Download Clinical case scenarios (slide set)

Opioids in palliative care:
safe and effective prescribing of strong opioids
for pain in palliative care of adults
Support for education and learning
Training slide set for primary and
secondary care
June 2012
NICE clinical guideline 140
What this presentation covers
Part 1
• Background/ scope
• Aims and learning objectives
Part 2
• Clinical case scenarios
Part 3
• Discussion and evaluation
Part One
Background
• Pain which results from advanced disease remains
under-treated
• Strong opioids, especially morphine, are the principal
treatments for pain related to advanced and progressive
disease
• Prescribing advice has been varied and sometimes
conflicting
Scope
This guideline covers:-
• first-line treatment with strong opioids for patients
• the following drugs: buprenorphine, diamorphine,
fentanyl, morphine and oxycodone
• the clinical pathway needed to improve pain
management and patient safety when prescribing
strong opioids as a first-line treatment
Aims
The aims of the workshop are to:
• promote awareness and understanding of NICE’s
recommendations
• increase knowledge of how to apply them as part of
routine practice, whilst taking account of individualised
care
• practise identifying the risk factors and indicators
for use of opioids
Learning objectives 1
By the end of the session, participants should have
improved knowledge on:
• the verbal and written information on strong opioid
treatment that should be given to patients and carers
• patient side effects such as constipation, nausea and
drowsiness
• appropriate first line treatment for patients
Learning objectives 2
• actions to take for patients who have moderate renal or
hepatic impairment or are unable to take oral opioids
• ‘starting doses’ of strong opioids for patients
• how to effectively titrate opioid doses
• how to prescribe effective breakthrough medication
Pre-workshop quiz
Please complete the pre-workshop quiz
?
Part 2
Clinical case scenarios for
primary care
List selected scenarios……..
Scenario 1: Begum
Presentation
Begum Akhtar is a 38 year old woman who was
diagnosed with liver metastases from colorectal cancer 6
weeks ago. She has pain in her right upper quadrant
which she describes as intense 6/10 on a 10 point visual
analogue scale
She started taking strong opioids 4 weeks ago. She felt
drowsy when she started her morphine but her pain was
reduced usefully. One week after starting her morphine
the intensity of her pain increased and her dose
was adjusted
Scenario 1: Begum
Medical history
Begum Akhtar has been well since the onset of her
symptoms. Her only surgery is the hemi-colectomy 1
year previously
Begum Akhtar is married and has two children of
school age
Scenario 1: Begum
On examination
Begum Akhtar is taking morphine sustained-release 30
mg twice daily. She has a supply of morphine liquid but
is not using this as a dose of 10 mg makes her feel
drowsy. She has constant pain in her right upper
quadrant and is having difficulty sleeping. She has not
reported feeling constipated
She has tried taking other adjuvant medications such as
non-steroidal anti-inflammatory drugs (NSAIDs),
regular paracetamol and a small dose of
dexamethasone, with no effect
Scenario 1: Begum
Next steps for management
1.1 Question
What medication advice do you give to Begum Akhtar?
Scenario 1: Begum
1.1 Answer
Advise Begum Akhtar to try increasing her sustainedrelease morphine to 40 mg twice daily for 1 week and
then increase to 50 mg twice daily. She should try taking
a dose of morphine liquid 10 mg at night to help her
sleep
At each dose change, discuss expected side effects
Explain that several dose adjustments might be
needed to achieve useful pain relief
Scenario 1: Begum
Next steps for management
Begum Akhtar comes back to the surgery 2 weeks later.
Sustained-release morphine 40 mg twice daily has
improved her pain to 5/10 in the day. She is struggling to
manage her daytime pain. She is sleeping better with
her night-time dose of immediate-release morphine
1.2 Question
What do you advise about Begum Akhtar’s medication?
