat moderate to severe pain. They start to work within 30 to 60 minutes and are usually taken 4 times a day.

Each co codamol and co dydramol tablet contains 500mg of paracetamol.

Tramadol is also available in a slow release preparation that is taken twice a day (every 12 hours).

How should I take my opioid medication?

You will be given instructions before leaving the hospital. Please note opioid medication is for the treatment of severe acute pain over a short period of time.

Advice

• As your body begins to heal a little each day, you should take less opioid medicine.
• Do not take additional pain relief containing codeine, dihydrocodeine or tramadol unless advised to do so by your doctor, as you will be more likely to experience side effects such as drowsiness or sedation.
• Do not start taking additional medicines to help you sleep, such as zopiclone or benzodiazepines (e.g. diazepam, lorazepam, temazepam) or medicines such as gabapentin and pregabalin (anticonvulsants used to treat some types of burning, shooting or stabbing pain) unless advised by your doctor or if you were taking these before your hospital admission. These medicines increase the risk of drowsiness and sedation.
• Always take prescribed opioids as instructed by your doctor - never take more doses than advised.
• Always read the directions on the label to see how much to take and how often.
• Do not take a larger dose or take more often than advised on the label.
• When taking liquid immediate release opioids, always use the oral purple syringe provided to measure your dose. After use, wash the syringe with warm soapy water, rinse and leave to dry.
• Never take opioids to help you fall asleep or manage anxiety or distress.

Are there any side effects when taking opioids?

The most common effects in the short term are:

Sickness (nausea)

To help prevent this, try taking your medicine with or just after a snack or meal.

Constipation

Make sure you are drinking plenty of water and try to include more high fibre food in your diet unless otherwise advised by the hospital. You may need a laxative if constipation is a problem.

Feeling sleepy or dizzy

This is common. If affected, do not attempt to complete complex tasks, such as operating machinery or even boiling a kettle. Do NOT drive.

Driving

Opioid pain medication can affect your ability to drive. It is illegal in England, Scotland and Wales to drive with legal drugs in your body if it impairs your ability to drive safely.

It is your responsibility to make sure that you are safe to drive. Speak to your GP if you are unsure whether you should be driving.

Further information can be found at: www.gov.uk/drug-driving-law

Can I have an alcoholic drink?

Do not drink any alcohol while taking opioid medication as this could increase drowsiness.

Will I become addicted?

Opioids have a serious risk of addiction, particularly with long term use. Therefore you should only take opioid medication for a few days, unless advised otherwise by your doctor or prescriber.

It is important that you do not take more opioid medication than you need.

If you are still in severe pain after a week, you should contact your GP for advice.

How should I store opioid medicines at home?

• Keep the medication in the original container and store at room temperature in a dry place.
• Keep out of the sight and reach of children.

What should I do with any unused opioid medicine?

• Return any unused medication to your local pharmacist for safe disposal.
• Do not flush unused medication down the toilet or throw it away.

Long term effects of opioids

Medical literature suggests that the risks to your health are increased when taking high dose morphine type medication for long periods of time (many months or years). It can cause:

• Reduced fertility.
• Low sex drive.
• Irregular periods.
• Erectile dysfunction in men (the inability to keep an erection).
• Reduced ability to fight infection.
• Increased levels of pain.
• Low mood.
• Dependence - the brain becomes reliant on the opioid medication, missing a dose or stopping it abruptly may cause withdrawal side effects.
• Tolerance to opioids: the need for larger doses of opioid to achieve the same level of pain relief.

Reducing your opioid medication

Suddenly stopping opioid pain relief can result in withdrawal type symptoms.

Withdrawal symptoms include:

• Shivers
• Diarrhoea
• Difficulty sleeping
• Sweating
• Widespread or increased pain
• Body aches
• Irritability and agitation
• Nausea and vomiting.

If you have been taking opioid pain relief for a few days or weeks, you can help to reduce the risk of these symptoms by gradually reducing the amount that you take over a few days.

On the next page is an example schedule for reducing short term use of tramadol, codeine, co codamol (contains paracetamol), dihydrocodeine, co dydramol (contains paracetamol) for acute pain.

If you are worried about any of these problems, please discuss this with your healthcare professional (GP, nurse or pharmacist) who will be able to tell you if you are at risk of developing these symptoms.

Further information

Taking opioids for pain Faculty of Pain Medicine, Royal College of Anaesthetists

Website: www.fpm.ac.uk/opioids-aware-information-patients/taking-opioids-pain

GOV.UK

Website: www.gov.uk/guidance/opioid-medicines-and-the-risk-of-addiction

Drug Driving Law

Website: www.gov.uk/drug-driving-law

Live well with pain

Website: https://livewellwithpain.co.uk/resources/opioid-zone/resources-to-use-if-starting-an-opioid-prescription/opioid-equivalence-risks-and-recommendations/

References

Opioids for Acute Pain Relief, Pharmacy Department, Dorset County Hospital

Opioids: Risk of dependence and addiction GOV.UK

https://www.gov.uk/drug-safety-update/opioids-risk-of-dependence-and-addiction

Live well with pain

https://livewellwithpain.co.uk/resources/opioid-zone/resources-to-use-if-starting-an-opioid-prescription/opioid-equivalence-risks-and-recommendations/

Opiate and Gabapentin reduction guidance for primary care

http://www.wales.nhs.uk/sites3/Documents/814/Opiate%26GabapentinoidReductionProtocolForABUHBprimaryCareFINAL.pdf

Taking opioids for pain

Faculty of Pain Medicine Royal College of Anaesthetists: https://www.fpm.ac.uk/opioids-aware-information-patients/taking-opioids-pain

The Medicines and Healthcare products Regulatory Agency (MHRA) Drug safety update September 2020 Opioids: risk of dependence and addiction

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/920770/Sept-2020-DSU-PDF.pdf

Tramadol patient information NHS

www.nhs.uk/medicines/tramadol/