Opioids and prescribing

Opioid painkillers, including codeine: what has changed and why?

You may notice that we now prescribe opioid painkillers in smaller quantities and for shorter periods, and if you take one regularly, we may invite you for a medication review. This is not about doubting your pain. It is about making sure the medicines you take are genuinely the right medications for you, and are not quietly doing you harm.

What we mean by opioids

Opioids are morphine-based painkillers: codeine and co-codamol (codeine combined with paracetamol), dihydrocodeine and co-dydramol, tramadol, and stronger drugs such as morphine and oxycodone. Codeine-containing medicines are by far the most commonly prescribed opioids in Devon.

Good for short-term pain, poor for long-term pain

Opioids are the strongest painkillers available and can be very effective for severe, short-lived pain: after surgery, after an injury such as a broken bone, or as part of cancer care. Used briefly, at the lowest effective dose, they are usually safe.

For pain lasting more than about three months, the evidence points the other way.

When you start an opioid, or increase the dose, pain usually settles for a few days or weeks. Your body then adapts and the pain returns to roughly where it was, but you are now on a higher dose with more side effects. This is called tolerance.
Opioids can also make you more sensitive to pain, at any dose. This is called opioid-induced hyperalgesia. The medicine can end up causing some of the pain it was meant to treat.
Codeine is converted into morphine by the body, and people vary a great deal in how fast they do this. Around three in every hundred convert it very quickly, so a routine codeine dose can act like a much larger dose of morphine.
The National Institute of Clinical Excellent (NICE), which sets NHS treatment standards, found no good evidence that opioids help chronic primary pain and advises against their use in chronic pain or starting them for it.

(NG193: https://www.nice.org.uk/guidance/ng193 )

Its guidance on low back pain and sciatica takes a similar

(NG59: https://www.nice.org.uk/guidance/ng59 )

The Faculty of Pain Medicine puts it plainly in its ‘Opioids Aware guidance’ : if you are taking an opioid and are still in pain, the opioid is not working and should be stopped, even if nothing else is available to replace it.

(https://fpm.ac.uk/opioids-aware/information-patients )

The MHRA, the UK medicines regulator, warned in 2020 that using opioids for more than three months for non-cancer pain significantly increases the risk of dependence and addiction. Opioid packs now carry an addiction warning for this reason.

The risks around opioid use

Common side effects include constipation, nausea, drowsiness, dizziness, itching, weight gain, low sex drive and reduced fertility. The more serious risks include:

– Falls and fractures – Older people taking opioids are around twice as likely to have a fall.

– Dependence and addiction – Uncommon after a short course, much more likely with continued use over weeks to a few months.

– Breathing problems – particularly at night and especially if you have sleep apnoea.

– Dangerous combinations – Risks rise sharply when opioids are taken with alcohol, benzodiazepines such as diazepam, or gabapentin and pregabalin.

– Medication overuse headache – Taking painkillers on more than about ten days a month can start to cause headaches in itself.

– Driving and heavy machinery use – You may drive on prescribed opioids if you follow your prescriber’s instructions, but it is illegal to drive if you are impaired. Take particular care in the days after starting or changing a dose.

How is Devon doing with opioid prescribing?

Recent prescribing data reviewed by NHS Devon shows that Devon is an outlier compared to the national average of opioid prescribing:

– People in Devon are about 10% more likely to be prescribed an opioid than the England average (5.7% of the population against 5.2%).

– Nearly two thirds of Devon patients on an opioid are given a codeine-containing medicine, more than all other opioids put together.

Around three quarters had been receiving it for at least 6-9 months, pointing to long-term rather than short-term use, which is not advised by guidelines
More than half of those long-term users are 65 or over, the group most vulnerable to falls.

How we will prescribe opioids at Albany?

All practices in Devon and across the England, are being advised to prescribe opioids less and reduce patients who have been on them for a long time or for chronic pain off of them, in line with guidance.

