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Opioid prescribing: tackling the ‘time bomb’ of long-term use and addiction

How to spot red flags, advise patients and help them find other ways to cope with chronic pain

How to spot red flags, advise patients on appropriate use and support them to find other ways to cope with chronic pain

  • Opioids are designed for short-term relief of pain or palliation, and the risk of addiction and harmful side effects can outweigh the benefits in long-term users
  • With evidence of overprescribing and a time bomb of patients with addictions, new NICE guidance will clarify safe prescribing of drugs associated with dependence
  • Red flags for signs of opioid dependence, facts about opioids to consider when prescribing, and a case study of the use of mindfulness to manage chronic pain after addiction

More than one in ten of the adult population were prescribed powerful

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How to spot red flags, advise patients on appropriate use and support them to find other ways to cope with chronic pain

  • Opioids are designed for short-term relief of pain or palliation, and the risk of addiction and harmful side effects can outweigh the benefits in long-term users
  • With evidence of overprescribing and a ‘time bomb’ of patients with addictions, new NICE guidance will clarify safe prescribing of drugs associated with dependence
  • Red flags for signs of opioid dependence, facts about opioids to consider when prescribing, and a case study of the use of mindfulness to manage chronic pain after addiction
Image of people chained to a medication bottle, representing addition to pain medication
Picture: iStock

More than one in ten of the adult population were prescribed powerful opioid pain medications in 2017-2018, a major review by Public Health England (PHE) found.

This equates to roughly 5.6 million people being prescribed these painkilling therapies.

Opioids and short-term pain management

The widespread use of prescribed opioid medications – and their potential for harm – is of concern for healthcare professionals at home and abroad.

Opioids are often prescribed for people with cancer, but may also be used for moderate to severe pain. And while patients may be advised to use them for as short a time as possible, this does not always happen.

They are generally not effective in managing chronic, non-cancer pain, while their use carries dangerous risks of addiction, withdrawal and, potentially, death.

In the United States, the number of opioid overdose deaths has been described as an epidemic by the Centers for Disease Control and Prevention, with more than 232,000 people dying from overdoses involving prescription opioids between 1999 and 2018.

While the UK has only moderate availability of analgesic opioids compared with other countries, concerns over inappropriate use of opioids is leading to changes in national guidance in the UK in how they are used and prescribed.

What are opioids?

Forms of opioids include:

  • Codeine (available over the counter in some forms)
  • Morphine
  • Tramadol
  • Fentanyl
  • Methadone
  • Oxycodone and hydrocodone
  • Pethidine

Some of these opioids are synthetic, while others are derived from the poppy plant. They work by mimicking endorphins and reduce pain but also give sensations of pleasure.

A change in national guidance on opioid prescribing

The National Institute for Health and Care Excellence (NICE) is developing new advice as a result of the 2019 PHE report, on how opioids should be used outside of cancer cases and how people should be supported to stop using them.

NICE has also updated guidance on a number of specific conditions, including osteoarthritis and lower back pain, to highlight issues related to opioid prescribing.

These updates emphasise the need to discuss the harms and benefits of prescribing opiates, and for shared decision-making with the patient.

‘There is a concern that we are creating a time bomb in terms of how many people will have suffered harm from opioids and other addictive medication such as tranquilisers. Clinicians are trying to help by prescribing these drugs, but actually make the problem worse’

Matt Griffiths, independent prescriber and representative for the Association for Prescribers

Becoming addicted to prescribed medication can have a devastating effect. It can destabilise people’s lives, affecting their self-esteem, employment, families and relationships.

‘Everything becomes focused on the opioids for that person and they face a lot of stigma due to their dependency,’ says head of nursing at the social enterprise Turning Point, Gill Campbell.

Impact of changes on nurse prescribers

Nurses who are independent prescribers can prescribe these controlled medications, and many nurses will administer them across community and acute settings.

Independent prescriber Matt Griffiths
Independent prescriber Matt Griffiths Picture: Charles Milligan

Matt Griffiths, independent prescriber, representative for the Association for Prescribers and quality improvement nurse at the Royal United Hospitals Bath, says the implication of the changes for opiates will affect the nursing practice of those prescribing and administrating.

‘There is a concern that we are creating a time bomb in terms of how many people will have suffered harm from opioids and other addictive medication such as tranquilisers,’ says Professor Griffiths.

