Download Pain Management in Palliative Care

Pain Management in
Palliative Care
Dr Tasha Nishiyama
Aim and Objectives
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To think about pain assessment and how this
may alter your management
To learn about opioids and how to calculate
and convert doses
To write FP10 prescriptions for controlled
drugs
To prescribe a syringe driver and other
subcutaneous medications for the DNs
Key Points About Pain
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A good pain history is vital
Aim to treat the cause of the pain (remember
that the pain may not be related to cancer)
Some pains are only partially opioid responsive
Some pains respond better to other medications
e.g. NSAIDs, steroids, amitriptyline etc
Remember non drug treatments e.g.
radiotherapy or surgery
Analgesic Ladder
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Step 1: paracetamol
Step 2: weak opioids
e.g.codeine, dihydrocodeine
Step 3: stong opioids e.g.
morphine, oxycodone,
fentanyl, buprenorphine
Adjuvants include: NSAIDs,
corticosteroids,
antidepressants,
anticonvulsants and
benzodiazepines
Opioids
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Safe drugs if administered and titrated appropriately
See conversion chart
Gold standard for strong opioids is morphine orally
or morphine/diamorphine subcutaneously
Important to calculate carefully – the safest way is to
convert back to oral morphine and convert out from
oral morphine
If in doubt get someone to check your calculations
Side Effects - Opioids
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Constipation
Nausea and vomiting – although often
transient and controllable
Drowsiness – often dose related and
temporary
Respiratory depression – although shouldn’t
occur if doses are titrated appropriately
Consider prescribing laxative and antiemetics
Case 1
A 76 year old lady with locally advanced ovarian
cancer comes to see you complaining of lower
abdominal pains which she describes as a constant
ache. She is already taking 2 co-codamol 30/500
QDS. She feels that this isn’t helping as much as it
used to. She is otherwise feeling well in herself. Her
bowels are regular and she has had no urinary
symptoms. Her abdomen is soft but a little tender
over the lower quadrants. Her bowel sounds are
normal. You decide to increase her analgesia. How
do you go about this?
Case 1
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As the patient has been taking regular opioid
analgesia it would be safe to convert them straight
to a modified release morphine e.g. MST – starting
dose would be 10-20mg MST BD.
Alternatively convert them to regular oramoprh 510mg QDS with a view to converting to a modified
release preparation when the pain is stable
In both cases the patient needs to be prescribed or
have instructions about using oramorph for break
through pain
Case 1
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The patient is commenced on 15mg MST BD.
What would is the breakthrough dose of
oramorph?
What would you tell the patient about how to
use it?
Breakthrough Pain
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All patients on MR morphine should have immediate
release morphine to use for breakthrough pain.
Two forms – oramorph (liquid) or sevradol (tablets)
The dose is calculated as a sixth of the 24 hour
morphine dose. In this case the breakthrough dose
would be 5mg
For oramorph be careful about the difference between
millilitres and milligrams. Standard strength oramorph is
10mg/5mls. So to give a dose of 5mgs the patient needs
to be advised to take 2.5mls
Short acting morphine tends to last for 4 hours –
normally tell the patient they can take it 2-4 hourly but to
contact the doctor if needing more than 3-4 doses/day
Case 1
You visit the patient several weeks later. She has
been seen by one of your colleagues in the
meantime and her MST has been increased to
30mg BD. She is getting on well with the MST and
hasn’t suffered any side effects. She has been
keeping a list of the times that she has used the
oramoprh. You can see from this list that on average
she has required 3 doses (10mg) a day on top of
her MST. With the extra doses her pain is much
improved. What changes are you going to make to
her medications?
Write a FP10 for her new prescription
Write an FP10
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If prescribing a controlled
drug on an FP10 the
quantity i.e. the number of
tablets needs to be given in
words and figures
Remember to check the
drug strengths available as
may need to prescribe 2
strengths to give one dose
Prescribe by brand e.g.
MST Continus
FP10 for Case 1
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Increase MST dose to 45mg BD (was taking a total
of 60mg of MST + 30mg oramorph in 24 hours)
Increase the oramorph dose to 15mg PRN
Need to write a prescription for 2 different doses of
MST as no 45mg tablets available (15mg + 30mg)
MST Continus is available in 5mg, 10mg, 15mg,
30mg, 60mg, 100mg and 200mg tablets. It is also
available in sachets of granules that can be mixed to
make a suspension
Other 12 hourly release morphines are morphgesic
SR and Zomorph. MXL is a 24 hour release
morphine
Case 2
A 68 year old with breast cancer is deteriorating.
She had been taking 90mg MST BD but over the
last few days has becoming increasingly sleepy. It
seems as though her disease is progressing. Her
pain has been well controlled. You are asked to
assess her as her husband reports that she is now
struggling to take her tablets, is drinking occasional
sips only and is now being nursed in bed. When you
arrive, she is settled and is able to have a short
conversation. How would you manage her pain?
Case 2
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This patient is likely to need a syringe driver
as she is no longer managing to take her
tablets. As her pain seems to be well
controlled on 90mg BD MST a direct
conversion seems to be appropriate.
Write a syringe driver prescription for the
district nurses on the pink prescriptions
sheets. Also complete the sheet for
breakthrough/anticipatory medications.
