Finding relief from severe pain can be a challenging and exhaustive experience – but no one has to do this without help.

In palliative care, with the right support, pain can be controlled. Daily activities become easier, less distressing and more comfortable [i]. Managing pain well can improve quality of life [ii].

An important part of pain management is, of course, the use of medicines only available with a prescription from a doctor. Some prescription medicines are quite strong and are used mainly for moderate to severe pain, such as codeine, morphine, oxycodone and fentanyl and other opioids [iii].

While opioid medicines are effective for helping people in palliative care to manage their pain, there is a growing concern about the use of opioids more broadly in Australia [iv]. Much of the concern is to do with an increasing number of people becoming dependent on opioid medicines [v], experiencing overdoses [vi], and, sadly, dying [vii]. It’s happening across the world, too [viii].

Part of the government’s response has been to start making opioid medicines harder to access. Any medicine containing codeine is now only available with a prescription [ix]. Also, all state governments have committed to new technology that closely monitors the prescribing of opioid medicines to try and help prevent issues from occurring [x].

The problem is that if we make opioid medicines too hard to access, then many Australians could miss out on their benefits, including those who are most vulnerable. Severe pain may go untreated, and cause great suffering, unnecessarily [xi].

Fortunately, opioid medicines are still recognised for their effectiveness in palliative care [xii] – and as such, there is an opportunity to support a balanced [xiii], and humane, approach to their use.

The science of opioid medicines and their benefits for palliative care

Opioid medicines activate receptors in the nervous system that influence the perception of pain [xiv], and can reduce its strength, providing relief [xv].

One way of imagining how opioid drugs and receptors work together to influence the sensation of pain is like a volume control: the level of perceived pain is turned down.

Every person does experience and manage pain differently – but in palliative care, opioid medicines are often used [xvi] to reduce pain strength [xvii], and other problems associated with pain, such as feelings of stress and irritability [xviii]. Sudden increases in pain can be controlled with opioids as well [xix].

Using the right opioid medicine is critical to effective pain management [xx]. Doctors and nurses work with patients to select the most appropriate kind and dosage of opioid medicine, which depends on things like the intensity of pain, how often it occurs, and the risk of side effects and other issues [xxi]. Constipation, nausea and drowsiness are common with the use of opioid medicines, but they can be reduced or managed while still taking opioids for pain relief [xxii].

With less pain, and by working with health professionals to use opioid medicines effectively and manage any side effects, people in palliative care are likely to have more energy, greater independence and be able to better enjoy the things they love to do.

Is Australia in the midst of an opioid crisis?

Given the clear benefits experienced by people in palliative care who use opioid medicines, its worrying to see media coverage of significant issues with opioids here and overseas, as well as government action restricting their use.

Many countries are seeing increasing rates of dependency and death associated with opioid medicines [xxiii]. In the United States, the problems have been described as reaching “epidemic proportions” [xxiv]. The US, as well Australia, requires a widespread response, from government, pharmaceutical companies and the health system, to doctors, families and communities at a grass roots level [xxv].

Australia is experiencing similar issues as the United States – but the evidence suggests that it has not reached the same levels of harms [xxvi].

The difference is likely to be due to factors such as Australia having a universal health system providing more protection and support, better access to healthcare generally, and less advertising of prescription drugs to the public [xxvii].

At the same time, evidence also finds that many Australians do use opioid medicines in ways that are risky, and there are signs that related problems are growing [xxviii].

In 2016, over 500 000 Australians aged 14 years or over used codeine containing medicines in non-medical ways, such as for recreational purposes [xxix]. Shopping for medications from different doctors and taking opioid medicines from family and friends is an issue [xxx] [xxxi]. Sometimes, opioid medicines are used for too long, without medical supervision, or mixed with alcohol, creating a risk of overdose, and death [xxxii].

So, what can we do, in our own families and communities, to both reduce the risk of problems with opioid medicines, and support their use for effective pain relief in settings such as palliative care?

How can people in palliative care be made to feel more comfortable when talking about pain and medicines?

Some of the answers may lie in working together towards a balanced approach when using opioid medicines. Specifically, we need to make sure that opioids are considered as part of an overall plan for the management of pain in palliative care [xxxiii], one that considers pain relief as well as side effects, and that we draw on existing forms of guidance and support.  

