Treating moderate or severe pain

Opioids

Medications for pain that is hard to ignore or feels very severe are known as opioids. Sometimes they are called narcotic medications. They are always prescribed by a doctor and there are many different types:

• Some opioids, such as codeine, are used for moderate pain.
• Strong opioids, such as morphine, oxycodone and hydromorphone, are safe and effective for moderate to severe pain. The dose of opioid is worked out for each person to match their pain level.
• Fentanyl is used mainly for severe stable pain. It is available as a skin patch that only needs to be changed every third day. Lozenges are also available for breakthrough pain.
• Targin ®  is a combination of the opioid oxycodone and another drug, naloxone. Naloxone decreases constipation.
• Buprenorphine can be given as a skin patch. It is used mainly for moderate to severe stable pain.

 

Generic and trade names for common opioids

Medications have a generic and a trade name. The generic name identifies the chemical compounds in the drug. The trade name identifies the manufacturer's version of the drug. Medications may have more than one trade name.

For example:

• Morphine is the generic name; Ordine and Severedol are the trade names
• Oxycodone can be found under the trade names Oxynorm and Endone.

Side effects

It can take a few days to adjust to taking strong pain medications. Opioids can affect people in the following ways:

• drowsiness - feeling sleepy is typical but usually only lasts for a few days until the pain relief dose is stable.
• tiredness - your body may feel physically tired, so you may need to ask family or friends to help you with household tasks or your other responsibilities. Rest is important, but it's also beneficial to do some light activity, such as stretches or walking to the letterbox.
• feeling sick - this passes when you get used to the dosage or can be relieved with other medication
• constipation - most people regularly taking opioid medications need a laxative. Drinking plenty of water, eating a high-fibre diet and getting some exercise helps reduce constipation
• itchy skin - some people find dusting cornflour over their skin helps relieve the itchiness
• dry mouth - chewing gum or drinking plenty of liquids helps
• confusion - this is rare so tell your doctor if it occurs.

Similar side effects can occur when you stop taking opioids too. These are sometimes called withdrawal symptoms or a withdrawal response. To reduce the chance of side effects, your doctor will reduce your dose gradually to allow your body to adjust to the change in medication.

Common questions about opioids

Q: Will I become addicted to opioids?

A: No - people taking opioids to relieve pain do not become addicted. However, after some time, the body gets used to opioids and if they are stopped suddenly, you may get withdrawal symptoms. This is normal and is not the same as an addiction. For people who have had addiction problems before, there may be a risk of addiction to opioids if they are later used for relief of cancer pain.

Q: Will I need injections?

A: Not necessarily. Strong pain relievers are usually given by mouth in either liquid or tablet form.

Opioids may be injected into a vein for short-term pain relief, such as after surgery. This is called intravenous opioid treatment and it is given in hospital.

In hospital, patients may also use a computer-controlled system to deliver doses into the vein whenever they need pain relief. This is called patient controlled analgesia (PCA).

 

Q: Will the opioids still work if I get used to them?

A: Sometimes people who have needed opioids for a long time may become tolerant to their original dose. Their doctor will need to increase the dose by a small amount to keep their pain under control.

 

Q: What if I get breakthrough pain between my regular doses of opioid?

A: You might get a flare-up of pain even though you're taking regular doses of medication. It may last only a few seconds or for several minutes or hours. It can occur if you've been more active than usual   but sometimes there seems to be no reason for the extra pain.

Your health care team will advise you on how to cope with breakthrough pain.

 

Q: Can I stop medication any time?

A: If your pain gets better, morphine and other opioids should be reduced slowly before stopping them completely. You should only reduce your dose or stop taking opioids in consultation with your health care team.

 

Q: Can I drive while using opioids?

A: Doctors have a legal responsibility to advise patients not to drive if they are a risk to others. During the first days of treatment, you might be less alert so driving is unwise. Once the dose is stabilised, you may want to consider driving. Seek your doctor's advice and keep the following in mind:

• Check if you're able to drive safely by doing a test run on a quiet road. Go with another driver, if possible.
• Don't drive if you're tired, have been drinking alcohol, are taking other medication that makes you drowsy, or if road conditions are bad. Avoid driving long distances or at night.
• If you have a car accident while under the influence of a drug, your insurance company may not pay out a claim. All cases are assessed individually.

 

Non-opioid medications

Some  drugs work on certain kinds of pain and might be prescribed with opioids to help you get the best pain relief. Later the dose of opioids may be reduced.

• Antidepressant drugs such as doxepin can be used to control burning nerve pain.
• Anti-convulsive drugs such as pregabalin are also used for burning or shock-like nerve pain.
• Anti-anxiety drugs such as lorazepam reduce muscle spasms with severe pain.
• Steroids reduce headaches caused by brain cancer.
• Bisphosphonates may help prevent bone damage and reduce bone pain.
• Local anaesthetics and NMDA blockers are sometimes used for severe nerve pain but require careful monitoring.