Patient information Using strong Opioids to control your pain Published: April 2013. Date for review: April 2016 Introduction This leaflet explains what strong opioids (pronounced oh-pee-oyds) e are and what you need to know about them. It will support conversations that you have with your doctor or specialist nurse. What are opioids? The words strong opioid describes a type of strong painkiller that is used to treat moderate to severe pain. Examples of strong opioids are morphine, oxycodone and fentanyl. For this leaflet we mainly discuss morphine because it is usually the first strong opioid that doctors will offer you. Why am I being prescribed morphine? Morphine is prescribed to treat moderate to severe pain. People who take morphine have usually tried a number of other painkillers like regular paracetamol or codeine. Codeine and co-codamol (codeine plus paracetamol) are preparations of weak opioid painkillers. Codeine is converted to morphine by our bodies. This means that people taking codeine are already on a low dose of morphine. However, codeine and other simple painkillers are often not strong enough to control moderate or severe pain and this is when morphine is recommended. So, what are the benefits of taking morphine? Well, pain can affect your mood and how much you re able to do. Morphine has an important role in getting pain more under control so that you feel better in yourself and are able to get on with some of the things you d like to do. But isn t morphine just used in the last stage of life? No, morphine is used to control pain at any time of life, for example morphine is often used when people are recovering from surgery. Other people, living with long-term pain, are on the same dose of morphine for many years because morphine helps them to keep pain under control so that they can live life more fully. 1
Will I become addicted to morphine? It is extremely rare for people with pain to become addicted to morphine. People who are addicted to a drug crave taking the drug for the feeling of wellbeing that it can give, and continue taking the drug despite the drug causing them harm. This is very different from taking a medicine as prescribed by your doctor, with the aim of controlling your pain and allowing you to do some of the things that you like to do. e If you take morphine for a long time your body can get used to morphine. If you suddenly stop taking morphine the pain may come back and you may get withdrawal symptoms. If you feel that you would like to reduce your dose or stop taking morphine this is perfectly possible, but the dose must be reduced gradually to allow your body to re-adjust. It is very important you contact your doctor or specialist nurse to make a plan together before making any changes to your dose of morphine. What are the side-effects? The most common side-effects are: Constipation: All strong opioid painkillers cause constipation. If you re taking strong painkillers, you should also take a laxative throughout your treatment. Drinking plenty of fluids, eating food that s high in fibre and keeping as active as possible can help you to open your bowels but these measures are not usually enough to overcome morphine-related constipation. It is important to keep taking your laxatives regularly (usually every day). When you open your bowels you should still take your laxatives that day and continue to take them regularly. This is because most laxatives that are taken by mouth will not act immediately but can take at least 1 day to take effect. If you only take laxatives when you are already constipated then it s a lot more difficult to treat your constipation. Sickness (or nausea and vomiting): some people feel sick or even vomit when they start taking morphine. This often goes away by itself after the first week of treatment. If you do feel sick, your doctor can offer you a medicine to stop this. Drowsiness: you may find you can t concentrate so well or feel more sleepy than usual. This often wears off after a week of taking the morphine regularly. If you do find it difficult to concentrate do not use machinery, sharp tools or drive (see section on driving below). Occasionally, when people take morphine they can feel very drowsy and can see or hear things that are not really there (hallucinate). It is important that you contact a doctor or specialist nurse if this happens because the dose or type of your opioid painkillers may need to be changed. 2
How and when do I take Morphine? Morphine can be taken in a number of ways, other than by mouth; these alternatives can be helpful if you can t swallow or are being sick. a However, since morphine is usually taken by mouth, that s the option we ll discuss now. Usually, people take a combination of two different forms of morphine: 1) a long-acting (or sustained-release) form. 2) a fast-acting (immediate-release) form. Long-acting morphine is taken as tablet or capsule that contains a substance to ensure that the morphine is slowly and gradually absorbed over 12 hours. This helps to prevent ongoing pain. Long acting medication is usually taken twice a day with each dose taken 12 hours apart, so for instance at 8am in the morning and 8pm at night. Fast-acting morphine can be taken as a liquid or a tablet. Liquid morphine has a bitter flavour that can be improved by mixing it with a fruit drink. a It starts working quickly, after about 20 to 30 minutes. The painkilling effect lasts for 3-4 hours. If your pain flares up, despite your taking your regular pain relief, you can take a rescue