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Palliative care for adults: strong opioids for pain relief

Recommendations

Communication

  • When offering pain treatment with strong opioids to a patient with advanced and progressive disease, ask them about concerns such as:
    • addiction
    • tolerance
    • side effects
    • fears that treatment implies the final stages of life
  • Provide verbal and written information on strong opioid treatment to patients and carers, including the following:
    • when and why strong opioids are used to treat pain
    • how effective they are likely to be
    • taking strong opioids for background and breakthrough pain, addressing:
      • how, when and how often to take strong opioids
      • how long pain relief should last
    • side effects and signs of toxicity
    • safe storage
    • follow-up and further prescribing
    • information on who to contact out of hours, particularly during initiation of treatment
  • Offer patients access to frequent review of pain control and side effects

Starting strong opioids—titrating the dose

  • When starting treatment with strong opioids, offer patients with advanced and progressive disease regular oral sustained-release or oral immediate-release morphine (depending on patient preference), with rescue doses of oral immediate-release morphine for breakthrough pain
  • For patients with no renal or hepatic comorbidities, offer a typical total daily starting dose schedule of 20–30 mg of oral morphine (for example, 10–15 mg oral sustained-release morphine twice daily), plus 5 mg oral immediate-release morphine for rescue doses during the titration phase
  • Adjust the dose until a good balance exists between acceptable pain control and side effects. If this balance is not reached after a few dose adjustments, seek specialist advice. Offer patients frequent review, particularly in the titration phase
  • Seek specialist advice before prescribing strong opioids for patients with moderate to severe renal or hepatic impairment

First-line maintenance treatment

  • Offer oral sustained-release morphine as first-line maintenance treatment to patients with advanced and progressive disease who require strong opioids
  • Do not routinely offer transdermal patch formulations as first-line maintenance treatment to patients in whom oral opioids are suitable
  • If pain remains inadequately controlled despite optimising first-line maintenance treatment, review analgesic strategy and consider seeking specialist advice

Care pathway

Care pathway algorithm

 

First-line treatment if oral opioids are not suitable—transdermal patches

  • Consider initiating transdermal patches with the lowest acquisition cost for patients in whom oral opioids are not suitable and analgesic requirements are stable, supported by specialist advice where needed
  • Use a recognised opioid dose conversion guide when prescribing, reviewing or changing opioid prescriptions to ensure that the total opioid load is considered.

First-line treatment if oral opioids are not suitable—subcutaneous delivery

  • Consider initiating subcutaneous opioids with the lowest acquisition cost for patients in whom oral opioids are not suitable and analgesic requirements are unstable, supported by specialist advice where needed

First-line treatment for breakthrough pain in patients who can take oral opioids

  • Offer oral immediate-release morphine for the first-line rescue medication of breakthrough pain in patients on maintenance oral morphine treatment
  • Do not offer fast-acting fentanyl as first-line rescue medication
  • If pain remains inadequately controlled despite optimising treatment, consider seeking specialist advice

Management of constipation

  • Inform patients that constipation affects nearly all patients receiving strong opioid treatment
  • Prescribe laxative treatment (to be taken regularly at an effective dose) for all patients initiating strong opioids
  • Inform patients that treatment for constipation takes time to work and adherence is important
  • Optimise laxative treatment for managing constipation before considering switching strong opioids

Management of nausea

  • Advise patients that nausea may occur when starting strong opioid treatment or at dose increase, but that it is likely to be transient
  • If nausea persists, prescribe and optimise anti-emetic treatment before considering switching strong opioids

Management of drowsiness

  • Advise patients that mild drowsiness or impaired concentration may occur when starting strong opioid treatment or at dose increase, but that it is often transient. Warn patients that impaired concentration may affect their ability to drive* and undertake other manual tasks
  • In patients with either persistent or moderate-to-severe central nervous system side effects:
    • consider dose reduction if pain is controlled or
    • consider switching opioids if pain is not controlled
  • If side effects remain uncontrolled despite optimising treatment, consider seeking specialist advice

* www.dft.gov.uk/dvla/medical/ataglance.aspx

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/cg140

National Institute for Health and Care Excellence. Palliative care for adults: strong opioids for pain relief.May 2012, updated August 2016.
First included: June 2012.