Scenario 1: Begum
1.2 Answer
Advise Begum Akhtar that her drowsiness may reduce in
a few days. If she still feels drowsy she should reduce
her dose back to 40 mg twice daily
Arrange to talk to her again within 5 days for a
medication review
Scenario 1: Begum
Next steps for management
Begum Akhtar still feels sleepy after 1 week on
morphine 50 mg twice daily. She has dropped the dose
to 40 mg twice daily and her pain has worsened
1.3 Question
What is the next best step?
Scenario 1: Begum
1.3 Answer
Begum Akhtar’s pain is responsive to opioids but she
is getting sedative side effects. A different opioid
should be tried – for example, buprenorphine,
diamorphine or oxycodone. Dose conversion tables
are a rough guide only
Always explain to the patient that they may get side
effects from the new drug
Scenario 1: Begum
1.4 Question
What should you advise Begum Akhtar about driving?
Scenario 1: Begum
1.4 Answer
Begum Akhtar should not drive if she feels drowsy or
has poor concentration. Opioid symptoms may vary at
different times of day. Lack of sleep and pain can also
interfere with driving. Opioids may be more sedating if
patients are given other medications in addition
Advise Begum Akhtar that she must consider whether
she feels fit on every occasion that she wants to drive
Scenario 1: Begum
Next steps for management
Begum Akhtar is taking a new opioid preparation. She
feels drowsy when she takes a dose that controls her
pain
1.5 Question
What do you suggest?
Scenario 1: Begum
1.5 Answer
You should seek specialist advice
Scenario 2: Helena
Presentation
Helena presents at her GP surgery with worsening
abdominal pain. The pain is mainly localised to the right
upper quadrant of her abdomen and can vary in nature,
but for the past 2 weeks has been present most of the
time
It has prevented her from sleeping for the past 3 nights,
and she feels exhausted
Scenario 2: Helena
Past medical history
Helena is 68 and retired. A year ago she was found to
have a large abdominal mass, which was found to be an
ovarian carcinoma
It was found to have spread throughout her peritoneal
cavity at presentation and therefore a palliative treatment
regimen was started. Despite chemoradiotherapy, she
developed widespread intraperitoneal lymph node
involvement
Continues on next slide
Scenario 2: Helena
Past medical history: continued
A recent CT-scan showed four separate small masses in
her liver, likely to be metastases
Recent blood tests including liver and renal function
have been normal
She has been taking two co-codamol 30/500 tablets four
times a day, but they only had a limited effect. She has
tried NSAIDs but cannot tolerate them as they give
her severe epigastric discomfort
Scenario 2: Helena
On examination
She is not jaundiced but does look very tired. Her
abdomen is distended and on palpating her liver the GP
notes that it is enlarged
The area around her right upper quadrant is very tender,
but there is no guarding or rebound tenderness
Scenario 2: Helena
Next steps for management
2.1 Question
She has been taking two co-codamol 30/500 tablets four
times daily
What would you discuss with her about next steps
specifically regarding pain management options?
Scenario 2: Helena
2.1 Answer
It would appear that she needs stronger pain relief, and
she should be offered regular oral morphine, either as an
immediate-release or as a sustained-release preparation
She should also be offered rescue doses of oral
immediate-release morphine for breakthrough pain.
You should also investigate the possibility of constipation
Scenario 2: Helena
2.2 Question
What dose of morphine would you start her on?
Scenario 2: Helena
2.2 Answer
She has been on two tablets of co-codamol 30/500 four
times daily. This equates to an equivalent daily dose of
oral morphine of approximately 24 mg over a 24-hour
period
She could be started on oral immediate-release
morphine 5 mg every 4 hours (amounting to a total daily
dose of 30 mg of oral morphine)
Continues on next slide
Scenario 2: Helena
2.2 Answer: continued
Alternatively she could be started on oral sustainedrelease morphine 15 mg every 12 hours
It is important that she also understands that if this dose
regimen is insufficient and she has breakthrough pain,
she can take additional oral immediate-release morphine
5 mg as required
Scenario 2: Helena
2.3 Question
When you mention the word morphine, she flinches and
says “Oh no!” What would you discuss with her?