dose of fast-acting morphine to relieve this pain. Doctors and nurses may use the term breakthrough pain to describe this occasional pain that breaks through despite your taking long-acting painkillers. When you are first prescribed morphine, your doctor may suggest that you take fastacting morphine every 4 hours over a 24 hour period. This helps to see how much morphine you need in 24 hours to control your pain. Once the best starting dose for you is decided then your doctor can prescribe long-acting morphine tablets/capsules of the right strength. What are you taking? Here is a space to write down your long- and fast-acting opioid: Long-acting opioid:... Fast-acting opioid:... How many doses of rescue (also called breakthrough ) fast-acting morphine can I take in a 24 hour period? Often people need 1 or 2 doses of the fast-acting rescue doses of morphine over a 24 hour period, on top of their long-acting morphine. Rescue doses should be taken when you need them, but no more frequently than 1 dose each hour. 3
If you need 3 or more rescue doses in 24 hours, do take them and contact your doctor or specialist nurse to let them know. This is because your regular morphine dose may not be sufficient and may need to be reviewed. Some people keep a diary of their rescue doses and this is really useful for the doctor or nurse looking after you. What should I do if I forget to take a dose of my LONG-acting opioid? You can take a dose of your LONG-acting opioid painkiller up to 4 hours late. However, if it s MORE than 4 hours late you should take a dose of your FAST-acting opioid instead, and take further doses of your FAST-acting opioid every 4 hours until it s time for your next dose of the LONG-acting opioid. Examples: 1) Pam usually takes her LONG-acting opioid painkillers at 7am and 7pm. One day she forgets to take her evening dose. She remembers at 10pm that she s forgotten her evening dose. As she s only 3 hours late in remembering her dose, she knows that it s safe to take her evening long-acting dose now. She then takes her morning dose at the normal time of 7am. 2) James usually takes his morning dose of LONG-acting opioid painkiller at 8am and 8pm. One day, he forgets to take his morning dose of LONG-acting opioid tablets with his breakfast. He then goes out doesn t get home until 1pm. As he is 5 hours late in taking his LONG-acting opioid tablets he knows that it is too late to take the dose now. Instead, he takes a dose of his FAST-acting opioid immediately and another dose of FAST-acting opioid at 5pm (4 hours later). He takes his evening LONG-acting opioid at the normal time of 8pm. Will the opioid painkillers become less effective as time goes on, meaning I will need more and more? It is very unusual for the painkilling effects of morphine to wear off as time goes on (this is called tolerance ). So, why does the doctor keep increasing my dose of morphine? When morphine is first started, it s common to start at a low dose and build up gradually to a dose that controls your pain. a Different people need different doses of painkillers. People vary in the type of pain they are experiencing and the way they absorb and process painkillers. It is therefore not always possible to say exactly what dose you may need from the outset. If your pain gets better or worse, the dose of your opioid painkiller can be adjusted. If the pain gets worse, you may only need a small increase in the dose to get your pain under control again, but if your pain is very bad, your doctors may increase the dose by a larger amount this is more likely to get on top of your pain than a smaller increase in the dose. a Equally, if your pain gets better the dose of morphine can be reduced slowly. Some people find that once they are on the right dose of morphine for their pain, they stay on that dose for some time. Your doctors and nurses will work with you to get the dose of opioid right. 4
Can I take opioids with other medication? Yes. Morphine does not usually cause problems with your other, regular medication. In fact it is often prescribed in addition to other painkillers, such as regular paracetamol or ibuprofen, because they work in different ways to help reduce your pain. If your pain is not controlled on codeine, your doctor may decide to switch to morphine and stop the codeine. Codeine works in a similar way as morphine, but has a weaker effect, so taking both morphine and codeine is not usually beneficial. Does morphine always work for pain? Although morphine is a strong painkiller, it does not work for all types of pain. If you have tried morphine and your pain has not responded to it, despite increasing the dose of morphine, your doctor can discuss other treatments and options with you. Can I drink alcohol? Alcohol and opioids together can cause sleepiness and poor concentration. c When you first start on opioids or when your dose has just been increased, you should avoid alcohol completely. c Once you are on a steady dose of opioid you should be able to drink moderate amounts of alcohol. c However, you may find that you notice the effects of alcohol after drinking a much smaller amount than usual. You should not drink alcohol if you are going to use machinery, sharp tools or drive (see below). c Is it safe for me to drive if I am taking opioids? Your ability to drive depends on many different factors and you will need to use your judgement to decide if you are safe to drive or not. Here is some advice on driving when taking strong painkillers: You should not drive for 5 days after starting or changing the dose of your strong painkiller. Sometimes you may need to wait longer before you are ready to drive again. You must not drive if you feel sleepy. You must not drive after drinking alcohol or taking strong drugs that have not been recommended by your doctor e.g. cannabis. You must not drive if you start taking other drugs that cause sleepiness, either prescribed by your doctor or bought from the chemist e.g. hay fever medicine. You must not drive on days where you have had to take extra ( breakthrough or rescue ) doses of a strong painkiller. d Restarting driving If after 5 days you are not sleepy, you may start driving. Make your first trip: Short On roads that you are familiar with At a time when the traffic is not too busy 5