To keep prescribing safe and consistent, we are adopting the following approach:

– Short, defined courses – New opioid prescriptions will be for small quantities and a set number of days, typically a 2 week course, with a clear plan for stopping, and issued as one-off acute prescriptions rather than added to your repeat list.

– Lower strengths and doses – Where codeine or an opioid is still needed, we will aim for the lowest strength and smallest quantity that keeps your pain manageable and reduces the risks of addiction and side effects.

– Separate paracetamol and codeine prescriptions – Where appropriate we may change co-codamol to separate tablets, so the codeine dose can be adjusted on its own. Most people then take less of it while keeping the same pain control.

– Regular review – Repeat prescriptions will be reviewed by our practice pharmacist or GP at set intervals to check the medicine is helping and is still safe and to review and institute step wise reductions.

– Early or excess requests – If prescriptions are requested ahead of schedule or are taken in larger quantities than agreed, we may decline the request, future date the prescription for when it would have been due and arrange a medication review before more is issued/or to discuss future issues. This is a safety check, not a punishment.

– Prescribing agreements – For some patients we may put a written agreement in place setting out what will be prescribed, how often, and who will review it, so everyone has the same understanding.

– Lost or stolen medications – due to the risky nature of these medications and because some opioids are controlled drugs, secure storage of these is vital for safety. If you lose your opioids medication or it is stolen, we may ask for a police crime number, if this happened recurrently we may decline to issue more.

If your opioid medication dose is being reduced

Please do not stop suddenly, stopping abruptly can be unpleasant and, in some cases, unsafe, in most cases a gradual reduction and withdrawal of medication is the best approach.

We will gradually be arranging for patients, who have been taking opioid medications for longer than 3 months, or who have no clear indication/reason for being on them or who are on them for chronic pain/back pain, to have a medication review with our practice pharmacist or GP. Together you and clinician will discuss the risks and benefits and arrange a gradual reduction in medication dose/strength. Reductions go at a pace you can manage, and can be paused, It can take many months, sometimes up to 2 years to come off of these medications, fortunately many people, who reduce gradually find their pain is no worse, and once off of them often get better response to opioids medications of needed as an acute short course in the future.

The local pain team recommends reducing by around 10% every week, with a pause of about a month after every 30% reduction. At that pace most people get no withdrawal symptoms and only small, short-lived flares in pain with each step down.

Specialists are clear that gradual withdrawal is safe and generally does not make pain worse. Most people who reduce carefully find that after a few weeks their pain is no worse than before, their head is clearer, and they feel less tired and muddled. Our local NHS pain service also asks that opioid reduction is underway or complete before they take on a referral, because opioids can mask what is really driving the pain.

Please do be aware that if you request your medication early or have taken more than is advised on your prescription, you may be switched to shorter duration issues of your medication eg 7 or 14 days, this is part of safe prescribing procedure and not a judgement on you. From time-to-time patients may also be asked to sign a prescribing agreement, that explains the risks of the medication and how often it will be issued and in what circumstances it will not be issued.

What other measures can help?

Long-term pain is rarely fixed by a tablet, in fact there is no single painkiller shown to help chronic pain in every case, which is why guidance advises against opioids for this. Stress, poor sleep, low mood, past trauma and worries about money or housing all feed into how much pain you feel, and addressing them often helps more than medication. Discussing how best to address these with your GP can be helpful. These resources are also worth exploring:

– ReConnect2Life – the local NHS pain rehabilitation programme

🌐 https://www.torbayandsouthdevon.nhs.uk/services/pain-service/reconnect2life/

– Opioids Aware: information for patients

🌐 https://fpm.ac.uk/opioids-aware/information-patients

– Live Well With Pain

🌐 https://livewellwithpain.co.uk/

– Tame The Beast

🌐 https://www.tamethebeast.org/

– TALKWORKS – free NHS talking therapies you can refer yourself to

🌐 https://www.talkworks.dpt.nhs.uk/

– NHS guidance on opioid medicines and the risk of addiction

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