‘Clinicians are trying to help by prescribing these drugs, but actually make the problem worse.’

The PHE report said that overall prescriptions have decreased slightly since 2016, but this follows many years of a steady increase. The number of strong opioids prescribed has also increased over the past ten years.

Overprescribing higher in areas of deprivation

The report found that prescribing rates for these addictive medications are higher in areas of greater deprivation.

Higher initial opioid doses and prior mental health problems were associated with long-term use of opioids and opioid dependence, respectively.

Prescribing opioid pain medicines for longer than 90 days was associated with opioid overdose and dependence.

A University of Oxford study in 2018 found that the highest opioid prescribers were in northern and coastal areas of the UK, and the lowest in Greater London.

Prescribing opioids for longer than 90 days is associated with overdose and dependence
Prescribing opioids for longer than 90 days is associated with overdose and dependence Picture: iStock

Larger practice list sizes and rural locations were also associated with greater high-dose prescribing rates.

Evidence gathered by PHE in the 2019 report suggested that patients experienced barriers to accessing and engaging in treatment services. They felt there was a lack of information on the risks of medication and that doctors did not acknowledge or recognise withdrawal symptoms.

Patients described not being offered any treatment options other than medication, their treatment not being reviewed sufficiently and a lack of access to effective management and NHS support services.

While opioids should only be prescribed for short-term use, long-term prescribing is relatively common.

Shared decision-making in pain management

NICE says its guidance covering safe prescribing of drugs associated with dependence, and the careful management of withdrawal from these drugs, should be published in the next 12 months.

It is also developing new advice on shared decision-making as part of this work.

‘With an average of five opioid-related deaths reportedly happening in the UK each day, and growing concerns about dependence on prescription drugs, our evidence-based recommendations will help drive improvements across the health and care system,’ a spokesperson says. ‘They will complement existing NICE guidelines in tackling the problem.’

The Faculty of Pain Medicine, which runs the Opioids Aware information resource, says that initial prescribing of opioid medicines for pain should be considered as a trial period, with outcomes of treatment agreed with the patient.

If, at the end of the trial, agreed outcomes have not been achieved or progress made towards them, the patient and prescriber need to discuss whether to continue treatment.

Side effects, which include nausea, vomiting and constipation, are common and these need to be considered and balanced with potential benefits. If patients continue to take medicines that provide limited analgesic benefit, then they are exposed to harms that are greater than the benefit the medicines provide.

When medicines are prescribed they should be used in combination with other treatment approaches to support improved physical, psychological and social functioning.

Prescribed opioid medication: its effectiveness and limitations

  • Opioids are very good analgesics for acute pain and pain at the end of life, but there is little evidence that they are helpful for long-term pain
  • A small proportion of people may obtain good pain relief with opioids in the long term if the dose can be kept low and especially if their use is intermittent – however it is difficult to identify these people when opioids are initiated
  • The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit: tapering or stopping high-dose opioids needs careful planning and collaboration
  • If a patient has pain that remains severe despite opioid treatment it means the medication is not working and should be stopped, even if no other treatment is available
  • Chronic pain is complex and if patients have disabling symptoms, particularly if they are on high opioid doses, a detailed assessment of the many emotional influences on their pain experience is essential

Source: Faculty of Pain Medicine

Prescribing for short periods

Professor Griffiths agrees it is vital that prescribers only issue short prescriptions for opioid painkillers to see if they are helping, and to assess if they should be continued.

‘We should be looking at short periods, perhaps two weeks, and then evaluating their effectiveness, particularly in non-palliative patients,’ he says.

‘When we are moving from one controlled drug to another, we need to be aware of the potential differences in how people react to them. We often need to reduce the potency of the controlled drug that we are changing to, while titrating them.’

All nurses play an important role in offering lifestyle and non-pharmacological advice on managing side effects, such as increasing fluid and fibre intake, to tackle the constipation often caused by opiate medication, he says.

Nurses administering medication or caring for patients using opiates should be alert for signs of drug addiction and escalate any concerns to the prescriber.

‘As with any other aspect of nursing practice, we should be evaluating patients as part of our care, and if we see they are not getting pain relief from the medication, or there is a risk of addiction, we need to be doing something about it,’ Professor Griffiths says.

