Reducing and Stopping Opioid Medicines | Hull University Teaching Hospitals NHS Trust

Patients, family, friends and carers can play an important role in the safe use of these medications and in reducing the risk of harm. Please share this information with them.

Most of your questions should be answered by this leaflet. It is not intended to replace the discussion between you and your doctor but may act as a starting point for discussion. If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team caring for you.

What are Opioid Medications?

Opioids are a type of medication that help to relieve pain. They are very effective over short periods of time to relieve moderate to severe pain. Opioids provide pain relief by acting on areas of the brain and spinal cord to block the transmission of pain signals. Opioids are considered, to be the strongest painkillers available, and are used to treat pain after surgery, serious injury and cancer. Opioid drugs can help to manage some but not all types of chronic pain.

Examples of opioids include Codeine (including Co-Codamol), Tramadol, Fentanyl, Buprenorphine, Morphine and Oxycodone.

These medications come in many different forms, such as injections, tablets, capsules, liquids and patches.

Why stop taking Opioid Medications?

Opioids are strong painkillers which are very effective for treating short-term pain after surgery or after an accident. This is known as acute pain. Acute pain, by definition, is pain that lasts for less than three months.

Opioids do not help long-term, chronic pain, and are not safe to use for longer periods of time. Long-term use of opioids can cause a range of side effects, addiction and even early death.

Oxycodone and Fentanyl are opioid medications which are even stronger than morphine. It is useful to work out the morphine equivalent dose for people who are taking these drugs to highlight how strong these medications are.

For example, 20mg of Oxycodone slow-release tablet is equivalent to 40mg of oral morphine a day and a Fentanyl patch 25mcg with a 72 hour duration is equal to approximately 60mg of oral morphine a day.

Current evidence highlights links between long term opioid use, tolerance and increased pain perception. “Opioid tolerance and increase in pain perception may occur in patients taking opioids. Opioid tolerance is likely if patients are taking more than 60mg of morphine a day, or its equivalent from other opioid medications, for 7 days or more” (Neilson, et al. 2016; Colvin, Bull, and Hale 2019). Research from the USA shows that people who take more than 100mg of morphine equivalent per day have an increased risk of death, from overdose or side effects, compared to people who take no opioids or a very small dose.

Side Effects of Opioids

The most common side-effects of opioid medications include the following:

· Nausea	· Vomiting	· Constipation
· Itching	· Drowsiness

For further information on using opioids safely and a full list of possible side effects please refer to the Patient Information Leaflet that came with your opioid medication and keep it handy.

Opioid medications can cause some problems when you take them for a long time. These problems include:

· Constipation	· Itching
· Weight gain	· Lack of sex drive
· Difficulty breathing at night	· Reduced ability to fight infection
· Increased levels of pain	· Reduced fertility
· Irregular periods	· Erectile dysfunction in men
· Opioid induced pain sensitivity

Long-term use of opioids can lead to opioid-induced sensitivity. This means that you may become more sensitive to pain. You may notice that gentle touch can feel painful and that something that you would expect to hurt a bit, such as a needle may be extremely painful. So, rather than helping to reduce your pain, the opioids can make your pain system more sensitive.

Stopping opioids completely can reverse this effect, so you may find that your pain gets better once you have stopped taking your opioids.

Can I Drive when I am taking Opioids?

In 2015 the law on drugs and driving changed, stating that if your driving is impaired for any reason, including taking prescribed medications, it is illegal to drive.

All opioid medications have the potential to impair driving. You are responsible for making sure you are safe on each occasion that you drive. The law in the UK allows you to drive if you are taking prescribed opioid medications in accordance with the instructions, however:

YOU SHOULD NEVER DRIVE IF YOU FEEL IMPAIRED OR UNSAFE.

How do I Know if I am Becoming Addicted Or Dependent?

Opioids can become less effective with time (this is called tolerance) meaning your body has got used to the pain-relieving effect of the medication. You can also become dependent on opioid medication (dependence). This means that if you stop taking the drug suddenly or lower the dose too quickly, you can get symptoms of withdrawal which can include the following:

· Tiredness	· Sweating
· Diarrhoea	· Runny nose
· Aching muscles	· Stomach cramps

What about addiction to opioids?

Addiction can happen gradually. It can make you feel that you are no longer in control of how much medication you need to take or how often you need to take it. You might feel that you need to carry on taking your medication, even when it doesn’t help to relieve your pain.

Talk to your doctor if your pain is becoming difficult to manage as your body may not be sensing its pain-relieving effect. This is referred to as “opioid tolerance” and could be an early warning sign that you may be at risk of becoming addicted to opioid medications.

Signs that you may be addicted to opioids include:

Craving for the medication
Feeling that you need to take more medicine than prescribed or as instructed on the medication packaging, even if it is causing bad effects on your overall health
Feeling that you need to take additional medications containing opioids or other pain relief medications to achieve the same relief
Experiencing withdrawal side effects when you stop taking the medication suddenly (see list below)
Taking opioid medications for reasons other than pain relief

If you notice some or all of the above signs, please talk to your doctor or pharmacist for advice and support.

