Comment: Opioids often make headlines usually for the wrong reasons, linked to words such as epidemic, addiction, dependence, overdoses and so on. They can be a blessing for those suffering from pain but can also become an unexpected burden.
We can’t put all opioids in the same basket, but we do need to understand how they’re being used in Aotearoa New Zealand. We need to understand if and when opioids can become dangerous, particularly among older adults, for whom the risks of opioid use are often underestimated.
Opioids are a class of medications derived from the opium poppy or made synthetically, which have been used for thousands of years for pain relief. They work by binding to opioid receptors in the brain and body and block the transmission of pain signals. Opioids are classified into weak opioids like codeine, tramadol and dihydrocodeine, and strong opioids such as morphine, oxycodone, fentanyl and pethidine; all regarded as “high risk” medications.
Without opioids, life would be a lot more painful. They are commonly prescribed after surgery, for injuries, for cancer and non-cancer pain, or as part of palliative care. For persistent non-cancer pain, benefits and risks need careful weighing. Alternative approaches (physiotherapy, non-opioid pain killers, self-management strategies) may be more appropriate for some patients.
The opioid epidemic in the US has cost hundreds of thousands of lives due to fatal overdoses, many linked to addiction and abuse. But what’s the difference between addiction and dependence?
Dependence is when your body adapts to a medication, where suddenly stopping it may cause withdrawal symptoms such as nausea, vomiting or hot flushes. Addiction means you’ve lost control, and you know something is causing you harm, but you aren’t able to stop using it. A patient can be dependent during a short treatment course without being addicted – but both patients and healthcare professionals should stay vigilant to warning signs.
Our research into opioid use in New Zealand is focused on opioid use among older adults – kaumātua – who can have an increased vulnerability to opioid-related adverse events due to changes in their bodies, such as compromised kidney or liver function, which makes them more susceptible to experiencing side effects.
Older adults can be more sensitive to opioids. Red flags include, but are not limited to, severe drowsiness, confusion, constipation, dizziness or falls, breathing difficulties, blue nails and lips and tiny pupils. These symptoms warrant prompt medical advice.
Older adults are often using multiple medications to manage chronic conditions, which can interact with opioids causing serious side effects due to drug-drug interactions. Therefore, opioid therapy should only be prescribed with monitoring and regular assessments to determine if they’re still needed.
Patterns of opioid use in New Zealand older adults
We examined national health records for more than 800,000 New Zealanders aged 65 and over from 2007–2018. We found that opioid dispensing rose steadily over the decade, particularly among females and those aged 85 and over.
We found that weak opioids were used more often than strong opioids, with codeine the most dispensed, followed by tramadol and dihydrocodeine. Among strong opioids, morphine was the most dispensed, followed by oxycodone, fentanyl and pethidine. Although codeine was the most dispensed opioid, fentanyl showed the greatest increase over the study period, especially after 2011.
In another study we did with nearly 270,000 older adults who’d never used opioids before, we found they were more likely to end up using opioids long-term (over three months) if they were prescribed fentanyl, slow-release opioids, strong opioids, had multiple health issues, a history of substance abuse, lived in more deprived areas, or used medications like anti-epileptics, non-opioid pain medications, antipsychotics, or antidepressants.
Both studies raise important questions about pain and proper opioid management in our older population. But we don’t know the reason behind the trends; there may be several reasons or a combination of them.
It could be because our ageing population is increasing, more chronic pain prevalence, unnecessary opioid prescribing or previous prescribing laws that may have contributed to higher rates of weak opioid dispensing.
Prior to October 2023, prescribing laws were less strict for weak opioids. Tramadol, for example, was classified as a prescription-only medicine rather than a controlled drug for many years and could be prescribed for three months at a time. Codeine was also allowed in three-month supplies, which likely explains their higher use.
Recently, policies have tightened with one-month limits to weak opioids, tramadol’s reclassification to a controlled drug, and changes to fentanyl scheduling — signifying a recognition by the Government of their risks.
Since the reasons for the increasing patterns are unknown, future research is needed to determine whether the increase in opioid dispensing is a consequence of overprescribing or reflects appropriate pain management practices.
What older adults need to know about opioids
A few important questions patients could ask themselves, and their doctors, which will help keep both doctor and patient on their toes:
Why do I need this medication?
What is the lowest dose for the shortest possible time?
What side effects should I look for, and what should I do if I experience them?
Will the opioid medication interact with my other medications?
How will we review it – and when should I expect to stop?
If you’ve been on an opioid longer than expected, ask, do I still need this? Sometimes the answer is yes. Sometimes it’s time to taper (gradually reducing the dose) – safely and with support of your doctor. Regular kōrero with your healthcare team helps ensure opioids are still needed.
What changes or steps would we like to see going forward?
The main aim of our research is to raise awareness around opioid use in older adults. Healthcare professionals should continue to talk openly with patients and their whānau about potential opioid benefits and risks, ensuring patients remain fully informed.
Counselling continues to be an integral part of healthcare professionals’ role, particularly around side effects. Patients deserve to know which side effects can be managed, and which ones they should report.
Opioids have many virtues. Without them, some pain would be unbearable. Most of us will be prescribed them at some point, and we shouldn’t be reluctant to use them when truly needed, but we should keep ourselves informed, vigilant, and willing to ask questions. Your voice in your healthcare matters.
The research papers referred to in this article were co-authored by associate professors Kebede Beyene, Amy Chan and Gary Cheung, as well as Andrew Tomlin.