Scenario 2: Helena
2.3 Answer
Establish what her concerns are and what her ideas
about morphine and strong opioids are. It is likely that
she has worries and preconceptions about morphine; for
instance, she may think morphine signifies the imminent
end of her life or that it will kill her. She may also be
fearful of addiction
You should offer her a follow-up consultation to discuss
these matters further and to review how her pain
control is going
Scenario 2: Helena
2.4 Question
She has a lot of questions about morphine, including
how often to take the medication and when to take
breakthrough doses
She also wants to know what side effects to look out for.
What would you do to provide her with more
information?
Scenario 2: Helena
2.4 Answer
She may need help in drawing up a timetable showing
the times when she should take her medication
It is also important to mention potential side effects like
constipation, nausea, vomiting, drowsiness and
hallucinations
You may wish to provide her with some additional
written information
Continues on next slide
Scenario 2: Helena
2.4 Answer: continued
If there is access to a specialist community palliative
care team, this may further help in following up
medication queries and monitoring response to
treatment
It is also important to discuss whom she can contact out
of hours, if her pain should get worse or she develops
side effects. When you mention possible interference
with driving Helena admits that she finds it too painful
and relies on her partner now to ‘chauffeur’ her
around
Scenario 2: Helena
2.5 Question
Helena returns 2 days later and says that the pain
control is working reasonably well, but that she is finding
taking regular oral immediate-release morphine every 4
hours cumbersome
She says she has read the leaflets and would like to
consider a sustained-release preparation. What would
you do?
Scenario 2: Helena
2.5 Answer
Establish how much immediate-release morphine she
has been taking regularly and how much she has been
taking in addition for breakthrough pain
Offer an oral sustained-release preparation of morphine
every 12 hours that is equivalent in dose to her current
oral immediate release preparation and advise her she
can take additional oral immediate-release morphine for
breakthrough pain as required
Continues on next slide
Scenario 2: Helena
2.5 Answer: continued
For instance, if she has been taking 5mg immediaterelease oral morphine every 4 hours (that is, six times a
day equalling 30 mg over 24 hours), offer oral sustainedrelease morphine 15 mg twice daily (every 12 hours)
In addition, she should be told that she can still take oral
immediate-release morphine for breakthrough pain
Scenario 2: Helena
2.6 Question
She returns several weeks later. Her sustained-release
morphine has been titrated up to 30 mg twice daily and
she is taking four additional doses of immediate-release
morphine 10 mg as rescue doses for her breakthrough
pain
Despite this, she remains in pain. She has also found
that she is seeing shapes and figures appear and
disappear. What action should you take?
Scenario 2: Helena
2.6 Answer
There are several issues here, so seek advice from
your local specialist palliative care team; her pain is
not being controlled and she is getting side effects
If her pain were well controlled, an opioid dose
reduction may have been indicated, but this is not the
case. Establish whether she thinks the oral morphine
is actually reducing her pain when she takes it
(that is, is this still an opioid-responsive pain?)
Scenario 3: Vera
Presentation
Vera is a 70 year old woman with bone and liver
metastases from a breast cancer primary
Past medical history
None, normal renal function, mild hepatic impairment
Scenario 3: Vera
On examination
Right upper quadrant pain, which is constant. Vera is
currently taking 30/500 mg co-codamol four times a
day
Next steps for management
3.1 Question
What strong opioid should Vera be prescribed and
at what dose?
Scenario 3: Vera
3.1 Answer
There is no renal impairment and only mild hepatic
impairment
Vera should be offered (unless contraindicated)
regular oral sustained-release or immediate-release
morphine (depending on her preference) with rescue
doses of oral immediate- release morphine for
breakthrough pain
Continues on next slide
Scenario 3: Vera
3.1 Answer: continued
The typical daily starting dose should be 10 -15 mg
sustained-release oral morphine 12 hourly plus
rescue doses of 5 mg immediate-release oral
morphine for breakthrough pain
or
2.5 - 5 mg immediate-release oral morphine 4-hourly
plus rescue doses of 5 mg immediate-release oral
morphine for breakthrough pain
Scenario 3: Vera
Next steps for management
Following discussion, Vera was started on 10 mg
sustained-release oral morphine 12-hourly and 5 mg
immediate-release oral morphine for breakthrough
pain
3.2 Question
What information should you provide to Vera about
the management of side effects at this point of
initiating opioid therapy?
