Palliative care prescribing: pain
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NICE guidelines
In 2012 NICE published guidelines on the use of opioids in palliative care. Selected points are listed below. Please see the link for more details.
Starting treatment
- when starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain
- if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. For example, 15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required
- oral modified-release morphine should be used in preference to transdermal patches
- laxatives should be prescribed for all patients initiating strong opioids
- patients should be advised that nausea is often transient. If it persists then an antiemetic should be offered
- drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered
SIGN guidelines
SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points
- the breakthrough dose of morphine is one-sixth the daily dose of morphine
- all patients who receive opioids should be prescribed a laxative
- opioids should be used with caution in patients with chronic kidney disease. Alfentanil, buprenorphine and fentanyl are preferred
- metastatic bone pain may respond to strong opioids, bisphosphonates or radiotherapy. The assertion that NSAIDs are particularly effective for metastatic bone pain is not supported by studies. Strong opioids have the lowest number needed to treat for relieving the pain and can provide quick relief, in contrast to radiotherapy and bisphosphonates*. All patients, however, should be considered for referral to a clinical oncologist for consideration of further treatments such as radiotherapy
Other points
When increasing the dose of opioids the next dose should be increased by 30-50%.
Opioid side-effects
| Usually transient | Usually persistent |
|---|---|
| Nausea Drowsiness | Constipation |
Conversion between opioids
| From | To | Conversion factor |
|---|---|---|
| Oral codeine | Oral morphine | Divide by 10 |
| Oral tramadol | Oral morphine | Divide by 10** |
Oxycodone generally causes less sedation, vomiting and pruritis than morphine but more constipation.
| From | To | Conversion factor |
|---|---|---|
| Oral morphine | Oral oxycodone | Divide by 1.5-2*** |
The current BNF gives the following conversion factors for transdermal perparations
- a transdermal fentanyl 12 microgram patch equates to approximately 30 mg oral morphine daily
- a transdermal buprenorphine 10 microgram patch equates to approximately 24 mg oral morphine daily.
| From | To | Conversion factor |
|---|---|---|
| Oral morphine | Subcutaneous morphine | Divide by 2 |
| Oral morphine | Subcutaneous diamorphine | Divide by 3 |
| Oral oxycodone | Subcutaneous diamorphine | Divide by 1.5 |
*BMJ 2015;350:h315 Cancer induced bone pain
**this has previously been stated as 5 but the current version of the BNF states a conversion of 10
***historically a conversion factor of 2 has been used (i.e. oral oxycodone is twice as strong as oral morphine). The current BNF however uses a conversion rate of 1.5