Safe and
Responsible Use
of Opioids for Chronic Pain
A Patient Information Guide
Revised October 2018 V2
IB 10-791, P96791
The healthcare providers and sta at the Department of Veterans Aairs
(VA) are concerned about your pain. We are committed to providing you
with the best possible care.
In this patient information guide, we review:
• Information about opioid medicines
• Your pain care plan involving specic types of treatments
andactivities
• Alternatives to opioids for pain management
• Possible side eects of opioid medicines
• How to take opioids in a safe and responsibleway
Introduction
1
Opioids are medicines that may be used to treat pain. Opioids also are called “opiates” or “narcotics.” Opioids
can be dangerous, even when prescribed and taken responsibly. Taking opioids at any dose may be harmful.
We want to make sure you have the information and strategies to keep yourself and others safe when using
these medicines.
Prescription Opioid Medicines Include:
• Hydrocodone (Vicodin®, Lortab®, Norco®)
• Oxycodone (OxyContin®, Percocet®, Endocet®,)
• Morphine (MS Contin®, Kadian®, Oramorph SR®)
• Hydromorphone (Dilaudid®)
• Fentanyl (Duragesic®)
• Codeine (Tylenol® with Codeine #3, Tylenol® with
Codeine #4)
• Methadone (Dolophine HCL®, Methadose
TM
)
• Tramadol (Ultram®)
• Buprenorphine (Butrans®)
• Oxymorphone (Opana®)
• Tapentadol (Nucynta®)
Opioids also can come from sources other than medicines you get from your healthcare providers. These
include medicines not prescribed to you (e.g., from family or friends) and “street drugs.” Any medicine that
you did not get from a pharmacy with a prescription can have extra risks. The ingredients and strength may
not be known, for example, counterfeit pills may contain fentanyl or carfentanil (“elephant tranquilizers”). It is
important for you to inform your provider(s) about all medicines and substances you are taking as some can
interact to cause harm, including overdose and death.
Your healthcare team will talk to you about the best ways to treat your pain. Together, you will discuss the
goals for your treatment and how much relief you can expect from the dierent options. An example of a
goal would be to improve your ability to move, exercise, and participate in activities you enjoy.
Opioids are not the most eective treatment for long-term, non-cancer pain. In fact, opioids are no longer
recommended for the treatment of most patients with chronic pain. If prescription opioids are used, you will
be given information on possible side eects, other risks, and monitoring needed for your safety.
Over the past 20 years, we have learned several important things about using opioids for chronic pain.
1. Tolerance
When opioids are taken daily, your body gets used to the medication. Over time, the opioid will be less
eective at lowering your pain. Needing higher and higher doses to achieve the desired eect is a sign that
you may be at risk for addiction and overdose and should alert you and your team to reassess your pain
treatment plan.
2. Risks
Opioids come with serious risks that are outlined on pages 4 and 5. The most serious risks include
respiratory depression (stopping breathing - also known as “overdose”) resulting in death, and the risk of
developing opioid use disorder (from moderate to severe is also known as “addiction”). Increasing the dose
of an opioid will increase the risk of opioid use disorder, overdose, and other side eects.
3. Risk increases with other health conditions, medicines, and substances
If you have health conditions such as sleep apnea, breathing problems, liver problems, or kidney problems,
you may have a higher risk for overdose and side eects even with low doses of opioids. Drinking alcohol,
2
using benzodiazepines, or taking other medicines that can make you sleepy can increase your risk of side
eects and overdose. These substances are not recommended in combination with an opioidmedicine.
4. Dependence
Dependence means that your body will depend on the opioid to feel normal. If you stop the opioid
suddenly or decrease the dose too quickly, you will feel increased pain and other symptoms of opioid
withdrawal. This may make it hard to stop even if you want to. Dependence can happen even when low
doses of opioids are taken for acute pain, such as dental procedures or fractures, for less than one week.