Scenario 3: Vera
3.2 Answer
Discuss the risk of constipation with Vera, and prescribe
laxatives when initiating strong opioids
Advise her that nausea may occur when starting opioid
treatment, but it is likely to be transient
Also advise Vera that mild drowsiness or impaired
concentration may occur when starting opioid treatment,
but that it is often transient
Scenario 3: Vera
3.3 Question
What drug group should be prescribed for Vera at the
time of initiating opioid therapy?
Scenario 3: Vera
3.3 Answer
Laxatives
Next steps for management
Vera lives alone and is anxious about using morphine,
believing that this signifies the end of her life. She is
also fearful that her pain will continue
3.4 Question
How should you manage Vera’s concerns?
Scenario 3: Vera
3.4 Answer
Advise Vera that morphine is used when a strong pain
medication is needed, many people may not recall that
they have taken it in this kind of situation
Using it does not mean that her condition has
changed, just that she needs strong pain medication
Continues on next slide
Scenario 3: Vera
3.4 Answer: continued
Provide written and verbal information about strong
opioid treatment for her and her family/carers
Plan the next review with Vera and provide contact
information before her planned review of who to
contact if her pain is not improved or if she
experiences persistent side effects
Scenario 3: Vera
Next steps for management
Vera returns to your surgery for her planned review 1
week later
In addition to taking the 10 mg sustained-release oral
morphine 12 hourly, she has needed an average of two
additional doses of 5 mg immediate-release oral morphine
every 24 hours to adequately control her pain
Her bowels are working regularly with regular laxatives
and she hasn’t experienced any side effects
Scenario 3: Vera
3.5 Question
What would your next steps be in opioid management?
Scenario 3: Vera
3.5 Answer
Increase sustained-release oral morphine from 10 mg to
15 mg 12 hourly and advise Vera to continue to take 5
mg immediate-release morphine for breakthrough pain
Scenario 4: Bill
Presentation
Bill is a 58 year old man with end-stage motor
neurone disease
Past medical history
None of note
Scenario 4: Bill
On examination
Bill has been taking strong opioid treatment for 3
weeks. His sustained-release oral morphine was
increased 1 week ago from 20 mg 12 hourly to
30 mg 12 hourly
Bill’s general muscular pain all over his body has
improved. Bill takes 5 mg immediate-release oral
morphine for breakthrough pain. Bill’s continued
expressed wishes are to remain and die at home
Continues on next slide
Scenario 4: Bill
On examination: continued
You receive a message at the surgery to inform you
that Bill called 999 last night because of all over pain
in his body. Bill was taken to the accident and
emergency department at your local hospital and
discharged the same night
You review Bill at home and he is comfortable and his
pain is controlled. There are no other factors
contributing to this pain. Before he called 999 Bill took
one dose of 5 mg immediate-release oral morphine,
which only partly reduced his experience
of the pain
Scenario 4: Bill
Next steps for management
4.1 Question
What should your management approach be?
Scenario 4: Bill
4.1 Answer
Increase the immediate-release oral morphine dose
to 10 mg when needed
4.2 Question
What other healthcare professionals might you
involve in Bill’s care?
Scenario 4: Bill
4.2 Answer
If not already done, inform out of hours services of
Bill’s diagnosis and current plan for analgesic
management
With Bill’s consent, ensure his end of life wishes and
analgesic management plan is entered on the local
end of life register (if available) to ensure continuity of
care by all professionals
Consider referral to community nursing and
community palliative care services
Scenario 4: Bill
4.3 Question
What information should you give to Bill about
future management of breakthrough pain at night?
