Narcotic pain medications

Most medications have a maximum dose. Usually, the maximum dose is one that you cannot exceed without suffering harm. In the case of most pain medications, taking more than the maximum dose will not improve the pain relief but may cause toxic side-effects such as stomach ulcers, kidney damage, liver damage, chemical imbalance in the bloodstream, or death.

Strong opioid medications are slightly different in this respect, which is fortunate for people who suffer from severe pain. With strong opioids, the dose depends on the amount of pain. These medications should not, however, be taken in combination with paracetamol or other non-opioid drugs when used to treat chronic pain.

People with intense pain can take very high doses of opioids without getting side-effects. Some people with intense pain take such high doses that the same dose would be fatal if given to someone who was not suffering from pain. In a patient with severe pain, that same high dose can control the pain and still leave the person awake enough to pursue his or her daily living activities.

• Long-acting opioids. The best way to treat chronic, severe pain is by keeping it under control all of the time. Your doctor can do this by using a long-acting opioid to keep the pain under control and a short-acting opioid to deal with those few times during the day when the pain breaks through. So if you were on morphine, you would get a slow-release tablet to keep your pain under control most of the time, and a short-acting tablet or liquid for those times when your pain broke through.
• Bad opioids. Some opioids are not recommended for chronic pain.
  • Pentazocine is not appropriate for treating chronic pain. It has a ceiling effect, which means there is a maximum dose beyond which raising the dose gives no further pain relief. Pentazocine also causes withdrawal symptoms when given to someone who is taking another opioid.
  • The opioid/paracetamol or opioid/NSAID (non-steroidal anti-inflammatory drug) combinations are fine for short-term use, but paracetamol is toxic to the kidneys and liver when used for a long time or at high doses. A number of NSAIDs are toxic to the kidneys and stomach when taken for a long time or at high doses.
• Complications of opioids
  • Nausea and vomiting. These are common side-effects at the start of opioid therapy. If they are a problem, they can be controlled with non-prescription medication for nausea or, in some cases, with prescription drugs such as prochlorperazine. The nausea and vomiting usually wear off within a few days, then the anti-emetic (anti-nausea and -vomiting) medication can be stopped.
  • Dizziness. Dizziness and sleepiness are common side-effects of opioids. That is why you are advised not to drive, drink alcohol or operate machinery while taking opioids. People with chronic pain often develop a tolerance for these side-effects and can pursue all the normal activities of daily living while on opioid therapy.
  • Constipation. Opioids always cause this problem, and constipation will continue to be a problem for as long as you take opioids. Constipation can become a serious issue if you do not deal with it. If the stool is completely blocked (faecal impaction), it has to be treated using a very uncomfortable procedure, in which the doctor or nurse puts a gloved finger up your rectum and pulls out pieces of faeces until the problem is cleared. Better, then, to prevent this problem rather than having it treated. There are a variety of laxatives available without a prescription, such as senna and docusate. Take enough of them to make sure your bowels move every day.
  • Addiction. Hospice patients worry about becoming addicted to opioids. In the hospice setting, though, addiction is rarely an issue. People with chronic pain also worry about addiction to opioids. But it turns out that, for most adults, if they do not already have a substance (alcohol or drug) abuse problem, addiction is not much of a concern even when opioids are used on a long-term basis.
    • In a study conducted in the US, 12,000 non-addicts who needed opioids were followed up to see if they became addicted. Only four out of 12,000 (less than one tenth of 1%) showed addictive behaviour.
    • Generally, the only people who develop addictive behaviour after being given opioids already had an addiction problem before the opioids were prescribed for pain. Most people take opioids until the pain goes away. Then they stop taking them because they do not want to feel dizzy or drowsy.
    • Anyone who takes any medication just to ’get high‘ is already showing addictive behaviour and needs to stop taking addictive substances immediately, including opioids, other addictive drugs and alcohol.
    • In fact, some people with painful illnesses are addicted to mind-altering substances. They get prescriptions because of their illness. Here's how the patient or their family can tell the difference between someone who needs opioids for pain and someone who is abusing opioids. Normally, the dose of opioids is determined by the patient telling the doctor how they are coping with the pain and daily living activities. A chronic pain patient who is not addicted to medication will tell the doctor the truth about his or her ability to function in everyday life.
    • Addicts, on the other hand, will lie about their capacity for daily living activities. They will say the pain is so severe that they need a higher dose, until they reach a level where they are asleep most of the time. Then addicts will tell the doctor they are doing fine and can handle all the activities they need to.
    • Selling opioids to others is a crime that could result in a long prison sentence.
    • Family members must let the doctor know what is happening in this kind of situation. When an addicted person actually has a painful syndrome, the doctor - with the help of the family - may have to decide what the right dose of medication should be, without reference to the dose the patient thinks is best. Sometimes, with severely addicted people, opioids should not be used at all. Some addicted people can be treated with opioids if necessary, as long as they co-operate carefully with the treatment plan.
  • Respiratory depression The most dangerous complication of opioid therapy is respiratory depression. Some drug addicts have been known to get pure heroin and die with the needle still in their arm, because they fell asleep and stopped breathing. That happens when someone who is not in pain takes a huge overdose of an opioid. Pain is a potent stimulator of the respiratory centre in the brain. So if you are in pain and your doctor increases the dose of opioids carefully until the pain is controlled, then stops raising the dose, you will not get respiratory depression.

Fortunately, for most people with pain, large doses of opioids can be used safely if they are needed to combat severe chronic pain.