Opioids may be needed for acute pain in some situations. To reduce the risk of dependence when treating
acute pain, opioids should be used for ve days or less.
5. Opioid Use Disorder
Opioid use disorder is a chronic brain disease that develops from repeated use of opioids. In its moderate
to severe form, it is also known as addiction and can be life-threatening. The risk of death from overdose is
6 to 20 times greater for those with opioid use disorder than for the general population. Symptoms include
preoccupation with and craving for opioids, continued use despite signicant opioid-related problems,
often using more opioids than intended, and other signs that one has lost the ability to control the use of
opioids. While not every patient who develops tolerance and dependence has an opioid use disorder, these
are two signs of increased risk of opioid use disorder. When carefully assessed, 25% to 40% of patients on
long-term opioid therapy (more than 90 days) has an opioid use disorder.
Your Pain Care Plan
Even if opioids are used to reduce pain, they will be most
eective when combined with other safer and more eective
strategies. You and your healthcare team will make a pain care
plan based on your condition and specic situation. Treatments
may include self-care activities, non-medication treatments or
therapies, medicines that do not contain opioids and, in some
instances, opioid-containing medicines. Here is a list of some
commonly used options that might be included in your pain
care plan.
1. Self-care
These activities include everything you can do on your own
to manage your health (including pain) and live your life as
fully as possible.
• General Health Activities
o
Develop or maintain supportive relationships.
o
Get a good night’s sleep every night.
o
Eat healthy foods including fruits and vegetables.
o
Move your body every day and do activities you enjoy.
o
Stop smoking and using other tobacco products.
o
Try meditation or other relaxing activities.
• Pain Management Strategies
o
Improve your posture: stand or sit up straight.
o
If you are overweight, lose weight. Consider enrolling in a weight management program.
o
Practice yoga, exercise, stretching, and/or Tai Chi.
o
Learn and practice deep breathing and relaxation exercises.
o
Use heat or cold packs on the painful areas.
o
Attend pain management classes and join support groups.
3
2. Non-medication Treatments
• Behavioral Therapies
o
Learn to react to pain in a way that helps you function better
and reduce your pain, for example, Cognitive Behavioral
Therapy (CBT), Acceptance and Commitment Therapy (ACT),
and/or mindfulness-based therapies including meditation.
• Acupuncture
• Spinal Manipulation (Chiropractic therapy)
• Physical Therapy and Occupational Therapy
• Nerve stimulation (like a Transcutaneous Electrical Nerve
Stimulator [TENS unit])
3. Non-opioid Medication Treatments
• Topical Treatments
o
Gels, creams, ointments, or patches that are applied to the skin on a painful area, for example,
diclofenac gel, methyl salicylate cream/ointment, lidocaine patch or ointment
• Oral Treatments
o
Anti-inammatory medicines – for muscle/bone pain
- Nonsteroidal anti-inammatory drugs (NSAIDs), for example, ibuprofen, naproxen, meloxicam,
etodolac, celecoxib
o
Antidepressant medicines – for muscle/bone and nerve pain
- Tricyclic antidepressants (TCA), for example, nortriptyline, desipramine, amitriptyline, imipramine
- Serotonin norepinephrine reuptake inhibitors (SNRI), for example, duloxetine, venlafaxine
o
Anticonvulsant medicines – for nerve pain, for example, gabapentin, pregabalin
4. Opioid Medicines
• Opioids are more eective in reducing acute pain than chronic pain
o
Usually only “take the edge o” chronic pain for a short time.
o
Daily use of opioids can actually make your pain worse over time.
• No matter how much you take, opioids will not take the pain away.
o
Any dose can be risky, even a small dose.
o
Higher doses usually cause more side eects, without reducing your pain.
• All opioids can cause respiratory depression (slow or shallow breathing) and overdose death.
• Methadone is an opioid that is sometimes used for chronic pain. Because it is so long-acting, the amount
can build up, putting you at risk for overdose.
o
Methadone can cause changes in your heart beat that you may not notice. Your heart beat should be
monitored by electrocardiogram (EKG) testing.
o
Many medicines interact with methadone and, in some cases, cause harm, including overdose
anddeath.
