Prescription opioid misuse and dependence: signs, risks and getting help in the UK

Opioids are strong painkillers. The NHS describes codeine, morphine and dihydrocodeine as opioid painkillers, available on prescription, used for pain after an operation or injury, pain from cancer or at the end of life, and often when paracetamol and ibuprofen have not worked. Tramadol is a related prescription painkiller whose NHS information stresses that it can be addictive.

In this guide, misuse means using a prescribed opioid in a way that differs from the prescriber's instructions: taking more or more often than directed, using it to cope with feelings rather than pain, or using someone else's supply. Dependence means the body and mind have come to rely on the medicine, so that stopping brings withdrawal and the person feels unable to manage without it. These are not moral failings. UK evidence reviews treat them as foreseeable risks of some medicines taken for long periods.

Misuse and dependence can happen to people who began with a genuine medical reason for the prescription, as well as to people who obtained opioids in other ways. The NHS drug addiction pages make the point that treatment is available on the same basis as for any other health problem.

No single sign proves dependence, and the sources used here do not give a checklist. The NHS pages on codeine, morphine and tramadol do identify the situations in which a conversation with the prescriber is advised, and the Public Health England patient summary lists the kinds of difficulties people reported.

• The medicine is not relieving pain as well as it used to, or you struggle with pain between doses. The NHS says to talk to your doctor if morphine taken for a long time is no longer working as well.

• You feel worried about addiction, or you notice you are taking the medicine for reasons other than pain.

• You get withdrawal symptoms when a dose is late or missed, such as feeling agitated or anxious, as the NHS describes for codeine.

• You have had an addiction to alcohol, prescription medicines or recreational drugs in the past. The NHS lists this as a reason codeine may not be suitable.

• You have side effects such as constipation, sickness, sleepiness or sweating that you are tolerating without telling anyone.

• You are running out early or looking for extra supplies. This is a signal to ask for a medicines review rather than something to hide.

Public Health England reviewed the evidence on dependence and withdrawal for five classes of prescribed medicines in adults, including opioids for chronic non-cancer pain. It reported that opioid pain medicines carry a risk of dependence and withdrawal, that higher initial opioid doses were associated with long-term use, and that prescribing for longer than 90 days was associated with overdose and dependence.

The NHS lists constipation, sickness, sleepiness and sweating as common side effects of codeine, and describes slow, weak or shallow breathing, an unusual heartbeat and low blood pressure as possible serious side effects. Taking an extra dose can be dangerous. The NHS also advises that it is best not to drink alcohol while taking codeine or morphine because it can increase drowsiness and side effects, so a medicines review should always cover everything you take and drink.

Not everyone is at equal risk. The review found associations between prior mental health problems and opioid dependence, and between opioid prescribing and areas of greater deprivation. People with chronic pain often have other health needs, so support should cover pain, mood and sleep together.

The NHS is consistent across codeine and morphine: if you need to take the medicine for a long time your body can become used to it, you should not stop it suddenly because you may get withdrawal symptoms, and your doctor will gradually reduce your dose over time. Public Health England adds that people should not stop a prescribed medicine on their own, and that stopping or limiting medicines can itself cause harm, including making some people seek supplies from less safe sources.

The review found patients reporting withdrawal effects that affected wellbeing and day-to-day functioning and that could last many months. Patients also described a lack of information about risks, feeling that withdrawal was not recognised and not being offered non-medicine options. If this has been your experience, it is reasonable to ask the prescriber for a planned, supported reduction and for information in writing.

A reduction plan is individual. A hospital spinal-surgery leaflet used as a source here advises that when opioids, gabapentin or amitriptyline are being stopped they should be tapered slowly in small steps to limit withdrawal effects, which is consistent with the NHS advice. Do not try to design a schedule yourself.

The NHS says a GP may be a good place to start, that they can discuss the problem and help get you into treatment, and that they will usually refer you to your local drug service. If you are not comfortable talking to a GP you can approach your local drug treatment service yourself. The NHS also points to the national drugs information service known as Frank for local support.

At a first appointment, staff ask about your drug use and about work, family and housing, and you may be asked for a urine or saliva sample. You are given a keyworker who supports you throughout treatment, and a plan is agreed with you.

The NHS advises following your doctor's instructions, swallowing slow-release products whole, and never taking two doses to make up for a missed dose. It also says your doctor will make sure you take only the amount you need to control pain, and that you should say if you are worried about addiction.

Public Health England recommends that clinicians consider all treatments that might work, including those that do not involve medicines, such as talking therapies or exercise, tell patients about benefits and risks, review regularly whether a medicine is helping, and change treatment if it is not. A useful question at any review is: is this still helping, and what would a gradual reduction look like?

If you are driving, the NHS says not to drive, ride a bike or use machinery if you feel sleepy or dizzy after taking opioid painkillers, and that it is best not to drink alcohol while taking codeine or morphine.

Most prescription opioid dependence is managed through a GP and NHS or charity drug and alcohol services, which are free at the point of use. The NHS notes that private drug and alcohol treatment organisations also exist and that you would need to pay for them. Whichever route you use, ask whether it includes a clear plan for pain management, so that reducing opioids does not leave a pain problem untreated, and whether your GP will be kept informed.