Scenario 4: Bill
4.3 Answer
Inform Bill to use 10 mg immediate-release oral
morphine as first line
If the above has no impact after 1 hour, repeat the
rescue dose. If after a further 45 minutes there is
still pain, call the local out of hours service
provider, not an ambulance
Ensure Bill has the out of hours contact numbers
available and accessible. If referral has been
made to community palliative care, provide
their advice line number if available
Clinical case scenarios for
secondary care
List selected scenarios……..
Scenario 5: Syed
Presentation
Syed is a 42 year old man who has recently been
diagnosed with a metastatic right renal cell carcinoma
He started strong opioids 5 days ago and has been
admitted with a 5 day history of nausea and 3 day
history of feeling bloated
Past medical history
None of note
Scenario 5: Syed
On examination
Syed is pale, tender over the lumbar spine area and
appears dehydrated. He has active bowel sounds
Next steps for management
5.1 Question
What medication should you prescribe for Syed?
Scenario 5: Syed
5.1 Answer
Syed should be prescribed an anti-emetic
When starting strong opioids there is a possibility
that the patient may become nauseated but this is
usually transient
Because the nausea has persisted for 5 days the
introduction of a regular anti-emetic should now be
considered
Scenario 5: Syed
Next steps for management
Because of starting opioid treatment Syed has also
been experiencing problems with his bowels. You
assess his bowel action
5.2 Question
Syed is constipated and feeling very uncomfortable.
What drugs should he be prescribed?
Scenario 5: Syed
5.2 Answer
Syed has been prescribed laxative treatment but
has not been taking this as he has felt nauseated
and bloated
Syed should be encouraged to take laxatives on a
regular basis
Syed should be informed that the treatment to
alleviate the constipation may take some time to
work
Scenario 5: Syed
Next steps for management
You ask Syed if he has any abdominal pain and
establish what his normal bowel pattern was
before starting strong opioids
You ask him if there is any change in micturition,
because urinary retention can be a complication of
constipation
You advise Syed to drink as much clear fluids as
he can tolerate
Scenario 5: Syed
5.3 Question
What other steps will be important to ensure Syed
feels supported in making these changes?
Scenario 5: Syed
5.3 Answer
For anyone starting on strong opioids it is important
to discuss the potential side effects with them
It is also vital that they are given written and verbal
information and details of who to contact for further
advice
Scenario 6: Maria
Presentation
Maria is a 44 year old woman with metastatic breast
cancer and spinal cord compression. She spends
most of her time in bed
Past medical history
Asthma
Scenario 6: Maria
On examination
Maria reports that while being washed in bed she has
particular issues with pain. Maria currently takes oral
sustained-release morphine sulphate 10 mg 12 hourly
On assessing Maria’s pain it is clear that she does not
just have pain when being washed in bed but at other
times as well
Scenario 6: Maria
Next steps for diagnosis
6.1 Question
You suspect Maria may have breakthrough pain. What
would your next step be?
Scenario 6: Maria
6.1 Answer
This indicates that her background pain is not well
controlled. On discussion you discover that when Maria
takes immediate-release morphine as rescue
medication her pain improves
Therefore Maria’s sustained-release preparation should
be increased to control her background pain. The dose
should be adjusted until there is an acceptable balance
between pain control and side effects
Scenario 6: Maria
6.2 Answer
Maria should be encouraged to have a rescue dose of
5mg immediate-release morphine before having her
wash in bed
It is important that healthcare professionals consider
Maria's pain needs with her, in enough time before
carrying out interventions such as washing which Maria
finds painful
Continues on next slide
Scenario 6: Maria
6.2 Answer: continued
Patients who are on background oral morphine and
who have breakthrough pain should be offered a
morphine immediate-release preparation as first-line
treatment for breakthrough pain
If the pain remains inadequately controlled then
specialist advice should be sought
Scenario 7: Costas
Presentation
Costas is a 48 year old man, married with a son aged
13 years. He has been a roofer since leaving school at
16
He was diagnosed with oesophageal cancer 10 months
ago. He is now undertaking a course of chemotherapy
as an outpatient with the goal of shrinking the tumour
before surgery
Scenario 7: Costas
Past medical history
Smoker of 20 years, pleural plaques diagnosed 10
years ago, extraction of two wisdom teeth at 18 years,
osteoarthritis in his knees and ankles
Scenario 7: Costas
On examination
Costas is a little short of breath. His oxygen saturations
are maintained at 92% on air. He is in a lot of pain and
is very anxious
Costas takes regular anti-inflammatories and gastroprotection, and has been titrated to 45 mg of oral
sustained-release morphine twice daily, with rescue
doses of 10 mg oral immediate-release morphine for
breakthrough pain
Scenario 7: Costas
Next steps for management
7.1 Question
He is still in pain, what would you prescribe for him?
