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Opioids for pain relief in palliative care

About

What is covered

This interactive flowchart covers safe and effective prescribing of strong opioids for pain relief in adults (18 years and older) with advanced and progressive disease.
It addresses first-line treatment with strong opioids for patients who have been assessed as requiring pain relief at the third level of the World Health Organization pain ladder. It does not cover second-line treatment with strong opioids where a change in strong opioid treatment is required because of inadequate pain control or significant toxicity.
The recommendations clarify the clinical pathway for prescribing strong opioids in palliative care, and will help to improve pain management and patient safety. They are aimed at non-specialist healthcare professionals initiating strong opioids for pain in adults with advanced and progressive disease. However, they are likely to be of relevance to palliative care specialists as well.

Updates

Updates to this interactive flowchart

8 August 2016 A recommendation on transdermal patches or subcutaneous delivery was deleted and replaced with a link to controlled drugs: safe use and management, which includes newer recommendations on the topic.
21 July 2015 Naloxegol for treating opioid-induced constipation (NICE technology appraisal guidance 345) added to managing constipation.
24 February 2015
  • Title changed from opioids in palliative care to opioids for pain relief in palliative care
  • Methylnaltrexone for treating opioid-induced bowel dysfunction in people with advanced illness receiving palliative care (terminated appraisal) NICE technology appraisal 277 added to managing constipation.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on prescribing strong opioids in adults with advanced and progressive disease in an interactive flowchart

What is covered

This interactive flowchart covers safe and effective prescribing of strong opioids for pain relief in adults (18 years and older) with advanced and progressive disease.
It addresses first-line treatment with strong opioids for patients who have been assessed as requiring pain relief at the third level of the World Health Organization pain ladder. It does not cover second-line treatment with strong opioids where a change in strong opioid treatment is required because of inadequate pain control or significant toxicity.
The recommendations clarify the clinical pathway for prescribing strong opioids in palliative care, and will help to improve pain management and patient safety. They are aimed at non-specialist healthcare professionals initiating strong opioids for pain in adults with advanced and progressive disease. However, they are likely to be of relevance to palliative care specialists as well.

Updates

Updates to this interactive flowchart

8 August 2016 A recommendation on transdermal patches or subcutaneous delivery was deleted and replaced with a link to controlled drugs: safe use and management, which includes newer recommendations on the topic.
21 July 2015 Naloxegol for treating opioid-induced constipation (NICE technology appraisal guidance 345) added to managing constipation.
24 February 2015
  • Title changed from opioids in palliative care to opioids for pain relief in palliative care
  • Methylnaltrexone for treating opioid-induced bowel dysfunction in people with advanced illness receiving palliative care (terminated appraisal) NICE technology appraisal 277 added to managing constipation.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Palliative care for adults: strong opioids for pain relief (2012 updated 2016) NICE guideline CG140
Naloxegol for treating opioid-induced constipation (2015) NICE technology appraisal guidance TA345

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

background pain is chronic, persistent pain; breakthrough pain is a transient increase in pain intensity over background pain, typically of rapid onset and intensity, and generally self-limiting with an average duration of 30 minutes
a dosage form that is intended to release all the active ingredient on administration with no enhanced, delayed or extended release effect
the dose of analgesic needed for the relief of breakthrough pain
morphine-like drugs (such as diamorphine, fentanyl, oxycodone, buprenorphine); codeine and dihydrocodeine are weak opioids
a subcutaneous injection of opioids is given in the fatty layer of tissue just under the skin
a dosage form that is designed to release a drug at a predetermined rate by maintaining a constant drug level for a specific period of time with minimal side effects
medicated adhesive patches that are placed on the skin to deliver a specific dose of medication through the skin into the bloodstream

Paths in this pathway

Pathway created: June 2012 Last updated: June 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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