4
5. Other Treatment Options
• You may benet from more specialized treatments available in
some primary care clinics or from some pain clinics.
o
These treatments may include trigger point injections in areas
of localized pain and muscle spasms, or steroid injections for
joint pain.
• Pain clinics may provide epidural steroid injections and several
types of pain blocks that can help some patients with spine
conditions. Rarely, spinal cord stimulation devices or spine
surgery may be considered.
o
These interventional pain procedures are for pain conditions
that have not or are not likely to respond to other treatments.
o
They are often used with the treatments listed above (1–4).
Known Side Eects and Other Risks of Opioids
• Unsteady walking
• Increased risk of
falls, broken bones,
orconcussion
Feeling tired, drowsy,
or foggy
• Car accidents
• You can be arrested
for Driving While
Impaired/Driving
Under the Inuence
It is important to report any side eects to your healthcare team. Tell your healthcare team if side eects
interfere with your daily activities. This information will help them to better manage your pain.
Side Effects and Other Risks of Opioids
Side Effect/Risk What This Might Mean
Sleepiness or Mental
Confusion (slow thinking)
Opioid dose may be too high.
• Increases risk of falls and may cause problems with making decisions.
Bad Dreams or
Hallucinations
Opioid dose may be too high, or the opioid may not be a good t for you.
• May need to reduce opioid dose or change to a dierent medicine.
Constipation All opioids cause constipation that, if severe, can cause intestinal blockage.
• Laxatives may be needed; exercise, eating more ber and drinking more
water may help relieve constipation.
Sweating Not a harmful eect, but uncomfortable; wearing light clothing may
decrease sweating.
Nausea and Vomiting Can happen when rst starting opioids or later in treatment.
• Usually goes away with time; medicines to help reduce nausea may
beneeded.
5
Side Effects and Other Risks of Opioids
Side Effect/Risk What This Might Mean
Itching
(possible allergic reaction)
Mild itching is a common side eect. More severe itching with hives is rare,
but if it happens, it is typically soon after starting an opioid.
• If you get a rash or hives, call your healthcare team right away.
• If you have shortness of breath, throat swelling, or feel like you may pass
out, tell someone to call 911 right away. This can be an allergic reaction
and may be life-threatening.
Decreased Sex Hormones May cause less desire for sex as well as depression, anxiety, lack of energy,
hot ashes, night sweats, loss of muscle mass, weakness, and loss of bone
(osteoporosis).
• In men, may have less ability to have an erection.
• In women, may cause irregular menses or lack of menstrual cycle.
Use of birth control is needed since opioids may harm a baby if you
becomepregnant.
Bone Loss Often occurs with taking opioids for months to years. Brittle bones
(osteoporosis) may result in bone fractures.
Dry Mouth, Tooth Decay Dry mouth may be uncomfortable and, in some cases, cause tooth decay
and loss of teeth.
• Chewing sugarless gum, sugarless candy, or ice chips can help.
• See your dentist regularly.
Worsening Pain For some people, opioids may increase pain. If this happens, a change in
your pain treatment plan may be needed.
Opioid Use Disorder
(moderate to severe is also
known as “addiction”)
Can happen even when opioids are taken as prescribed and it can be
life-threatening.
• Medication-assisted treatment for opioid use disorder (that is,
medications and counseling) can relieve pain and other opioid
withdrawal symptoms, decrease opioid craving, and reduce the risk of
overdose and death.
• Medicines for opioid use disorder include buprenorphine,
extended-release injectable naltrexone, and (when administered daily
through an Opioid Treatment Program) methadone.
If you are concerned that you may have developed opioid use disorder, talk
with your provider about getting treatment for opioid use disorder along
with ongoing pain care.
Respiratory Depression and
Overdose
Any opioid use increases risk for respiratory depression (slow or shallow
breathing) and possible overdose and death.
