Health Tips

As human beings, we’re wired to avoid pain. Hence, it’s not surprising that the earliest prescription of opioid painkillers can be traced back to 8000 years ago—in the form of hardened Sumerian clay tablets. 

Centuries later, opioids painkillers have shown its virtues and vices in various wars, disease outbreaks, and many opioid-abuse epidemics. When used correctly, strong opioids painkillers can relieve suffering; on the contrary, they can be addictive and prone to abuse, which may lead to drug overdose and death. The recent drug overdose epidemic in the United States is a cautionary tale for all countries around the world.

Cover photo credit: Photo by Michael Longmire on Unsplash

Medical usage of prescription strong opioids painkillers

Strong opioids painkillers are commonly used in treating long-term, severe pain, such as:

• those experienced by cancer patients

• people who are at the end stage of their lives (palliative care)

• those who suffer from long-term non-cancer pain but do not respond well to weaker painkillers 

Photo by National Cancer Institute on Unsplash

Strong opioid painkillers can be prescribed in two ways: regular pain medication and for breakthrough pain. As a regular painkiller, the person takes it at the time interval determined by the doctor (e.g. every 4 hours); as a breakthrough painkiller, the person takes the medication whenever pain arises (with a certain limit capped by the doctor’s prescription). 

In Malaysia, the use of strong opioids painkillers is heavily regulated by the Dangerous Drugs Act 1952 and Regulations. Only registered doctors, dental surgeons, pharmacists and individuals who are authorized by the Minister of Health can supply strong opioid painkillers to patients.

In general, doctors prescribe painkillers for pain based on The World Health Organization analgesic ladder, which is a step-wise approach to prescribing painkillers based on the pain severity reported by patients.

Image credit: 1. Tredgett K. Pain control in palliative care. Medicine [Internet]. 2020 [cited 21 September 2021];48(1):2-8. Available from: https://doi.org/10.1016/j.mpmed.2019.10.003

Non-opioid refers to painkillers such as paracetamol (Panadol^®) and the non-steroidal anti-inflammatory drugs (NSAIDs). Adjuvant drugs are not primarily prescribed alone for pain, but they can be helpful to relieve pain if used together with other painkillers, such as corticosteroids and certain antidepressants.

Examples of strong opioid painkillers commonly used in Malaysia:

• Morphine (available in injection, solution, tablets and suppository)

• Fentanyl (available in injection,transdermal patch and sublingual tablets)

• Oxycodone (available in tablets and solution)

• Buprenorphine (available in transdermal patch)

Proper use of prescription strong opioids painkillers

Here we provide a few guides on how to use strong opioids safely.  Nevertheless, you’re encouraged to consult your doctor and pharmacist for further information.

Morphine sustained-release tablets

Image credit: https://www.mims.com/singapore/drug/info/mst%20continus?type=full

• Although morphine is available in both immediate-release and sustained-release tablets, the latter is preferred because the person only needs to take twice daily (sometimes three times daily) instead of every four hours for immediate-release.

• Morphine sustained-release tablets have special formulation that allows morphine to be released at a slower rate in the body.

• Available strength of morphine sustained-release tablets: 10mg, 30mg and 60mg.

Note: The information below is also applicable to oxycodone controlled-release tablets (OxyCONTIN®) and oxycodone controlled-release/naloxone tablets (Targin®).

• How to take morphine sustained-release tablets:

  • Take exactly as instructed by your doctor. Do not exceed the dose prescribed by your doctor. 

  • Swallow your tablet as a whole with a glass of water. Do not chew, crush or break the tablet, as it will destroy the special formulation that is crucial to its sustained-release pattern.

  • If a tablet is chewed, crushed or broken, the entire dose of morphine may be absorbed rapidly by your body. This can be dangerous, causing serious problems such as drug overdose, which can be fatal.

• If you missed a dose and remember it within 4 hours of the usual time your tablet was due, take your tablet straight away. If it has been more than 4 hours, skip the dose and resume your usual time of taking the tablet next day. 

• You may still take your breakthrough pain medication even though you miss a dose of your regular pain medication. 

• Do not take a double dose to make up for the missed dose.

Aqueous Morphine (morphine solution)

• Available strength of aqueous morphine solution: 10mg/5ml

• Aqueous morphine is a colorless and very thick solution.

• How to take aqueous morphine:

  • Take exactly as instructed by your doctor. Do not exceed the dose prescribed by your doctor. 

  • Aqueous morphine is usually taken every 4 hours, but your doctor may prescribe you with more doses or higher frequency based on your pain severity.

  • Take the aqueous morphine by mouth, just like how you would take other liquid medication. You are encouraged to use a plastic syringe to measure the accurate volume prescribed by the doctor.

• If you missed a dose, take it as soon as you remember and take your next dose at the usual time. 

