Leeds Palliative Care Services: Using morphine and other opioid painkillers to treat moderate to severe pain in palliative care patients

Morphine is one of a group of painkillers called ‘opioids’ that are taken to relieve moderate to severe pain. Other common medicines in the opioid group include oxycodone, fentanyl, buprenorphine and diamorphine.

This booklet provides information about opioids that are taken by mouth or absorbed through the skin from patches.

The strength and the preparation of the opioid painkiller are likely to change as your opioid dose requirements change.

Your doctor, nurse or pharmacist will explain how to use the medicines safely. This booklet has been given to you or your carer as a reminder of what has been discussed as well as containing some additional information you may find useful. There is also written information about your opioid painkiller in the company patient information leaflet supplied with your medicine.

1. About opioids

• Opioids can be used for the management of pain due to conditions requiring palliative care. When used in this way, they are not usually addictive.
• They may be used at any stage of that illness if your pain becomes a problem.
• They can be taken along side other types of painkillers, such as paracetamol and medicines for inflammation or nerve pain.
• They are usually taken by mouth but can be given through the skin by applying a patch.
• If needed, morphine, diamorphine or oxycodone can be given by injection by your nurse. This may be needed if you are unable to take medicines by mouth, or if you are being sick.

Different opioid preparations

(please see page 2 of this booklet for the name of your medicines).

Follow the instructions on the medicine’s pharmacy label.

2. What happens when I need to start taking opioids on a regular basis?

• Your doctor, nurse or pharmacist will explain how to take your medicine and the instructions will also be on the pharmacy label.
• You will be supplied with either, an immediate release preparation to be taken on a regular basis or a modified release preparation / opioid patch, starting at a low dose.
• If you are starting on an immediate release preparation, once your pain is well controlled, your doctor or nurse will normally change you to a modified release preparation or an opioid patch.
• Your doctor or nurse will arrange to review your pain relief regularly so that the opioid dose can be adjusted until your pain is controlled.

3. What should I do if I experience pain even though I am already on a modified release opioid or opioid patch ?

• To help “breakthrough” pain, your doctor or nurse will usually have told you to take a “rescue” dose of your immediate release opioid medicine.
• If you still have pain, even though you have taken a “rescue” dose, you can repeat the rescue dose.
• Always follow the instructions on the medicine’s label, which should tell you how long to leave between “rescue” doses and how many “rescue” doses you can take in a day.
• If this is not clear, seek healthcare advice.
• If you regularly need to take two or more “rescue” doses per day for “breakthrough” pain, you should contact your doctor or nurse as you may need your “background” dose increasing. Never change any doses of your opioids without discussing with your doctor or nurse first.

4. What are the most common side‑effects of opioids?

• Constipation is very common. You should be prescribed a laxative to take regularly, while you are on opioid medicines. You will probably need to take this for as long as you are taking an opioid medicine.
• Feeling and being sick. This is common but usually wears off within the first few days of starting or increasing the dose of opioid. You may be prescribed anti-sickness medicine to prevent this.
• Mild drowsiness or dizziness can occur when you first start taking opioids or when you increase the dose. These mild symptoms usually wear off within a few days.

5. What should I do if I think I am experiencing any side‑effects from my opioid medication?

• If you get side-effects which do not settle as expected, ask your doctor, pharmacist or nurse for advice.
• If your side-effects are severe or you are worried about them, contact the emergency doctor.
• You should not stop taking your opioid suddenly, particularly if you have been taking it for a long time. Your doctor or nurse will tell you when and how to stop taking the opioid, which will normally be gradually withdrawn so that you do not suffer from ‘withdrawal effects’.

6. What should happen if I develop confusion or severe drowsiness while taking opioids?

• If you become drowsy or confused, contact a doctor or nurse for advice as soon as you can.
• Severe drowsiness due to opioids is rare – if this happens, dial 999 for an ambulance.
• If an ambulance is called, please remember to keep any medicines that have been taken and their containers to show the doctor, nurse or paramedic.

7. Can I drink alcohol when taking opioids?

• Opioids may make you more sensitive to the effects of alcohol; however, many people continue to drink small amounts. Ask your doctor or nurse if you feel unsure about this.

8. Driving and travelling

Can I drive while taking opioids?

• You should not drive while taking strong opioids until you know whether or not it affects your ability to drive. You are advised not to drive for 5 days after starting or changing the dose of your opioid medication and should not drive within 3 hours of taking an extra dose of your medication. It is not against the law to drive if you are taking opioids as prescribed and your driving is not impaired; however, it is against the law to drive if your driving ability is impaired by this medicine.
• It is your responsibility to judge whether you are fit to drive. If restarting driving, you are advised to make your first trip short in daytime hours and on familiar roads. It may be helpful to be accompanied by another driver.
• You should not drive if you feel sleepy, dizzy, unable to concentrate or make decisions, or if you have blurred or double vision.
• Be aware of the risk of exacerbating these effects if you have also taken alcohol or other medications which can cause drowsiness, i.e. hay fever tablets.
• You do not need to inform the DVLA that you are taking opioid medications but there may be other information about your condition that you need to let the DVLA know. Ask your doctor or nurse for further advice about this.
• You are advised to keep a copy of your prescription in your car in case you are stopped by the police.
• If in any doubt about your ability to drive, it is safest not to drive.
• For further information go to:
  www.gov.uk/drug-driving-law
  www.gov.uk/browse/driving/disability-health-condition
• You are advised to check whether your motor insurance company requires information about your medical condition and any medicines you are taking to keep your insurance valid.

What must I do if I’m travelling abroad and need to take my opioids with me?

• You should be able to take enough of your medicines with you. Talk to your doctor, nurse or pharmacist who will able to advise you about taking opioids, when travelling outside the UK.
• You may need a letter from your doctor or a special licence to take with you.
• Medicines should be taken in their original container in your hand luggage when flying.
• The restrictions on quantities of liquids in your hand luggage also apply to medicines. You may want to switch to a tablet or capsule form of immediate release opioid for “breakthrough” pain before you travel, instead of a liquid form.

9. Other Information

Can somebody else collect my strong opioids from the pharmacy for me?

• Yes, a responsible person over 16 years, with some form of identification can do this.
• They must sign the prescription to show that they are collecting the opioids and state their relationship to you.
• If possible, telephone the pharmacy to tell them who will be collecting your medicines on your behalf.

What other advice about taking my medicines is important?

• Always keep an up-to-date list of your current medicines, including ones you buy from the pharmacy and supermarket, via the internet and from health food shops. Take this to all health-related appointments and if you are admitted to a hospital or hospice.
• Do not stop taking your prescribed medicines without discussing with your prescriber.
• Never let other people take any medicines that have been prescribed for you.
• Seek advice if you are unsure about anything.

How should I store my opioids at home?

• Securely closed in the original container with the label intact.
• Out of sight and reach of children or pets.
• Safely where you or your carer can easily find them.
• Away from direct sunlight, heat and moisture.

How should I dispose of unwanted opioids?

• For used patches only – remove, fold with the sticky sides together, put it back in a patch wrapper or wrap in tissue and throw in a rubbish bin, where children or pets cannot get hold of them. Then, wash your hands. The used patch may still contain some opioid.
• Other unwanted opioids (including patches that have not been used) must not be flushed down the sink or toilet, or placed in a rubbish bin – return them to any pharmacy for safe disposal.