This piece was written by one of our contributors; consultant anaesthetist – Anna Williams.
A flurry of alarming headlines, anecdotes and half truths about “addictive” prescribed opioids came pouring out of the US and British media in 2019. But what are the facts? How addictive are they? Should they be avoided at all costs?
The Office of National Statistics released data in August 2019 on the 2018 ‘Deaths related to drug poisoning in England and Wales’. They reported 4,359 deaths related to drug poisoning, both the highest number and the highest increase (16%) since the data was first collected. There is a caveat to this figure though, this encompassed all deaths related to drug poisoning that includes heroin, over the counter medication, but also deaths related to the complications of drug misuse such as severe infection (sepsis) and blood clots.
One of the big headline makers coming out of the US was ‘Fentanyl’ a potent opioid type painkiller with a rapid onset to affect and offset. In England and Wales there were 74 fentanyl deaths in 2018, which was very similar to the levels in 2017.
Most pain experienced by us is self-limiting and we either cope without taking anything, doing some exercise, making a hot water bottle – whatever helps for you, or take some simple over the counter medications such as paracetamol or ibuprofen. It is important to remember that if you feel the need to take tablets to help with pain, then that is absolutely fine and there is no shame in that! On occasions though, after an injury, accident, operation or illness, stronger, more potent painkillers are required.
We define pain as being either ‘acute’- short term – lasting days to weeks, or ‘chronic’ longer term – usually more than three months. There is also “Acute on Chronic”, which may be a flare up of a longer-term pain or unrelated such as pain after an operation, when a patient has a background of chronic pain. There is good evidence that severe untreated acute pain can lead to the development of chronic pain.
All pain has a psychological component and can be affected by our mood and anxiety as well as any past unpleasant experiences of pain. Interestingly, even memories unrelated to pain can influence how we perceive pain. There is much data that demonstrates that patients with associated mental health difficulties or a history of previous substance dependency are more likely to receive opioids for pain, likely to receive prescriptions for higher doses, as well as other classes of drugs used for anxiety.
Most people’s contact with opioids or opioid based pain relief will be during a hospital admission, most likely after an accident or operation. Although the act of relieving pain is vital from a psychological perspective it is also vital in preventing postoperative complications by ensuring that you are comfortable enough to mobilise and get out of bed, reducing incidences of deep vein thromboses (DVTs), blood clots in your lungs and chest infections.
After an operation, we, as anaesthetists, may well prescribe fentanyl or morphine in combination with other pain relief such as paracetamol and ibuprofen. These are different classes or types of pain relief, and they all work in different ways to help you become as comfortable as possible. Prescribers have a responsibility to ensure that opioid-type medications are not prescribed for any longer than the expected tissue healing and therefore the worst pain is expected.
After some types of operations, you may be offered a ‘Patient Controlled Analgesia’ (PCA) device. This allows you to press a button to administer a painkiller such a morphine or fentanyl straight into your vein. It is very safe, and has a timed lock out meaning even if you keep pressing the button, it will not administer any more of the drug until it is safe to do so.
The side effects from opioid based painkillers are very common, and although in the short term unpleasant, shouldn’t have longer lasting effects if used for short periods for acute pain. In clinical trials, up to 80% of patients experienced at least one side effect. Side effects are often multi-system, and include, but not limited to dry mouth, itching, nausea, vomiting and constipation.
More serious effects can occur on your body’s breathing system, and can occur when opioid naïve patients haven’t developed a tolerance. Tolerance describes a phenomena where patient’s end up taking increased doses of the opioid based painkillers to gain the same analgesic affect. The effects can include decreasing your brain’s ability to drive your breathing mechanics, which can lead to ineffective breathing and more serious sequelae.
Longer term effects are varied and can be significant, but unlikely to have any bearing if you are taking them in the short term for acute, severe pain. Falls and fractures, particularly in older populations is a particular risk, but there are a plethora of potential effects that can occur on your body’s hormone system. Any patients exhibiting any symptoms that can be linked to your hormones can be referred to a specialist in that area, an endocrinologist, but there is no evidence for doing so in patients exhibiting no symptoms.
Pain Medicine is a complex sub-speciality of anaesthetics and a proportion of their workload is surrounding the area of “opioid induced hyperalgesia’. This describes a state where prolonged exposure and use of opioid type pain relief can lead to patient’s experiencing abnormal pain sensitivity.
Given this, it would be easy to want to avoid there type of medications all together, but actually the potential benefits in the short term are not to be ignored, in fact, evidence demonstrates that inadequate management of pain in the short term actually can increase the likelihood of delayed recovery and even relapse on addiction on those with a prior history and the use of illegal or street drugs.
The headlines surrounding opioids misuse and the relative ease of consumption, perhaps more so in the US, are certainly that: headlines. But it is important to remember that as UK prescribers, there are a normal of principles that are vital to managing good pain relief. The importance of establishing good clear communication, whilst liaising with all members of the team, as well as you as the patient, and doing a comprehensive assessment of physical as well as any emotional or psychological symptoms ensure that any pain medications are optimised from the start. If you need to be discharged home with opioid type analgesia then it is vital that there is a clear, easy to follow plan for dose reduction as the acute pain subsides, and your GP in the community kept fully in the loop with the plan.
There are a number of patient populations that can be described as “at risk” for developing more chronic use and then associated dependence. The healthcare professional will take a full history and ask a series of questions for those patients for whom there is an index of suspicion or they are demonstrating a set of behaviours that are concerning to the development of longer term dependence.
Once a conclusion of opioid has been reached, patients and healthcare workers will work collaboratively to start treatment, either by maintaining on opioid or to detoxify. This is a complicated and complex process but the importance of open and clear communication is key.
If a patient has a past history of opioid dependence, but requires strong painkillers for acute pain, a number of strategies can be used, utilising non-opioid type painkillers, as well as alternative techniques using local anaesthetic.
Although opioids provide excellent pain relieving properties for acute short-term pain there is little evidence for their use in more longer term chronic pain, and although there is potentially morbidity and even mortality associated with their use, healthcare professionals can work together to ensure safe and effective prescribing.
Office of National Statistics: Deaths related to drug poisoning in England and Wales
Faculty of Pain Medicine of the Royal College of Anaesthetists
Why trauma and deprivation is fuelling a shocking rise in opioid addiction, New Start magazine, published 12/12/2019
Perioperative management of opioid-tolerant patients, BJA Education, Volume 17, Issue 4, April 2017, Pages 124–128