• Do not take a double dose to make up for the missed dose.

Transdermal fentanyl patch

Image credit: MIMS

• Available strength of fentanyl patch: 12mcg/hour, 25mcg/hour, 50mcg/hour, 75mcg/hour and 100mcg/hour.

• Fentanyl, the painkiller, is contained in a sticky patch. When the patch is stuck onto the skin surface, fentanyl will be released gradually across the skin barrier into your bloodstream.

• Transdermal fentanyl patch is usually used by individuals who have tried other strong opioid painkillers (such as morphine) before but do not get adequate pain relief or for other reasons, such as difficulty to swallow or kidneys do not work well. The use of morphine is not recommended in those who have kidney problems, which makes fentanyl a preferred choice.

The following information is also applicable to transdermal buprenorphine patches.

• How to use transdermal fentanyl patch:

  • Choose an intact (no wound, irritation or sore) and hairless spot on the surface of the upper arm or upper body. 

  • You may cut the skin hair if it’s too long, but do not shave it as it may further irritate the skin surface if fentanyl patch is applied.

  • If you are undergoing radiotherapy, do not stick the fentanyl patch on a previous radiotherapy site.

  • Ensure the skin is dry and clean before sticking.

• Remove the patch from the packaging and protective foil, and stick it onto the chosen spot. Press it firmly against the skin surface with your palm and hold it for 30 seconds to ensure it adheres well.

• Leave the patch on skin for 72 hours (3 days). If it's a buprenorphine patch, leave the patch on for 7 days (1 week). You may write the starting date on the patch with a permanent marker. 

• You may bathe or shower with patch on as it is waterproof.

• After 3 days, remove the patch from the skin. Immediately fold the used patch in half and throw it away.

• Apply a new patch right away on a newly chosen skin surface. If it’s a buprenorphine patch, you’re advised to rotate the application site and leave a 3-week window before the same spot is used again.

• Do not cut or divide the fentanyl patch unless told to do so.

• Do not stick an extra patch unless told to do so.

• If the fentanyl patch has fallen off, DO NOT reuse it. Put on a new patch as soon as you realise.

• If you have forgotten to change a patch, and there’s a long delay, you may need to take extra doses of immediate-release painkillers while waiting for the effect of fentanyl to kick in, which may take a few hours. 

• Avoid exposing the application site to direct external heat sources such as heating pads, prolonged hot baths, saunas and spa baths. This is because increase in temperature may increase the concentration of fentanyl, which can lead to toxicity and overdose.

• If you develop fever while using a fentanyl patch, consult a doctor immediately.

• Inform your doctor if you develop skin reaction while using the patch.

Managing side effects of prescription strong opioids painkillers

The most common side effects of strong opioid painkillers are:

• Constipation — Therefore, a laxative is commonly given together with strong opioid painkillers. Laxatives such as syrup lactulose or bisacodyl can stimulate your bowel movement, thus helping you to defecate.

• Nausea and vomiting — This side effect is usually more prominent on the first few days of taking the strong opioid painkillers, which should wear off as time goes by. If it becomes unbearable, consult your doctor to get a prescription for anti-emetic, i.e. medication that relieves nausea and vomiting.

• Drowsiness — This side effect is more likely to occur when you first start taking strong opioid painkillers, and it should wear off as time goes by. Throughout this period, avoid driving or operate heavy machinery.

If your pain is not relieved despite taking the prescribed dose as well as your breakthrough dose, do consult your doctor. It may warrant a review on your analgesic regimen.

Will I get addicted to prescription strong opioids painkillers?

Addiction, or more accurately known as physical dependence, is different from developing tolerance for painkillers. For someone who develops physical dependence or addiction to opioids, they may show withdrawal symptoms when the medication is stopped. Whereas if someone develops tolerance, it means that they might need to take more medications to achieve the same pain relief as before. 

Prescription opioid painkillers come with addiction potential, but don’t let that stop you from seeking treatment for your pain. Here are some tips that may guide you to make an informed decision:

Source: CDC

If you’re interested to learn more about pain and other types of painkillers, read our previous article here.

A word from DOC2US

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Disclaimer: As a service to our users and general public, DOC2US provides health education contents. Please note the date of last review or update on all articles. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.

Specific references have been linked in its relevant part of the article. 

References:

1. Pharmaceutical Services Programme, Ministry of Health Malaysia - Pain Medication Therapy Management Services: Guideline for Pharmacy 2018

2. Malaysian Association for the Study of Pain - A guide to the use of strong opioids in chronic non-cancer pain 2015

3. NICE - Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults 2012

4. Durogesic® Transdermal Patch product leaflet

Cover photo credit: Photo by Michael Longmire on Unsplash

Written by

Ms Joyce Toh