Scenario 7: Costas
7.1 Answer
Increase sustained-release oral morphine from 45mg to
60mg 12 hourly and advise Costas to continue to take
20 mg immediate-release morphine for breakthrough
pain
Ask him to keep a pain diary and a record of
breakthrough doses to help to optimise the regular
dose
Scenario 7: Costas
Next steps for management
Costas returns at his next outpatient appointment
stating that he is now finding it difficult to swallow
(dysphagia) so he is finding it difficult to take his oral
medication
7.2 Question
What would your next step in his opioid management
strategy be?
Scenario 7: Costas
7.2 Answer
Because Costas is now finding it hard to swallow but
the level of medication is controlling his pain, through
discussion with Costas you should suggest he has the
equivalent medication via a transdermal patch
Costas could have been prescribed Morphine Sulphate
Tablet (MST) granules if he had preferred
Scenario 7: Costas
Next steps for management
Costas now reports that his pain has become very
erratic and is not being well controlled
7.3 Question
How would you respond to his pain management
needs?
Scenario 7: Costas
7.3 Answer
You agree with Costas that because he is finding
swallowing oral medication difficult and his pain is no
longer controlled
Subcutaneous medication should be prescribed and
that you will contact pain specialist colleagues for
advice on managing his pain
Scenario 8: Arthur
Presentation
Arthur is a 68 year old man who has carcinoma of his
prostate with bone metastases
He is in hospital after being noted to be very unwell in
clinic, when he was due to have a bisphosphonate
infusion for his bone metastases
He is admitted acutely and has subsequently been
diagnosed with bronchopneumonia, and is now
receiving intravenous antibiotics for this
Scenario 8: Arthur
Past medical history
Arthur has a past history of hypertension, angina and
osteoarthritis
On examination
He is still markedly dyspnoeic and is receiving
supplementary oxygen via a mask. He has known bone
metastases and is especially tender over his right lower
rib-cage, an area where he had radiotherapy to 3
weeks previously
Scenario 8: Arthur
Next steps for management
He is on regular oral paracetamol 1g four times daily and
oral ibuprofen 400 mg four times daily
Despite this, he is complaining of a lot of pain in his ribs
about three or four times a day, which can come on quite
suddenly and lasts for hours
At home he was taking oral immediate-release morphine
10 mg about twice a day, which did help the pain, but
made him quite sleepy
Continues on next slide
Scenario 8: Arthur
Next steps for management: continued
He has no renal or hepatic complications. You notice
on the hospital drug chart that the ‘as required
medicines’ section has been left blank by the admitting
medical officer
8.1 Question
What would you prescribe initially?
Scenario 8: Arthur
8.1 Answer
The bisphosphonate that Arthur is receiving is also
analgesic. Despite this, his pain is still uncontrolled.
Arthur has considerable pain so needs regular opioid
analgesia as well as some rescue doses of oral
immediate-release morphine for breakthrough pain
The hospital doctor may wish to offer him a regimen of
immediate-release morphine 5 mg orally every 4 hours
(six times daily)
Scenario 8: Arthur
8.1 Answer: continued
Alternatively, he could be offered 10 or 15 mg of oral
sustained-release morphine twice daily
Whichever option is chosen, he should also be
prescribed rescue doses of oral immediate-release
morphine 5 mg in the ‘as required medicines’ section of
his hospital drug chart
He should be able to request these for breakthrough
pain, or be offered them when he appears in
discomfort
Scenario 8: Arthur
8.2 Question
What else would you prescribe alongside the
morphine?
