End of Life Care - Opioids in Palliative Care

What are opioids?

Opioids are pain medication which are used to treat pain when weaker pain medication such as paracetamol, ibuprofen or codeine have not fully helped. They can also be used to help breathlessness.

Commonly used medicines in this group include morphine, oxycodone, fentanyl, alfentanil and buprenorphine. These medicines may sometimes be called by different brand names depending on the company which produces them.

How should opioids be taken?

Your doctor, nurse or pharmacist will discuss with you how you should take or use the opioid you are prescribed. You might be prescribed tablets, capsules, liquids, patches or other forms of the pain medication depending on which one is thought to be best for you.

Modified release medications

Often, people are prescribed ‘modified release’ or ‘slow release’ opioids in the form of a twice daily capsule or tablet (for example Zomorph® or Oxycontin®). Other opioid products include fentanyl or buprenorphine patches.

Opioid patches

Opioid patches release fentanyl or buprenorphine through the skin and are changed every 3 or 7 days, depending on the manufacturer. Please read the patient information leaflet with your patches to check how to use your brand correctly.

Patches should be changed at roughly the same time of day.
 
You should remove the old patch (and dispose safely) before applying a new patch. The new patch should be put on a different area of non-hairy skin on the upper body or arm. Avoid areas with cuts, scars, swelling or where you have had radiotherapy.

Being exposed to heat or having a fever can increase the amount of opioid medication you get from your patch. Avoid using heat treatments such as hot water bottles over the area a patch is applied and remove the patch before prolonged heat exposure
e.g. hot bath, sauna. Take medication such as paracetamol or ibuprofen for a fever (if you are able). If you have a high or prolonged fever, seek medical advice.

During MRI scans your patch should be removed.

Immediate release medications

If you are taking a slow-release opioid and experience ‘breakthrough’ pain (a flare up of pain that breaks through when pain is mostly controlled) an ‘immediate release’ opioid may also be prescribed. These are used as an extra top-up or rescue dose.

Sometimes people only need the immediate release form of opioids and don’t need a slow release one as well. Immediate release morphine can also be taken for feelings of breathlessness. The dose is much lower than a pain dose and is taken less frequently.

Immediate release opioids may come in the form of liquids, tablets or capsules depending on whether morphine or oxycodone is prescribed, (e.g., Oramorph® or Oxynorm® liquid, Sevredol® tablets or Oxynorm® capsules). They should work within about 30 minutes and last for 4-6 hours.

How well do opioids work?

Opioids can work well for treating pain; however, everyone is different in how they respond.

Doses may need to be raised or lowered depending on how well a medicine works or to manage any side effects that might occur. Changes in dose should be discussed with your nurse or doctor.

It might not be possible to control pain with opioid medications alone.

Sometimes other types of pain medication are also needed, for example, medicines for nerve pain such as gabapentin, pregabalin or amitriptyline.

Will I become addicted to morphine?

Some people worry that they may become ‘addicted’ to opioids - in fact, if used for pain relief in the correct way and monitored, addiction to opioids is extremely unlikely.

If I use opioids now, will they work in the future?

Some people worry that if they start pain medication too early, they will not work as well in the future. Whilst the side effects of opioids may reduce over time, the pain-relieving effects often do not. If pain does worsen, careful changes in the dose of opioid medication can be very effective.

Does taking an opioid mean I am coming to the end of my life?

No. These medications are used at different stages in many different conditions.

What if I miss a dose?

If you have missed a dose of a modified-release opioid medicine, do not take two doses together. You should take the next dose when it is due and use immediate release medicine if you have increased pain before this.

What are the common side effects?

• Constipation is very common. You should be prescribed a laxative while you are on an opioid medicine. Opioid patches can cause less constipation than other opioids, but you may still require a regular laxative
• Feeling sick or nauseous is common when starting opioids or when the dose is increased, but this often improves with time. You may be prescribed anti-sickness medicine to help with this
• You may feel mildly drowsy or find it difficult to concentrate when you first start to take an opioid medicine; again, this often improves with time

If you experience side effects which do not settle, ask your doctor, nurse or pharmacist for advice. Do not stop your pain medication abruptly.

When should I seek advice from a health professional?

You should contact your doctor/nurse if you experience any of the following:

• If you become more drowsy or sleepy than usual
• If you are vomiting or feeling sick for more than 24 hours
• If you feel confused
• If you experience hallucinations

In the event that you develop breathing difficulties or impaired consciousness while taking opioids you should seek urgent medical advice or dial 999 for an ambulance.