Good communication, regular assessments and other ways to support a balanced approach

A number of useful tools and strategies are available that can help manage the use of opioid medicines in palliative care for effective pain relief – and help to avoid the risk of dependency, overdose and other issues being experienced more generally across Australia.

For doctors, nurses and other health professionals, the Royal Australian College of General Practitioners provides guidelines for health professionals on the use of opioid medicines in palliative care. While the guidelines are not recent, they do provide specific advice on how to choose a medication, appropriate forms of administration (e.g. oral, transdermal), and the correct dose.

Online platforms can provide assistance with dosage calculations for opioid medicines, such as the Australian and New Zealand College of Anaesthetists free opioid calculator smartphone app, and the Centre for Palliative Care Research and Education’s GP Pain Help app and website.

Beyond practice guidelines, the decision to use opioid medicines can be made as part of planning for pain management [xxxiv]. Through planning, health professionals and patients can communicate better to create a shared understanding of the experience of pain in palliative care. Fears of side effects with opioids, such as drowsiness and dependency, can be addressed, as well as strategies to manage them. The short term use of opioids has rarely been reported to cause issues with dependency, and the risk of issues with dependency in the short term are low[xxxv].

Regular assessments as part of planning are also a chance for health professionals to check the dosage of opioid medicines is working, and the levels of pain experience by patients. Some opioids are faster acting than others, and may be more appropriate for pain that is episodic [xxxvi]. Breathing difficulties, other respiratory issues and side effects can also be checked during assessments [xxxvii].

For patients, family members, carers and others who want to learn more about managing pain in palliative care, Palliative Care Australia provides information on what to expect when using opioid medicines. The information covers how to track pain with diaries and charts, the different kinds of medicines available, and things to speak about with health professionals.

Pain Bytes, an online resource developed by the Agency for Clinical Innovation, is also useful. The resource contains information about the self-management of pain, including the role of nutrition, physical activity and sleep.

With more understanding of how to manage pain using opioid medicines, the palliative care community can set an example for the rest of Australia to follow. Opioid medicines will always carry a risk of side effects and other issues – but by using a balanced approach, we can choose to manage that risk carefully, holistically, and with greater compassion.

End Notes 

[i] National Institute for Healthcare and Excellence, “Palliative Care for Adults: Strong Opioids for Pain Relief” (United Kingdom: NICE, 2012).

[ii] S Dalal and E Bruera, “Access to Opioid Analgesics and Pain Relief for Patients with Cancer,” Nat. Rev. Clin. Oncol. 10, no. 2 (2013): 108–16, https://doi.org/10.1038/nrclinonc.2012.237.

[iii] Raymond S. author Sinatra, The Essence of Analgesia and Analgesics. (Cambridge : Cambridge University Press, 2010).

[iv] Rae et al., “Is There a Pill For That?” (Melbourne, Australia: Alcohol and Drug Foundation, 2016).

[v] Australian Institute of Health and Welfare, “Alcohol and Other Drug Treatment Services in Australia 2013-14: Drug Treatment Series No. 25” (Canberra: AIHW, 2015).

[vi] National Drug and Alcohol Research Centre, “More Australians Dying of Accidental Overdose of Pharmaceutical Opioids” (NDARC, 2017), https://ndarc.med.unsw.edu.au/news/more-australians-dying-accidental-overdose-pharmaceutical-opioids.

[vii] Amanda Roxburgh et al., “Trends and Characteristics of Accidental and Intentional Codeine Overdose Deaths in Australia.(Report)” 203, no. 7 (2015): 299, https://doi.org/10.5694/mja15.00183.

[viii] David Herzberg et al., “Recurring Epidemics of Pharmaceutical Drug Abuse in America: Time for an All-Drug Strategy.,” American Journal of Public Health 106, no. 3 (March 2016): 408–10, https://doi.org/10.2105/AJPH.2015.302982.

[ix] Therapeutic Goods Administration, “Codeine Information Hub,” 2018, https://www.tga.gov.au/codeine-info-hub.

[x] Paola, “Real-Time Monitoring on Track,” AJP, 2018.

