The Problem With Opioids

You may have read about ‘the opioid crisis’ in the USA and Canada, but a report in 2019 (see more on the BBC website or visit the OECD library) showed that the UK was the country with the third fastest growing rate of opioid use. So what are opioids, why might they be prescribed and what are the problems with using them long-term?

What are opioid medications?

Opioids and opiates are a broad class of medications used normally as pain killers (‘analgesics’) that includes morphine, codeine, oxycodone, fentanyl and buprenorphine. Opioids and opiates are slightly different chemically, but we will use the term opioid here as a short-hand for all of them. They can be very useful to treat short-term severe pain (particularly after surgery), and also pain related to illnesses at the end of life, and they are sometimes prescribed break the cycle of dependence on heroin.

Why is growing opioid use worrying?

Opioid drugs work on receptors on opiate-sensitive cells, to reduce pain messages and feelings of pain. Some of the biochemical brain processes triggered by this action are ‘rewarding’ and pleasurable in the same way as eating and sex. This can motivate repeated use of the medications and lead to dependence (where people become physically or psychologically reliant on a medication – also sometimes called addiction).

Opioids can also cause reduce the drive of the brain and body to breathe, causing ‘respiratory depression’ and in extreme cases can lead to death. Combining substances (other medications or illicit substances or alcohol) with opioids, or having pre-existing health conditions (eg sleep apnoea) increases this risk.

In addition, over time our bodies become more used to the action of opioid drugs and need a larger quantity for the same result (called tolerance) which can lead to escalating doses. Larger doses are linked with an increased risk of accidental overdoses.

The increased use of opioid dependence, which often starts with a prescription, in some countries is leading to a large black market in such medications; often what is sold illicitly contains other ingredients or incorrect doses, so risk of harm is significant.

Side effects

Side effects from opioid prescriptions, even at low doses, are very common. People mostly complain of nausea, vomiting, constipation, itch, dizziness, dry mouth and sedation. These usually resolve when the medication is stopped (see Faculty of Pain Medication).

Due to the side-effects of opioid medication, it is important to know that driving may be impaired, and DVLA rules state the problematic opioid use needs to be declared, and may result in the loss of license until resolved (see Drug or alcohol misuse or dependence: assessing fitness to drive).

Long-term harms of opioids

As well as the risks described above, there are further longer-term risks associated with prolonged use of opioid medications. These include:

• Fractures and falls, particularly in the elderly
• Hormonal abnormalities, including sexual dysfunction, changes to periods, infertility, depression and fatigue
• Abnormal pain sensitivity – increased pain due to brain changes caused by long term opioid use (known as ‘opioid-induced hyperalgesia’)

Best use of opioids

Given the risks of harms related to opioid medications, there are ways in which they should be prescribed and used to minimise problems.

• They should only be used short-term for moderate to severe pain, or in pain related to conditions at the end of life
• They should not be continued beyond 12 weeks use except in exceptional circumstances
• Doses beyond 120mg morphine daily are very risky and have no benefit in further pain reduction over smaller doses.
• Never buy opioids that you haven’t been prescribed – you cannot be sure that they are as described and may contain contaminants, other drugs, poisons or the wrong dose which can be very dangerous.

If you are worried about your opioid prescription or wish to discuss your prescription (or use of non-prescribed opioids) with your doctor or our clinical pharmacist, please do make an appointment; we are very keen to help your symptoms in the best way possible, with the fewest side-effects or risk of harm.

Further reading

• Patient information on Taking Opioids for Pain