Driving and Opioids

Under the Law (changes made in 2015) it is illegal to drive if you’re unfit to do so because you’re on legal* or illegal drugs. If it impairs your driving, then driving with the legal drug in your system is illegal. It is your responsibility to make sure your driving ability is not impaired for any reason.

*Legal drugs are prescription or over-the-counter medicines taken as advised by a healthcare professional. If you’re taking them and not sure if you should drive you should talk to your doctor, pharmacist or healthcare professional.

Additionally, you are advised to talk to your doctor about whether you should drive if you’ve been prescribed any of the following drugs:

• Opioids, for example Morphine, Methadone, Oxycodone, Codeine, Tramadol, Fentanyl, Buprenorphine
• Benzodiazepines, for example Clonazepam, Diazepam, Flunitrazepam, Lorazepam, Oxazepam, Temazepam
• Amphetamines, for example dexamphetamine or selegiline
• Ketamine

Your medication may have a ‘brand name’ so please make sure you check the ‘generic name.’ Some examples of brand names for opioids are Zomorph, MST, Oramorph, Oxycontin.

If you are taking opioids as prescribed and you understand how the drug affects you and are not impaired by these, then you are not breaking the law when driving. As such, we recommend that you avoid driving for at least five days when you start or change doses or regimen of any strong painkiller or opioid. Once you are on a stable dose and regimen, and you assess yourself as not impaired to drive, then you may drive.
 
It is important that you take your medications as prescribed and advised by a healthcare professional. If you take your medication differently from advised, you may be prosecuted for driving with these in your system even if your driving is not impaired.

It may be helpful, when driving to keep with you evidence that the opioid you are taking is a medicine which has been prescribed by a healthcare professional.

Please note that it is also law that you must tell the DVLA about any medical condition that affects your driving. You only need to tell the DVLA about medications if it impairs your driving.

You are advised to check with your insurer directly as some insurers will want to know about both medical conditions and medications you are taking. Failure to inform them could invalidate your insurance.

For more information on this please visit: https://www.gov.uk/ drug-driving-law

Can I drink alcohol whilst taking opioids?

Using alcohol at the same time as taking opioids may increase drowsiness and affect concentration, particularly when a new opioid medication is started, or the dose is being increased.

When you are taking a steady/stable dose of opioids, you should be able to drink alcohol in moderation, though you may feel its effects a little more.

How should opioids be stored?

You should store opioids in their original packaging in a cool, dry place which is out of reach of children.

Can I take opioid medications abroad?

If you are planning a trip abroad, you may need a letter from your doctor or a special licence. You should check the laws of the country/countries you are travelling to as different countries have different rules on the importation and use of opioid medicines.
The UK-based embassy or consulate of a country may be able to offer advice on this.

Opioid medicines should be kept in the original containers in hand luggage, and you should be aware of any restrictions on the amount of liquids you are allowed to carry in hand luggage.

How should I dispose of unwanted opioids?

You should return unused opioid medication to a pharmacy for safe disposal; do not flush them down the toilet or put them in a bin.

To dispose of used opioid patches, fold them in half so they are stuck together firmly. This can then be put in the household rubbish. Ensure they are disposed of safely and cannot be picked up by others (especially children).

Contacts

My GP ________________________________________________________ Telephone _______________________________________

My community Palliative Care Nurse ______________________________________________________________________________

Telephone    ________________________________________________

Contact Numbers for all Hospital sites and Community Settings

Please ring the relevant Hospital/Community telephone number where your loved one is being cared for.

Royal Oldham Hospital and Oldham Community
Hospital Specialist Palliative Care Team - 0161 778 5918
Oldham Community Specialist Palliative Care Teams - 0161 357 5190

Fairfield Hospital and Bury Community
Hospital Specialist Palliative Care Team - 0161 778 2679
Specialist Palliative Care Team 0161 206 4354 8am - 4pm Monday to Sunday
District Nurses/Out of hours for palliative patients - 0300 323 3316 between 8am - 4pm or 0161 716 1557 between 5pm - 8am

Rochdale Infirmary and Rochdale Community
Hospital Specialist Palliative Care Team - 0161 778 2679
Heywood/Middleton/Rochdale Community Specialist Palliative Care Teams (SPCT) - 01706 752360
Rochdale BARDOC - 0161 763 8525 - The admin will take a message and contact the District Nurses who will return call.

Salford Royal Hospital and Salford Community
Hospital Specialist Palliative Care Team - 0161 206 4609
Salford Community Specialist Palliative Care Teams (SPCT) - 0161 702 5406 between 8.30 am to 4.30pm (Monday to Sunday)
Salford Palliative Care Homes Team - 0161 206 1868