This is not always easy, the Faculty of Pain Medicine says, due to ‘complex presentations characterised by many of the more difficult behaviours and complex psychosocial effects of continued opioid use’.

Red flags for potential opioid dependence

Nurses should be aware of the following red flags in people with a long-term opioid prescription:

  • Current or past psychiatric illness or profound emotional trauma, or drug or alcohol misuse
  • Reports of concern by family members, carers, pharmacist or other healthcare professional about opioid use
  • Insistence that only opioid treatment will alleviate pain and refusal to explore other avenues of treatmentIcon representing seeking repeat prescriptions or prescriptions from more than one source
  • Refusal to attend or failure to attend appointments to review opioid prescription
  • Resisting referral for specialist addiction assessment or other specialist care
  • Repeated seeking of prescriptions for opioids with no review by a clinician, or repeatedly losing medications or prescriptions
  • Taking doses larger than those prescribed or increasing dosage without consulting the clinician; often coupled with seeking early replacement prescriptions. Associated with continued requests for dose escalations
  • Seeking opioids from different doctors and other prescribers
  • Obtaining medications from the internet or from family members or friends

Source: Adapted from Faculty of Pain Medicine

Holistic assessments of chronic pain

Turning Point’s Ms Campbell says it is essential that people with chronic pain receive holistic assessments, and that nurses and other healthcare professionals suggest and explore non-pharmacological ways of managing pain.

‘We know that opioids are often not that effective at managing chronic pain, so other options that help people live with and manage their pain have to be considered,’ she says.

Alternative therapies, such as cognitive behavioural therapy, should be explored
Alternative therapies, such as cognitive behavioural therapy, should be explored Picture: iStock

‘That can be a difficult conversation, as people don’t want to hear that their pain can’t be cured. The whole approach tends to be pharmacologically driven, but chronic pain is often a complex problem, those affected are more likely to live in a deprived area and all aspects of their lives needs to be considered. It needs more than medication.

‘Psychosocial interventions can be helpful, such as cognitive behavioural therapy and mindfulness, while social prescribing, supporting people towards healthier diets and taking exercise can all help.’

Attitudes towards opioids are changing among healthcare professionals, she says. But there remains a severe shortage of services for people struggling with dependency.

‘The stabilisation of the number of opioid prescriptions over the past couple of years shows that there is much greater recognition that they can be misused and cause harm,’ Ms Campbell says.

‘The changes to NICE guidance are also helping to raise awareness. While we have not experienced anything like the same scale of the problem in the US, we are learning from them and don’t want to replicate their terrible opioid crisis.’

Living with chronic pain: how I found an alternative to opioids

Twenty five years ago, Sean Jennings developed chronic pain due to an infection following a hernia operation.

For many years, he was prescribed large doses of opioids which presented numerous side effects and yet he still suffered from continued chronic pain.

Long-term coping strategies for living with pain

His experience was made into a film in 2019 by NHS England and NHS Improvement on how long-term use of high-dose opioid prescribing affected his quality of life – and how therapy that does not involve medication has been ‘life changing’.

As the pain continued to get worse despite taking opioids, Mr Jennings asked his GP to be put on a pain management programme. The programme was specifically designed to help patients develop appropriate long-term coping strategies for living with long-term pain.

Sean Jennings, who has stopped taking medication to deal with his pain
Sean Jennings: mindfulness has helped him to stop taking medication to deal with his pain

‘Every day I was taking more and more painkillers, and I thought I was all right, but I really wasn’t very well,’ recalls Mr Jennings, who lives in Cornwall.

‘I realised that I wasn’t functioning properly and sought further help from my GP as I just couldn’t cope. He put me on the pain management programme and that changed my life.’

A convert to mindfulness

Through alternative therapies such as mindfulness and meditation, Mr Jennings is able to deal with his pain without the reliance on opioids. The film aims to encourage and inspire other patients with chronic pain to seek alternatives to prescription opioids to help deal with their condition.

‘I learnt how to exercise gently and do a little bit of Tai Chi and mindfulness.,’ Mr Jennings adds.

‘To start with – mindfulness, I didn’t understand it but, speaking as an initial sceptic, it works. I’ve gone 18 months now without taking opioids, no gabapentin, nothing for pain whatsoever. The pain hasn’t gone away – it’s simply the way I deal with it now, and I do this through mindfulness.’

Adapted from NHS England and NHS Improvement


Further information


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