Health: be wary of strong painkillers – you could easily become addicted

It could happen to you very fast – and unintentionally. You’ve bad menstrual pain or sciatica, for example, so you take over-the-counter codeine-based medications like Solpadeine, Solpadol or Nurofen Plus.

You use them longer than three days and find that, over time, you want more because the codeine in the drug is habit-forming. If you don’t get more, or you can’t source them, you experience unpleasant ‘cold turkey’ symptoms.

Or perhaps you have had severe pain like that of shingles and your GP has prescribed strong opioid-based painkillers and now that the condition is easing, you feel you can’t do without these prescribed drugs.

You could be on a waiting list for surgery, also, overusing prescribed painkillers in the meantime to cope with the pain and find that you’ve now become addicted.

Misuse

“No one is immune to painkiller misuse or addiction and no one sets out to become an addict,” says Dr Conor Hearty, a consultant in pain medicine and anaesthesiology who is passionate about highlighting the issue of opioid use disorder (OUD).

As well as treating patients presenting with ongoing acute or chronic pain and some cancer pain at his pain management clinics in Cappagh Orthopaedic Hospital and the Mater, he also teaches doctors about the dangers of opioid overuse and over-prescribing.

“While it’s important for strong pain medication to be there for those who need it, we do see some people who have become addicted,” says Dr Hearty.

“While these drugs effectively tackle severe pain, the problem is that some people can become dependent on opioids and struggle to withdraw.”

He points out that addiction to opioids can be very rapid.

“It can happen after three days and you could die from your very first use of an opioid, depending on the dose. That’s how dangerous they can be.”

Need for vigilance

Dr Hearty is highlighting the need for vigilance around these drugs.

“There is a need to monitor not just over-the-counter pain medicines but also prescription painkillers,” he says.

Currently one-fifth of all prescriptions for pain medication in Ireland are opioid-based with sales of codeine-containing medicines reaching €4.53m in 2021 (most recent figure available).

Opioids are a product of the poppy plant, he points out. They were in the form of laudanum and morphine in the 1800s and later manufactured into heroin, methadone and oxycondone. They are also known as narcotics.

Opioids provide pain relief by acting on areas in the spinal cord and brain to block the transmission of pain signals.

“They can also, however, affect the pleasure centre of the brain, an aspect that makes them dangerous.”

Because of what he sees in pain management clinics, Dr Hearty has been advocating for closer monitoring of opioid medication use since 2015. He sees his role now as one of opioid stewardship.

“The more opioids that are prescribed by doctors and the more that are available in the community, the more people are going to get into addiction issues. If we can use them in a rational, sensible way we can reduce the numbers getting problems.”

Dr Hearty first started talking about opioid overuse at the start of his consultant career, having seen problems develop when working in pain clinics in Australia.

“I remember when I came back saying we shouldn’t be using certain types of opioids for acute pain and some people didn’t agree with me but ultimately, in 2016, a huge amount was written about them by the Centre For Disease Control (CDC) in the US.

“They published opioid guidelines in reaction to the sheer number of people who were dying there from opioid overdose and addiction, particularly oxycontin, which was heavily marketed. There were more young people dying there from opioid prescription drugs than from car crashes.”

A place for Opioids

While he doesn’t want to be critical of health professionals or patients, it was apparent to him that opioids were being prescribed too liberally here at that time.

“Opioids are really important if you have surgery or if you have cancer. They are part of how people recover and get better quickly. The role becomes less clear when we think of chronic pain and also acute pain which doesn’t seem to resolve fast enough.”

Sometimes doctors like him need to reduce these medications for people’s long-term good, even though people feel they are helpful, he says.

“We may not even prescribe these types of drugs for people who have pain because we know from bitter experience that they are not going to improve that person’s quality of life.”

Leaving unused painkillers lying around in your house is not a good idea, he says, as it can lead to others getting access to these dangerous drugs. “Traditionally, what would happen is that someone would be prescribed opioids and they wouldn’t take them all because they didn’t need them,” he says.

“They’d put them in their medicine cabinet and their teenage granddaughter or grandson would take them from the press. The advice is, ‘don’t leave these drugs in your medicine cabinet. You don’t leave a gun lying around the bathroom. Why would you leave something there that’s equally dangerous?’

Easy access increases the likelihood of addiction, he believes.

“The more that are prescribed and the more there are in community, the more likely people are to get addicted. That’s why we need controls. We don’t want a reservoir of these drugs in the community.”

Difficult to address addiction

When assessing how best to help a patient who presents with chronic pain, the situation can be difficult to address if addiction to opioid painkillers has already set in.

“If they have a condition that does warrant an opioid prescription, it can be very difficult to disentangle,” he says. “What we find is that there’s a whole subset of patients who may be using opioids for purposes other than pain relief. They may be taking them to help them sleep, because they are sad or because they are having a difficult time at home. We would think of those as aberrant drug taking behaviours, using them for non-medicinal purposes.

“As a pain specialist, there is a whole spectrum of conditions where we carefully question why the opioid is being used, how it’s being used and we would try to monitor it as best we can.”

Privilege rather than right

Dr Hearty has a good way of summing up how opioid prescriptions should be regarded.

“I’ll often say to patients that a prescription for these drugs is a privilege rather than a right. It’s like a driving licence. If you don’t abide by the rules, it’s taken away from you. If we see that addiction is developing or has developed, we would stop prescribing even for people who may have a rational reason for taking them.”

Strategies with patients may include entering into a contract with them.

“We’d say ‘you must go to one prescriber, you must go to one pharmacy, you mustn’t self-escalate and if you lose your prescription, that’s your problem not ours’.

“We would refer those who are addicted on to addiction psychiatry services, which unfortunately, are very poor in this country.”

Opiate use disorder (OUD) relates to someone using an opioid for unsanctioned purposes. That usage is associated with the four Cs of addiction – craving, control, compulsion to use and continued use despite harm.

The big problem with addiction is that it is by definition retrospective, Dr Hearty says.

“When a person is diagnosed with an addiction disorder, they are already addicted and the damage is done, so the goal is to avoid addiction happening.”

• Different types of opioid

The common opioid medications available in pharmacies are Solpadeine, Solpadol and Nurofen Plus, while prescription opioids include Tramadol and Ixprim.

Stronger controlled ones include MST and oxycodone (the generic name for oxycontin, which has led to many deaths and legal cases in the US against the company that marketed it, Pharma Purdue). Doctors do not always highlight that they are prescribing opoids.

• Doctor and pharmacy shopping

Going from GP to GP or pharmacy to pharmacy to source the painkillers is a sign of opiate use disorder, he says.

“I see this quite frequently,” he says. “To get around that I would give patients a relatively short prescription and I will also write to their GP saying I have given this. Communication is key.”

• Advice for patients

Destroy unused opioids. If you are taking more than prescribed, that is misuse and you should discuss this with your doctor. Take as few as possible for as short a time as possible.

• Advice for doctors

Make sure opioids are prescribed sensibly and that the more potent ones are only used for patients who really need them.

“It’s very similar to antibiotic stewardship,” he says. “If we don’t put some sensible frameworks around opioid use, there aren’t going to be opioids available for those of us who need them in the future.”