You may find it helpful for an experienced driver to accompany you. d Your GP or a member of the Specialist Palliative Care Team will be happy to help you decide when it is safe to drive. d Drivers Vehicle Licensing Agency (DVLA): You do not need to inform the DVLA that you are starting a strong painkiller. However, there may be other information about your illness that the DVLA needs to know. Your doctors or the DVLA can advise you about this. d How to contact the DVLA: Telephone - 0870 600 0301 for licensing enquiries. Have your driving licence number available. Website address - www.dvla.gov.uk Postal Address - DVLA, Longview Road, Morriston, Swansea, SA99 8QD. Car insurance: you may need to inform your motor insurance company about your current state of health and what medication you are taking. Each insurance company is different. It is best to discuss your circumstances with your insurance company to be sure that you are covered. d Who will keep a check on the morphine? The doctor and medical team that have first prescribed the morphine should give you information on how you will be followed-up. Ask your medical team about follow-up if you are unsure. Usually, in the initial phases of taking morphine, your medical team may see you frequently to establish the right dose for you. Your medical team might be your GP practice, an oncologist or your specialist palliative care team. It is helpful to keep a record of your key professionals, and your GP should always be informed about medication changes. What if something goes wrong outside normal working hours, when my usual team is not around? If you are in hospital, call the nurse and explain what you are experiencing. If you are at home contact your Out-of-Hours GP service. Their phone number is available locally and your GP surgery s answer-phone message should provide you with their phone number. Your doctor may also provide you with contact details for your local specialist palliative care team. If you, your family or carer(s) are worried that there is something seriously wrong, you must call 999 straight away. 6
It is worth writing all these local contact numbers down and keeping them close to hand, ideally by your landline phone or stored in your mobile telephone. Your GP:... Your Community District Nursing Service:... GP Out-of-Hours medical provider number:... Community Palliative Care Team:... Palliative Care Out-of-Hours advice line:... Other (state who)...:... How do I store morphine? Morphine is a powerful drug and so it must be stored carefully. Here is some advice to keep you and your family safe: It is important that only you take the morphine prescribed for your pain. You should keep your morphine out-of-sight in a locked cupboard. Morphine should be kept out of the reach of children, vulnerable adults and pets. Make sure that all your medications are properly labelled. Your medicines should be kept in a dry, cool place (not in the bathroom cupboard!). Check that your medication is still in date. e 7
This information leaflet This information has been written as a joint venture between Wye Valley NHS Trust and St. Michael s Hospice to comply with the guidelines on the use of strong opioids in palliative care from the UK s National Institute of Clinical Excellence (NICE). Authors: Dr Olivia Bush and Dr Sally Johnson. Correspondence to: Palliative Care Dept., Macmillan Renton Unit, Wye Valley NHS Trust, The County Hospital, Union Walk, Hereford. HR1 2ER Website: www.wyevalley.nhs.uk Thank you to the Specialist Palliative Care Team at Velindre Hospital NHS Trust who have allowed us to amend their comprehensive leaflet for our use in Herefordshire: M Tauber, N Pease, M Jefferson, R Owen Opioids in Palliative Care version 2.0: [Online]. Available from: http://www.wales.nhs.uk/sites3/page.cfm?orgid=357&pid=4903 [accessed January 2013] Other References: a. Macmillan Using strong painkillers for cancer pain [Online] Available from: http://www.nhs.uk/ipgmedia/national/marie%20curie%20cancer%20care/assets /StrongpainkillersforcancerpainMCCC5pages.pdf [accessed January 2013] b. Macmillan Overview of painkillers for cancer pain [Online] Available from: http://www.nhs.uk/ipgmedia/national/macmillan%20cancer%20support/assets/p ainkillersforcancerpainmcs6pages.pdf [accessed January 2013] c. British Pain Society Opioids for persistent pain: Information for Patients [online] Available from : http://www.britishpainsociety.org/book_opioid_patient.pdf [Accessed January 2013] d. N Pease Strong Painkillers and Driving [online] Available from: Hereford NHS Trust intranet, not publically available. e. Pain Relief Foundation Strong opioids for chronic pain [online] Available from: http://www.painrelieffoundation.org.uk/docs/painseries%20-%20strongopioids.pdf [Accessed January 2013] 8