This module looks at how to provide information about opioids in a way that supports informed decision making. First, take a look at the video below, which shows a simulated consultation between a practice pharmacist and a patient.
As you watch the video, reflect on the following: What went well? What didn’t go well? What do you think contributed to that? What would you do differently, in light of your learning so far?
During consultations with patients on opioids it’s likely that you will identify some mistaken beliefs about opioids, perhaps some concern about or resistance to reducing them or at least some gaps in the patient’s knowledge. It can be tempting to jump in straight away to provide information to correct any mistaken assumptions and to try to persuade the patient of the need to change. As we saw in the video, this often doesn’t work well and can increase resistance from patients.
The presentation below outlines a different approach to providing information that is more likely to be effective.
Some suggestions
Below are some suggestions of how to explain some of the topics that commonly come up. Feel free to use or adapt these to your own style
Why opioids often don’t work for persistent pain
Opioids are strong painkillers and they work pretty well for short term pain and cancer pain at the end of life. Long-term (persistent, chronic) pain is different – it’s very complex and influenced by lots of different factors. Any medicine can only act on one part of this very complex system and if that isn’t what’s causing the pain, the medicine won’t help. Some pains don’t seem to respond to any medicines.
Why opioids stop working
When people take opioids regularly, it’s very common to notice less and less benefit as time goes on. This is because your body gets used to the opioids and stops responding to them. This is called building up tolerance. Increasing the dose isn’t the answer, even if it seems to help at first, you will soon become tolerant to the higher dose and it’s likely to cause more side-effects and other problems.
Why pain isn’t necessarily worse if opioids are reduced
It’s understandable to be concerned that pain will be even worse if opioids are reduced or stopped but our experience is that most people do not suffer worse pain if opioids are tapered gradually with the support of a healthcare professional. Some people may notice a short term increase in pain, but this usually settles within a few weeks, and many people say they feel better overall, probably because they have fewer side-effects of opioids.
Why we are concerned about opioids
It’s understandable that you are confused (or frustrated or angry). You’ve been prescribed opioids for all this time, through no fault of your own, and now we’re suggesting this may not be such a good idea. What’s changed is that research studies have helped us better understand the longer-term effects and risks of opioids and that changes the advice we give about opioids – because your safety is our top priority.
Discussion about the harms of opioids should be tailored to their experience of any benefits / side-effects and their personal risk factors. For example:
You can discuss how any unwanted side-effects of opioids may interfere with their ability to engage in activities that would improve their quality of life and wellbeing. For example, daytime sleepiness stopping them going out, or being able to concentrate to read a book they might otherwise enjoy.
You can explain that research studies (or scientists) have discovered that people taking long-term opioids are more likely to develop other problems and then highlight those of particular relevance from the following: more likely to fall, have lower sex drive, be more prone to infections, and have poorer quality sleep, low mood, reduced fertility.
Physical dependence
It is common for people who take opioids regularly to become physically dependent on them. This means that if you run out or stop taking opioids suddenly, you can get withdrawal symptoms such as worse pain, feeling restless, feeling anxious or irritable, sweating, aching muscles, diarrhoea, stomach cramps and a runny nose. But physical dependence is not the same as addiction and it is possible to come off opioids without withdrawal symptoms by gradually reducing the dose, a little at a time, to give your body chance to adjust.
Addiction
Most people who are prescribed opioid medicines for long-term pain do not become addicted to opioids, but around 1 in 10 people may develop signs of addiction such as craving their opioid medicine, feeling out of control about how much they take or how often, and continuing to take it even when it has a negative effect on their physical or mental health.
Opioid-induced hyperalgesia
Some people who regularly take opioids develop increased pain sensitivity. This means that their opioids actually make the pain worse and they may start to hurt all over. When this happens, reducing opioids gradually eventually improves the pain.