As we learn more about the impact of opioid treatments, new side eects and risks may be identied. Ask
your healthcare team if you have questions or concerns.
6
What Can You Do to Reduce Your Risk When Taking Opioids?
A good plan starts with a conversation. Your healthcare team will
talk with you about the risks, possible benets, and any alternatives
to using opioids to manage chronic pain. This will be done before
any opioids are prescribed. After answering your questions, you will
be asked to sign an informed consent form.
Signing this form shows that you understand and agree with your
treatment plan that includes opioids and the possible risks when
taking them for chronic pain. You will learn about ways to reduce
risks and increase the chance that your plan will help you manage
your pain.
Tips to Reduce Your Risks
Tips Reasoning
ü Take all your medicines
as prescribed.
Taking more opioid pain medicine than you need puts you at risk for side
eects and possible overdose and death. Talk with your healthcare team
before making any changes involving your medications.
ü Talk to your healthcare
team if you are having
more pain.
Do not take extra doses of opioid medication. You may run out of pills
early and this can cause withdrawal symptoms. Taking extra doses can also
increase your risk of overdose and death.
ü Recognize side eects. If you are having side eects that you cannot tolerate, take a lower dose or
stop the medication, and call your healthcare team.
ü Let all your providers
in the VA and outside
of the VA know you are
takingopioids.
Tell all your providers, including dentists, surgeons and specialists, that you
are taking opioids. Taking opioids from multiple providers may lead you to
use more than needed which can cause an overdose.
ü Tell your VA providers
about all medicines
and supplements you
aretaking.
Tell them about over-the-counter medicines, herbal supplements, and if
you take medicines or substances that are not prescribed to you. Many
medicines and substances can interact. When your provider knows
about what you are taking, they are better equipped to make the most
appropriate pain plan for you. This will put you at a lower risk for side eects.
ü Do not take medicines
prescribed for someone
else. Do not give away or
sell your medicines.
Taking medicines that are prescribed to someone else, including a family
member, is illegal and can put you at risk for harmful side eects and
possible overdose and death. Keep your medicines in a safe and secure
location. If someone steals your opioids or your opioid prescription,
promptly report the theft to the police. Then, speak to your healthcare team
about your options because early rells may or may not be approved.
ü Avoid alcohol and
streetdrugs.
Combining opioids with alcohol, marijuana, or using “street drugs” can cause
severe harm or death. It is important that your provider know about all
substances you are taking. Your provider cannot safely continue prescribing
opioids if using these substances creates a safety concern.
ü Be informed about
the risk of developing
opioiddependence.
Anyone taking opioids can develop dependence. The risk goes up the
longer you take opioids and with higher doses. Treatments are available
for opioid dependence. Talk to your healthcare team if you feel this may be
happening to you.
7
Tips to Reduce Your Risks
Tips Reasoning
ü Talk to your provider
about decreasing your
opioid medication.
If you have been taking opioids for more than a few weeks, your body has
become used to them (tolerance). If you stop them all at once, you can have
withdrawal symptoms. Your healthcare team will work with you on a plan to
slowly reduce (taper) your opioid medicines. If you have any problems, let
themknow.
ü Learn how to prevent
overdose and ask for
naloxone. Get support
from your family
andfriends.
Talk to your healthcare team about your overdose risk. Learn how to
decrease your risk and what to do if you overdose. Naloxone can reverse the
eects of opioids during an overdose. Your family members, friends, and
roommates should all receive training on how to recognize an overdose and
use naloxone. Keep naloxone with you at all times.
ü Use caution when driving
or operating machinery.
Sleepiness and confusion are common side eects from opioids. Do not
drive or operate machinery if you feel sleepy or confused. Alcohol and other
sedating medicines can increase these symptoms. State laws may limit the
type of work you can do if you take opioids.
ü Dispose of unused
opioidmedicines.
Ask your pharmacy for instructions for safe disposal of any unused
opioidmedicines.
