Narcotic Information

Narcotics are drugs that mimic the body's natural pain killers. Historically opium which was derived from opium poppies was used. Morphine was isolated from opium in the 19th century and is still used.

Today a variety of narcotics are available besides morphine. These include:

• Codeine (Tylenol 1-4, 292's, Codeine Contin)
• Oxycodone (Percocet, Percodan, Superdol, OxyContin)
• Hydromorphone (Dilaudid, Hydromorph Contin)
• Meperidine (Demerol)
• Fentanyl (Duragesic)
• Methadone

Q: Are injections or necessary?

A: While narcotics are given by injection for acute pain with surgery, injury or illness, injectable narcotics should only be given in chronic pain in exceptional circumstances. Most people are able to get effective relief with oral or transcutaneous narcotics although it may take some time to find a combination that works. Aside from not being necessary, repeated therapy with injectable narcotics puts you at risk for bruising, infection, and scarring and nerve injury.

Q: Are narcotics appropriate for chronic pain?

A: While narcotics were widely used prior to the 20th century, their use except for acute pain was generally discouraged in the first half of the 20th century. Experience with the use of narcotics in patients with cancer lead to their prescription for chronic pain starting around 1990.

The doctors in our clinic believe that prescription of narcotic analgesics can be an effective part of a program of pain management in certain patients.

Q: Are there alternatives to therapy with narcotics?

A: There are a variety of non-narcotic drugs that can be used, some of which you may already be on. You should discuss this with your pain clinic or family doctor.

There are a variety of non-medication options for the treatment of chronic pain. You should discuss this with your pain clinic or family doctor.

Q: Are there any patients who are at higher risk of addiction?

A: Addiction to other substances including smoking or behaviours such as gambling may predict a higher risk of addiction. A family history of such behaviours may also predict this.

Even in these patients the risk is still low and they can be safely prescribed narcotics with increased vigilance.

Q: Can any doctor prescribe narcotics?

A: Any physician may prescribe narcotics. With the exception of codeine, in Alberta all narcotics require a special prescription form. Narcotics cannot be phoned in and it will usually be necessary for you to make an appointment to get a refill.

Methadone requires a special license. All the doctors in the Multidisciplinary Pain Clinic have such a license. Family doctors can obtain a license by applying for it.

Q: Can narcotics lead to drug overdose?

A: Overdose of narcotics usually manifests as respiratory depression (dangerously slowed breathing). This is very uncommon in patients in pain who are prescribed narcotics in appropriate doses. Respiratory depression may occur when narcotics are taken in doses higher than prescribed, when they are taken with sedatives, tranquillizers or sleeping pills, or with alcohol. Respiratory depression may occur when oral medications are chewed or injected. Sometimes the administration of other drugs may slow the metabolism of drugs especially methadone leading to respiratory depression.

If narcotics are taken by people who are not used to taking them in the doses that have been prescribed to you they may develop respiratory depression leading to death. This includes children.

Q: Does the use of narcotics lead to addiction?

A: Addiction is a complex phenomenon with contributions from biological, psychological and environmental factors. A small minority of patients who are prescribed narcotics will become addicted. We feel the potential benefit of narcotic therapy in the vast majority of patients outweighs this. We also take a number of steps to ensure that our patients are using their medications effectively and to help them to avoid addiction.

Most patients on narcotics will develop tolerance to the effect of the drug, requiring higher doses. This is a normal phenomenon that can be managed by increasing the dose of drug or switching to a different drug. Most patients will eventually reach a plateau dose.

Patients who take narcotics regularly will become physically dependent on narcotics. If they stop taking them they will develop a withdrawal syndrome consisting of nausea, sweating, a rapid heart rate, insomnia and severe pain. This can be managed by weaning off narcotics slowly or using other drugs to help with the side effects.

In the past patients who developed tolerance or dependence were often labeled as addicted. We now know addiction to be entirely different.

Q: How are narcotics taken?

A: In most patients with chronic pain, it is our practice to prescribe narcotics orally as long acting medications. This is because most patients have pain all the time. By taking long acting narcotics on a scheduled basis, you will stay ahead of your pain. These of some of the long acting medications that are available: Sustained release preparations have the drug in a matrix from which it is released over a period of time (usually 12 hours).

• MS Contin
• M-Eslon
• Kadian
• OxyContin
• HydroMorph Contin
• Codeine Contin
• Drugs that are broken down slowly by your body (ie. Methadone)
• Transcutaneous preparations release the drug slowly through your skin at a fixed rate over three days (ie. Duragesic patch)

Sometimes you will be prescribed a breakthrough medication. This will be a short acting medication usually but not always the same as your long acting medication. The intent is that you should only take this medication when your pain is greater than 50% above baseline and you should usually take less than 3 doses a day.

Occasionally you may be prescribed short acting narcotics only for your pain. This is usually in the following circumstances:

• You are not able to take a long acting medication for various reasons
• You have any episodic pain
• Your doctor is trying to see how much long acting medication you will require prior to starting you on a long acting medication.

Q: How will narcotics affect my function?

A: While narcotics can cause drowsiness, this is usually a side effect that is short lived. In many patients the enhanced pain relief will enable you to increase your activity.

Q: Is there anything else I should know?

A: Regrettably some people use narcotics for purposes other than relieving their pain and therefore may want to steal your medication. This includes friends and family! You should treat your medication as you treat your money.

• At home your narcotics should be in safe secure, preferably locked place.
• When away from home if you take your narcotics with you they should be in a pocket. Do not put them in a coat pocket or purse if you intend to hang them up or check them.
• Keep your narcotics in the container they are dispensed in by the pharmacy.
• If you lose your narcotics or if they are stolen you will have to file a police report and bring a copy to your next appointment. You might not be given any more narcotics until the next appointment.
• Do not give your narcotics to anybody else.
• Definitely do not sell or trade your narcotics. (If you are caught doing this you will receive no more narcotics from the Multidisciplinary Pain Clinic and you could face criminal charges).
• You may be required to undergo drug screening at any time during your treatment and a screen that is positive for any non-prescribed medication may result in you not receiving any more treatments.

Q: What are the side effects of narcotics?

A: Respiratory depression has already been mentioned.

There are a number of side effects of narcotics:

Drowsiness

Narcotics can make you drowsy. Many chronic pain patients are sleep deprived and on starting a therapy which reduces their pain, they will sleep during the day until they have made up their sleep deficit. Usually the drowsiness will get better with time.

You should avoid driving for at least a week after starting a narcotic drug or increasing the dose.

Nausea

All narcotics will make you nauseous. This usually gets better after a period of time. Your doctor will often prescribe an anti-nauseant as a routine. You should contact your doctor before taking an over the counter anti-nauseant. Occasionally you make get less nausea if you switch to a different narcotic.

Constipation

This is a side effect of all narcotics although it varies between drugs and between patients. Your doctor can prescribe a medication for this. In general drugs that increase the activity of your bowel like Senokot are preferred. Bulk forming agents and stool softeners should be avoided early on but can be added. You should drink lots of water and exercise as much as you can.

Itching

This side effect can be treated with anti-histamines. If the itching is accompanied by a rash, swelling or difficulty breathing you are having an allergic reaction and should seek medical attention. Decreased sex drive or amenorrhea in women

Narcotics used chronically depress your sex hormones. This can be treated in men with testosterone supplementation.

Swelling

The cause of this side effect is not known. It sometimes responds to switching narcotics and occasionally to diuretics.

Q: Will narcotics take my pain away completely?

A: Narcotics will only reduce your pain. The usual target we aim for is a reduction of 30%. Attempts to reduce pain above that often lead to side effects.