How can I Safely Stop taking my Opioid Medications?

If you have been taking your opioid medicine for a long time, do not stop taking it suddenly because this may cause unpleasant withdrawal side effects. It is important to get the right help and support when you are ready to stop taking your medications.

Talk to your doctor, nurse or pharmacist. They will be able to help you come off your opioid medication slowly to reduce the unpleasant withdrawal side effects. Safely coming off your opioids can take a long time, and everyone will have their own experience. Take any unused opioids back to the pharmacist for safe disposal.

Withdrawal side effects may include a combination of the following:

· Shivers	· Sweating	· Body aches
· Diarrhoea	· Widespread pain	· Increased pain
· Difficulty sleeping	· Nausea and vomiting	· Irritability and agitation

If you experience any of the above symptoms, then please talk to the person who prescribed your medication or your GP or pharmacist.

It is important to build a support network of family and friends who can understand that this is an important but difficult process for you to do. It can take a long time to stop taking your opioids altogether and to feel back to normal, so this ongoing support is essential to help you succeed. The following section contains a list of resources and advice to help you manage the reduction and stopping of your opioid medication.

Advice and Resources

Learning to live well with pain – Learn to accept that you may have chronic/persistent pain and learn ways to manage it while keeping focused on living a full and meaningful life. This is often the most important step forward in helping to reduce and stop your opioid medication.
Support – Build a support network of friends, family, healthcare professionals, work colleagues, etc. to help understand the process you are going through. There are many support groups and charities in communities and online that may be able to offer further advice and support.
Talking Therapies – You may find that you become more anxious, irritable or depressed while reducing and stopping your opioids. If this becomes a problem, then it may be useful to speak with your GP or refer to the available Talking Therapies services.
Relaxation and Distraction These are useful skills to develop, especially if you experience any unwanted side-effects of reducing your opioid medication. These could include:
- Reading a book
- Going for a walk
- Listening to music
- Watching a film
- Meditation and breathing exercises
Record your progress – Healthy changes start with little changes. It can be useful to see how far you have come and remind yourself of what you have achieved. Losing weight, drinking less alcohol, quitting smoking and exercising can help to improve your mood and enable you to be better equipped to manage your pain. Visit nhs.uk/better-health

There are many resources which can help you to understand and manage your pain available to access on the Internet. Listed below are some useful resources:

General Resources:

The Pain Toolkit – A useful and practical guide for people living with persistent pain.

Website: www.paintoolkit.org

British Pain Society – A professional group dedicated to understanding and managing pain.

Website: www.britishpainsociety.org

Live Well With Pain – A group of healthcare professionals using a self-management approach to help patients manage pain.

Website: www.livewellwithpain.co.uk

Pain UK – A UK charity dedicated to providing a voice to people with pain.

Website: www.painuk.org

Headspace App – A mindfulness and meditation app that offers guided exercises to help manage stress, anxiety, and pain.

Website: www.headspace.com

Video Resources:

Hunter Integrated Pain Service (Australia) – A five-minute overview of chronic pain.

Video: www.youtube.com/watch?v=5KrUL8tOaQs

Brainman Stops His Opioids – A video explaining how to manage opioid use.

Video: www.youtube.com/watch?v=MI1myFQPdCE

How Your Mood Can Affect Your Pain – A video explaining the relationship between mood and pain.

Website: www.tamethebeast.org

HealthTalk: Chronic Pain Management – A video about managing chronic pain.

Website: www.healthtalk.org

Chartered Society of Physiotherapy – A video about back pain.

Video: www.youtube.com/watch?v=24P7cTQjsVM

World Health Organisation (WHO) Animated Videos:

Depression: www.youtube.com/watch?v=XiCrniLQGYc

Stress: www.youtube.com/watch?v=E3Cts45FNrk

Reporting Side Effects (Yellow Card Scheme):

If you experience side effects from your opioid medicines, you can report them directly to the Medicines and Healthcare products Regulatory Agency (MHRA) through the Yellow Card Scheme. You can report side effects in the following ways:

Via the Yellow Card website: yellowcard.mhra.gov.uk
By calling the free helpline: tel: 0800 731 6789.

REFERENCES

Medicines and Healthcare Products Regulatory Agency – Opioid Medicines and the Risk of Addiction (2020).

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

Opioids Aware 2016 – Faculty of Pain Medicine, Royal College of Anaesthetists.

Website: www.fpm.ac.uk/faculty-of-pain-medicine/opioids-aware

Moore, P. (2015) – The Pain Toolkit.

Website: https://www.paintoolkit.org

Nielsen S., Degenhardt L., Hoban B., Gisev N.A. (2016) – Synthesis of Oral Morphine Equivalents (OME) for Opioid Utilisation Studies.

Pharmacoepidemiology and Drug Safety, 25(6), 733-737.

DOI: 10.1002/pds.3945

Colvin L.A., Bull F., & Hales T.G. (2019) – Perioperative Opioid Analgesia: When is Enough Too Much?

Lancet (London, England), 393(10180), 1558-1568.

DOI: 10.1016/S0140-6736(19)30430-1

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Pain Service on tel: 01482 478868.