Syringe Driver Prescription
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Sample Prescription
Syringe driver prescription should contain
either 60mg diamorphine/24 hours or 90mg
morphine/24 hours
Prescription of Anticipatory
Medications
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Sample Prescription Sheet
Breakthrough analgesia should be
diamorphine 10mg or morphine 15mg (she
can still use 30mg oramorph as is she is able
to tolerate it)
Other anticipatory meds – haloperidol,
midazolam and buscopan
First Line Anticipatory
Medications
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Pain – Morphine or Diamorphine (use the same as
whatever is in the syringe driver). Doses dependant
on background analgesia
Nausea and Vomiting – Haloperidol 1.5-3mg (max
dose in 24 hours = 10mg)
Respiratory Tract Secretions – Buscopan 20mg
(max dose in 24 hours = 120mg)
Aggitation – Midazolam 2.5-5mg (normally give an
initial max dose of 25mg/24 hours)
Dyspneoa – morphine/diamorphine as above
Syringe Drivers
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Used for symptom control when other ways of
administering the medication is unsuitable or inadequate
Uncontrolled pain on it’s own is NOT an indication for a
syringe driver
It can take several hours after commencing a syringe
driver before it reaches therapeutic levels (may want to
consider giving a bolus dose at the start)
The syringe needs to be changed every 24 hours – this
is done by the DNs or hospice at home team
NOTE: not all drugs can be mixed in a syringe driver.
Compatibility must be checked. Information can be found
at http://www.palliativedrugs.com or by contacting the
palliative care team
Case 3
A 31 year old patient with a spindle cell carcinoma of
his right arm is deteriorating. His pain has been
difficult to control. He currently has 150μg/hour of
fentanyl patches in situ. He already has a syringe
driver with 90mg ketorolac (NSAID). Over the past
24 hours he has stopped taking anything orally. The
district nurses have been attending multiple times a
day and he has had an extra 120mg diamorphine in
the past 24 hours. The patient clearly states that he
wants to be nursed at home. The district nurses
have requested a visit as they feel that his analgesia
needs increasing. How would you address his pain?
Case 3
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This patient needs his analgesia increasing. The best
way to do this would be via a syringe driver.
Fentanyl patches can be increased but they take 12-24
hours to become effective and so a syringe driver would
be more appropriate for uncontrolled pain.
Similarly the patches take 12-24 hours for their effects to
wear off and so if they were to be taken off it would
require some close titration of the syringe
driver/analgesia over this time (not likely to be
achievable in the community)
For patients with fentanyl patches already in situ the
easiest way to do this is to leave the fentanyl patches on
and start a syringe driver that just takes into account the
extra analgesia he has required. In this case up to
120mg diamorphine/24 hours
Case 3
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Breakthrough analgesia for this case can be
calculated as follows:
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150 fentanyl patch (x3.6) = 540mg oral morphine
120mg diamorphine (x3) = 360mg oral morphine
Total daily oral morphine = 540 + 360 = 900mg
Total daily diamorphine = 900 ÷ 3 = 300mg
Breakthrough diamorphine = 300 ÷ 60 = 50mg
As a rule it is best to give the same drug PRN
and in the driver.
Oxycodone
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Strong opioid with similar properties to morphine.
Used second line (usually patients unable to tolerate
morphine)
Available as a MR preparation know as Oxycontin
Immediate release oral preparation is Oxynorm
If prescribed subcutaneously then should be
prescribed as oxycodone
Useful in patients with renal failure as tends to
accumulate less
Fentanyl
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Trans-dermal administration via a patch
Need to be changed every 72 hours
Suitable for patients with severe chronic pain (long half
life – as per case 3)
Patches available in 12, 25, 50, 75 and 100μg/hr
strengths
May have more than one patch on to make doses not
otherwise available (e.g. 12 + 25 = 37μg/hr)
Patients with a fentanyl patch should have oramorph first
line for breakthrough pain
Short acting preparations are available but these should
only be prescribed on the advice of palliative care.
Buprenorphine
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Trans-dermal patch (long acting) or sublingual
tablets (short acting)
Patches useful for chronic pain (long half life)
Two different types of patch:
 BuTrans: available in 5, 10, 20 μg/hr. Need to
be changed every 7 days. May not reach full
effect for 72 hours
 Transtec: available in 35, 52.5 and 70 μg/hr.
Need to be changed every 96 hours. May
not reach full effect for 24 hours
Adjuvants
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NSAIDs – especially useful in bone, musculoskeletal
and liver capsule pains (can be given
subcutaneously – ketorolac). Consider PPI cover.
Corticosteroids – used for raised ICP, nerve or cord
compression and liver capsule pain.
Dexamethasone most commonly used.
Amitriptyline – neuropathic pain. Very useful if the
patient is also depressed
Gabapentin/Pregabalin – neuropathic pain
Don’t forget the anxiolytics (as anxiety can be a big
contributing factor) e.g. diazepam or lorazepam
Useful Sources Of Information
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YCN Guide To Symptom Management In Palliative
Care (http://www.ycn.nhs.uk)
Palliative drugs (need to register but is free)
http://www.palliativedrugs.com
Palliative Care Handbook (includes an opioid
conversion calculator) http://book.pallcare.info/index
Bradford and Airedale Palliative Care
http://www.bradford.nhs.uk/PalliativeCare/Pages/wel
come.aspx
Further Advice
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Colleague at the practice
Macmillan Nurses – can be contacted on
01274 323511
Palliative Care Consultant (on call 24/7) –
can be contacted via the hospice on 01274
337000
Summary
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Pain is the most commonly seen symptom in
palliative care
It can be managed in many ways - it is important to
try and establish why the patient has pain.
Remember adjuvants and non drug treatments
Opioids are generally safe if titrated correctly
Be careful if calculating conversions
There is always someone available to ask