Stopping Opioid Therapy Through Tapering
You or your provider may decide that opioid therapy is not right for you and that the dose of the opioid
should be reduced (tapered) and eventually stopped.
If you and your provider decide to reduce your opioids, your provider will try to prevent or lessen any
withdrawal symptoms. Decreasing slowly makes it easier to stop opioid medicines. Unless there are urgent
safety concerns, a gradual reduction helps you to avoid withdrawal symptoms.
Your provider will explain how to slowly lower the dosage of your opioid medication. Your provider will
discuss other methods to help reduce your pain and include these in your new pain care plan.
When slowly reducing your opioid medication, do not increase your dose or take extra doses. Your body is
no longer used to higher doses and you may overdose. Follow the plan and discuss what you are feeling
with your healthcare team.
If you have extra opioids left over from your prescription, ask your pharmacy for instructions about safe
disposal of any unused opioid medicines.
8
Working Together with Your Healthcare Team
Communication is key! You are a respected member of your healthcare team. Honest communication will
help you achieve your healthcare goals.
Be honest when you give your health, drug, and alcohol history. Let your provider know about drug or
alcohol use in your family.
Ask your provider about any questions or concerns you have about your pain care plan.
Tell your VA providers about opioid prescriptions from other providers and the pharmacies you use if you
are not getting all prescriptions lled by the VA.
Emergency rooms and urgent care clinics are not good places to get treatment for chronic pain. If you
must go to an emergency room, tell the provider about your pain care plan.
Follow your pain care plan.
When you start taking opioids, you may see or talk to your provider or members of your healthcare team
more frequently—in some cases, once per week. Once the opioid dose is stable, you will need to connect
with your healthcare team at least every three months.
Try to keep all your pain care and other clinic appointments. Please update your contact information at
every visit so your healthcare team can stay in contact with you.
Urine drug testing is part of the pain care plan when opioids are prescribed. These urine drug tests will
show which substances and medicines you have been taking. This can help determine if there are added
risks for side eects or overdose from opioids when they are used with other medicines or substances
(e.g.,marijuana, street drugs, and alcohol). The VA does not use these tests for law enforcement or
employment purposes. Some urine test results may require your healthcare provider to change your pain
care plan based on concerns for your safety.
Your provider, nurse, and pharmacist are required to track when you renew and rell opioids—both within
and outside the VA—as part of the prescription drug monitoring program (PDMP). Laws are established in
each state about how often providers are required to check the PDMP. VA and other healthcare providers
may get and share information about your opioid prescriptions without your specic consent.
9
Filling Opioid Prescriptions
Ask your healthcare team how to renew your
opioidprescriptions.
If there is a problem getting your opioids by mail at your
address, you may have to ll your opioid prescriptions
in person according to the plan you make with your
healthcare team.
When ordering by mail:
• Contact your healthcare team or pharmacy at least 10
business days before it is due.
• Make sure that you or someone you trust gets the
package when it is delivered.
Plan ahead! The pharmacy may be closed on weekends,
holidays, and after regular clinic hours.
Protect Your Opioids from Damage, Loss, or Theft
Keep your opioids in a safe, locked place, out of reach of family, children, visitors, and pets.
Always keep your opioids in their original labeled container.
If you travel, carry your current labeled container of opioids with you in case you are asked questions by
airport security or law enforcement.
If you are concerned about the safety of storing medicines in your home, talk to your healthcare team.
If someone steals your opioids or your opioid prescription, promptly report the theft to the police. Then,
speak to your healthcare team about your options because early rells may or may not be approved.
At the VA, we are committed to helping you achieve the goals of your pain care
treatment plan in a way that keeps you and your friends and family safe. If you have
any questions, please contact your VA healthcare team.
Please call ________________ with any questions or concerns.
Veterans Crisis Line
1-800-273-TALK (8255) or Text - 838255
Revised October 2018 V2 IB 10-791, P96791