Opioids and musculoskeletal pain

We have a long and complex relationship with opioids. Humans have been actively growing poppies and enjoying their medicinal benefits since at least 3,400 B.C. The Sumerians referred to it as Hul Gil or the ‘joy plant’.

However, we now know that while these medicines can provide significant pain relief when used appropriately, they can also cause great harm.

Did you know that every day in Australia, nearly 150 people are hospitalised, and 3 people die due to issues related to opioid use? (1)

That’s why in 2020, the Australian Government made changes to how we use and access opioids.

What are opioids?

Opioids are pain-relieving medicines that come in various formulations, dosages and strengths. They include tramadol, codeine, morphine, oxycodone and fentanyl.

There are two groups of opioids:

• opiates – created using the milky substance found inside the pods of the opium poppy, and
• synthetic or man-made opiods – created in a laboratory using chemicals.

Opioids can be taken as tablets, injections or patches on the skin.

How do they work?

Opioids attach to opioid receptors in the nervous system and slow down the messages between the body and brain, including pain messages. This dulls your perception of pain – it’s not gone, nor is the cause of the pain. It’s simply been dampened so that you can function with less discomfort. They also cause the brain to release the hormone dopamine, making you feel happy or relaxed.

However, opioids can also slow your heart rate and breathing.

Opioids are used to treat severe pain associated with cancer or acute pain, for example following surgery.

They’ve also been used for many years to help people with severe, persistent non-cancer pain, like the pain associated with musculoskeletal conditions.

However, extensive research now shows that opioids don’t provide ‘clinically important improvement in pain or function compared with other treatments’ for most people with persistent pain or chronic pain.(2) This research, combined with our knowledge of the serious side effects of opioid medicines, particularly with long-term use, mean that these medicines should be used with caution.

Side effects

All medicines have side effects, so it’s important to know what they are. Side effects of opioids include sleepiness, constipation and nausea. More serious side effects include shallow breathing, slowed heart rate and loss of consciousness. These serious side effects may be due to too many opioid medicines being taken (an overdose). This can be life-threatening, so you need to ensure that you know when and how to take your medicines to prevent an accidental overdose.

Addiction is also a possible side effect of opioids.

Opioids, when taken long-term, can also make you feel more pain. This is called opioid-induced hyperalgesia. It happens because opioids make the brain and nerves more sensitive to pain.

Tolerance, dependence and withdrawal

Your body adapts to opioids when you use them long-term. This is called tolerance. To get the same pain relief, you need to increase the dosage. However, it’s not safe or sustainable to continue to increase the dosage of opioid medicines because of the serious risk of harm associated with their long-term, high-dosage use.

Dependence is when your body requires a specific dose of the medicine to avoid withdrawal symptoms when the dose is reduced or stopped. Symptoms of withdrawal can include: disturbed sleep, hot and cold flushes, sweating, feeling anxious or irritable, cravings for opioids, nausea, vomiting, diarrhoea, lack of appetite and tremors.(3) You’re more likely to experience withdrawal symptoms if you’ve been taking opioids for a long time and/or taking high doses.

Your doctor will slowly reduce your dosage to lessen your risk of withdrawal symptoms. This is called tapering.

Using opioids safely

Because of the risks associated with their use, opioids aren’t a first-line treatment for managing pain associated with musculoskeletal conditions. Instead, your doctor may suggest strategies such as exercise, maintaining a healthy weight, cognitive behavioural therapy (CBT), heat and cold packs, distraction, and short-term use of medicines such as paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs).

If you are prescribed opioids, it’s important that you:

• take them as prescribed
• don’t drink alcohol while you’re taking them
• don’t change the dosage or stop taking them without discussing this with your doctor – you may need to reduce your dosage gradually
• talk with your doctor about other medicines or supplements you’re taking – some may not be able to be used at the same time you’re taking opioids
• let your doctor know about any side effects you experience
• discuss other options you can use to help manage your pain with your doctor – for example, gentle exercise, CBT, heat and cold.

While using opioid medicines, you should also monitor whether or not they’re working for you. If you’re still experiencing severe pain that’s affecting your quality of life and ability to do daily activities, discuss this with your doctor. Together you can look at alternative treatment options.

Finally – it’s important to understand that opioids reduce our perception of pain. They don’t ‘kill it’, because there’s no such thing as a ‘pain killer’. Medicines and other strategies such as heat and cold, exercise, distraction and CBT can help you reduce pain to levels that enable you to live a healthy and happy life.

Contact our free national Help Line

If you have questions about managing your pain, musculoskeletal condition, treatment options, mental health issues, COVID-19, telehealth, or accessing services, call our nurses. They’re available weekdays between 9am-5pm on 1800 263 265; email (helpline@msk.org.au) or via Messenger.

More to explore

• Managing your pain: An A-Z guide
  Musculoskeletal Australia
• More changes to opioid access
  Musculoskeletal Australia
• Opioid medicines and chronic non-cancer pain
  NPS MedicineWise 
• Patient guide to managing pain and opioid medicines
  Choosing Wisely Australia 
• Prescription opioids: Information for consumers, patients and carers
  Therapeutic Goods Administration
• Prescription opioids: What changes are being made and why
  Therapeutic Goods Administration
• What are opioids?
  Alcohol and Drug Foundation

References

1. Prescription opioids: What changes are being made and why
   Therapeutic Goods Administration 
2. Prescription opioids: Information for consumers, patients and carers
   Therapeutic Goods Administration 
3. Opioid withdrawal symptoms
   Healthdirect