Scenario 8: Arthur
8.2 Answer
You would explain that regular opioids are very likely to
cause constipation, and that most people who start
them will get this side effect
Offer regular laxatives
You should also mention that some people get nausea
and/or vomiting when they start taking opioids, and that
this is usually transient. You could consider prescribing
some ‘as required’ anti-emetic medication on his
hospital medication chart
Scenario 8: Arthur
8.3 Question
Both Arthur and his wife, who has just arrived on the
ward, want to know how the morphine works, at what
times it is given and what other side effects it has
What do you discuss?
Scenario 8: Arthur
8.3 Answer
It is important that they are fully informed about why he
has been prescribed opioids and what side effects he
might experience
Provide verbal and written information on strong opioid
treatment to patients and carers
Continues on next slide
Scenario 8: Arthur
8.3 Answer: continued
• 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
Scenario 8: Arthur
Next steps for management
Arthur is now on oral sustained-release morphine
tablets 15 mg twice daily. His pain is better 3 days
later but he still gets some pain about four times a day
in the area where he has known bone metastases (his
ribcage)
He finds the rescue doses of oral immediate-release
morphine 5 mg helpful
Scenario 8: Arthur
8.4 Question
What would your next step in his opioid management
strategy be?
Scenario 8: Arthur
8.4 Answer
Initially, carefully re-establish whether this is his
ongoing pain (bone metastases) or whether there is a
new problem such as a rib fracture or another
underlying disease process
For his pain management, offer him a higher dose of
oral sustained-release morphine in line with the
amount of breakthrough medication he has needed
Continues on next slide
Scenario 8: Arthur
8.4 Answer: continued
For instance, if he has had four additional doses of oral
immediate-release morphine over the past 24 hours, this
means he has had 4 x 5 mg additional oral morphine
(that is, 20 mg in total over that period of time)
To add this to his oral sustained-release regimen of
morphine 15 mg twice daily, he could be titrated to oral
sustained-release morphine 25 mg twice daily
Scenario 8: Arthur
Next steps for management
He finds the rescue dose of immediate-release morphine
helpful but the nursing staff tell you he is very reluctant
to ask for them and only ‘bothers them’, as he puts it,
when he is in severe pain
The healthcare assistant on the ward tells you that she
had a chat with him and established that he is worried he
will get ‘hooked on the morphine’ and that it will kill him
eventually
Scenario 8: Arthur
8.5 Question
How do you address this?
Scenario 8: Arthur
8.5 Answer
Establish what his concerns are, and what his ideas
about morphine and strong opioids are. It is likely that
he has worries and preconceptions about morphine,
for instance, he may think morphine signifies the
imminent end of his life or that it will kill him
Address ideas about addiction and discuss the
concept of dependence
Continues on next slide
Scenario 8: Arthur
8.5 Answer: continued
Reassure him that he should request medication
when he is in pain, that staff are there to help, and that
by ensuring his pain is well controlled it is easier to
find the best stable dose of medication for his pain
You should offer him a follow-up consultation to
discuss these matters further and to offer him the
chance to ask further questions
Scenario 8: Arthur
Next steps for management
He deteriorates rapidly one evening and is found to be in
renal failure. He appears to be getting opioid toxicity
(drowsiness, hallucinations and myoclonic jerking), but is
also in a lot of pain. His regular ibuprofen is discontinued
8.6 Question
What approach would you take with regard to his pain
management, now that he has gone into renal
failure?
Scenario 8: Arthur
8.6 Answer
His hospital team should obtain specialist palliative
care advice about ongoing pain-control and what
medication, mode of delivery and doses to choose
Part 3
108
Post-workshop quiz
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Discussion
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of opioids for people with advanced and progressive
disease to implement the recommendations?
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