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Making changes to opioid prescribing

by Emma Davies

You cannot currently escape press reports about ‘dangerous painkillers’ and ‘a UK opioid crisis’; many making comparisons with the acknowledged opioid crisis in North America.

Many people using opioids are likely to feel scared with all this publicity: scared they are going to become addicted; scared the medicines are going to be taken away from them and scared what they will do without them. Primary care in particular, is coming under increasing pressure to act and make changes to opioid prescribing.

If you are seeing people on opioids, particularly high doses and those still reporting pain, perhaps the follwing information will help…

Background information for conversations with your patients
Addiction – how likely is it?

Addiction to prescription analgesics is entirely possible but still, reasonably rare in practice. However, many more people using these medicines will develop a dependence on them for functioning or for making them just feel better about things.

What if I suddenly stop?

Suddenly stopping medicines can lead to withdrawal symptoms but this, on its own, is not a sign of addiction. Withdrawal is a normal reaction to the sudden cessation of the drug and the reason that drugs such as opioids, need to be withdrawn slowly and carefully.

Addiction isn’t the only concern

We are as concerned about the lack of effectiveness of opioids in persistent pain conditions and their potential harm, as we are about addiction and dependence. There is very little evidence to support the use of opioids in persistent non-cancer pain.

There is a maximum above which harm can be caused

The internationally agreed maximum dose of opioids in non-cancer pain is 120mg morphine equivalence per day. Above this, opioids have been shown to have little benefit in terms of pain reduction but there is a significant increase in potential and actual harm.

Harms include sedation, not being able to think clearly or take an active part in social interactions, depression and anxiety, falls and osteoporosis, increased risk of infection and hypersensitivity – where the drugs make pain worse rather than better.

Concerned about a patient's opioid use? Here are some questions to ask

• Do you still have pain despite using your opioid medication regularly?

• Does your medication cause side-effects that affect your daily activities e.g. drowsiness that stops you driving?

• Have you or your family / friends noticed a change in how you interact or take part in social situations?

• Have you noticed a change in your sex drive or sexual function?

• Do you take your medication because it helps you to relax?

If the patient answers ‘yes’ to any of these questions, it is likely that the opioid medication is not doing what you, as the prescriber, intended and may be causing harm.

What are the first steps to making change?
Reassurance

People will be concerned that with less medication, their pain will be a lot worse.  In most cases this will not be true but anxiety can negatively affect a person’s perception of their pain and so worries need to be allayed before making any changes.

Small steps

Agree with the person that the first reduction will be the smallest possible.  Examples are: a single co-codamol tablet per day; a 5mg reduction in modified-release morphine or a 12microgram/hour reduction in fentanyl patch.

Take plenty of time

Make the change and then review the person after a week.  It is not necessary to make another change at that stage but to provide support and reassurance that they are doing well and to keep going. Changes can be made fortnightly or monthly – weekly changes are generally too fast for most people in a primary care setting. Encourage the person to be involved with decisions over the timescale of change – this may be slower than you, as the prescriber, would like but in the early stages, it is important to empower the person and allow them some control over the process.

Set realistic targets

If you have someone currently prescribed 500mg morphine a day, suggesting it is reduced to stop is likely to cause panic and make for a very difficult consultation.  Go for e.g. ‘lets see if we can slowly reduce to 450mg a day over the next few months’.  Once achieved, set the next target.  By keeping the target in touching distance, you are more likely to reach it and without too many problems.  This will hopefully, encourage you and the person you’re supporting to keep going, as it has not been as difficult as feared.

Don’t go back

When reviewing; if the person has struggled with the latest change, do not be tempted to simply increase the medication back to where it was before.  People will have other impacting factors e.g. stress in the family, another condition to manage etc.  These all have the potential to affect their ability to make changes and feel good about it.  When setbacks occur – keep things where they are – leave the dose as it is and arrange to review in a couple more weeks.  In most cases, by then things will have settled down and you can start negotiating the next change more easily.

Remember:  Any reduction is a good thing, in terms of improving the general health and well-being of the person using the medications. So go low, go slow but keep going…

This Clinician Resource was added in November 2017.

Related resources

Prescribing opioids as part of rehabilitation

Dr Tim Williams explains the basis on which he would prescribe strong opioids – and when he would not  Watch the video >

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