[xi] M Mofizul Islam and Ian S McRae, “An Inevitable Wave of Prescription Drug Monitoring Programs in the Context of Prescription Opioids: Pros, Cons and Tensions,” BMC Pharmacology & Toxicology 15, no. 1 (2014): 46–46, https://doi.org/10.1186/2050-6511-15-46.

[xii] Royal Australian College of General Practitioners, “Medical Care of Older Persons in Residential Aged Care Facilities” (RACGP, 2006).

[xiii] NCETA and Flinders University, “A Matter of Balance: NCETA Background Discussion Paper to the Development of the National Pharmaceutical Drug Misuse Strategy” (NCETA, 2011).

[xiv] Adam T Hilgemeier et al., “Pain Perception and the Opioid Receptor Delta 1,” Cureus 10, no. 2 (2018): e2149, https://doi.org/10.7759/cureus.2149.

[xv] Yuan Feng et al., “Current Research on Opioid Receptor Function,” Current Drug Targets 13, no. 2 (February 2012): 230–46.

[xvi] Nicole Heneka et al., “Opioid Errors in Inpatient Palliative Care Services: A Retrospective Review.,” BMJ Supportive & Palliative Care 8, no. 2 (June 2018): 175–79, https://doi.org/10.1136/bmjspcare-2017-001417.

[xvii] Ross Pinkerton and Janet R. Hardy, “Opioid Addiction and Misuse in Adult and Adolescent Patients with Cancer,” Internal Medicine Journal 47, no. 6 (2017): 632–36, https://doi.org/10.1111/imj.13449.

[xviii] Dalal and Bruera, “Access to Opioid Analgesics and Pain Relief for Patients with Cancer.”

[xix] Giovambattista Zeppetella and Andrew N. Davies, “Opioids for the Management of Breakthrough Pain in Cancer Patients.,” The Cochrane Database of Systematic Reviews, no. 10 (October 21, 2013): CD004311, https://doi.org/10.1002/14651858.CD004311.pub3.

[xx] Amelia Swift, “Opioids in Palliative Care: The NICE Guidance.(National Institute for Health and Clinical Excellence),” Nursing Times 108, no. 45 (2012): 16.

[xxi] Swift.

[xxii] Swift.

[xxiii] Herzberg et al., “Recurring Epidemics of Pharmaceutical Drug Abuse in America: Time for an All-Drug Strategy.”

[xxiv] Herzberg et al.

[xxv] NCETA and Flinders University, “A Matter of Balance: NCETA Background Discussion Paper to the Development of the National Pharmaceutical Drug Misuse Strategy.”

[xxvi] Briony Larance et al., “Pharmaceutical Opioid Use and Harm in Australia: The Need for Proactive and Preventative Responses,” Drug and Alcohol Review 37, no. S1 (2018): S203–5, https://doi.org/10.1111/dar.12617.

[xxvii] Larance et al.

[xxviii] Winfried Hauser, Stephan Schug, and Andrea D. Furlan, “The Opioid Epidemic and National Guidelines for Opioid Therapy for Chronic Noncancer Pain: A Perspective from Different Continents.,” Pain Reports 2, no. 3 (May 2017): e599, https://doi.org/10.1097/PR9.0000000000000599.

[xxix] Stephan A Schug, Malcolm Dh Dobbin, and Jennifer L Pilgrim, “Caution with the Forthcoming Rescheduling of Over-the-Counter Codeine-Containing Analgesics,” The Medical Journal of Australia 208, no. 1 (2018): 51, https://doi.org/10.5694/mja16.00881.

[xxx] Benny Monheit, Danusia Pietrzak, and Sandra Hocking, “Prescription Drug Abuse - a Timely Update,” Australian Family Physician 45, no. 12 (2016): 862–66.

[xxxi] Larance et al., “Pharmaceutical Opioid Use and Harm in Australia: The Need for Proactive and Preventative Responses.”

[xxxii] Rae et al., “Is There a Pill For That?”

[xxxiii] Swift, “Opioids in Palliative Care: The NICE Guidance.(National Institute for Health and Clinical Excellence).”

[xxxiv] Swift, “Opioids in Palliative Care: The NICE Guidance.(National Institute for Health and Clinical Excellence).”

[xxxv] Swift.

[xxxvi] Swift.

[xxxvii] Swift.