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Opioids in palliative care

Short Text

Safe and effective prescribing of strong opioids for pain in palliative care of adults

Introduction

This pathway covers safe and effective prescribing of strong opioids for pain relief in adults (18 years and older) with advanced and progressive disease.
The pathway 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.
This pathway clarifies the clinical pathway for prescribing strong opioids in palliative care, and will help to improve pain management and patient safety. It is aimed at non-specialist healthcare professionals initiating strong opioids for pain in adults with advanced and progressive disease. However, it is likely to be of relevance to palliative care specialists as well.

Source guidance

The NICE guidance that was used to create the pathway.
Opioids in palliative care. NICE clinical guideline 140 (2012)

Quality standards

Quality statements

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on:

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.

Updates to this pathway

19 November 2013 Minor maintenance updates.
22 February 2013 Minor maintenance updates.
13 September 2012 Education tool added to pathway.
26 June 2012 Links repaired to audit tools and podcast, and learning resources added to pathway.

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.
A rescue dose is 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.

Person with advanced and progressive disease requiring strong opioids

Person with advanced and progressive disease requiring strong opioids

Communication and review

Communication and review

Communication and review

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.

Source guidance

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Starting strong opioids: titrating the dose

Starting strong opioids: titrating the dose

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 (also see Communication and review).
Seek specialist advice before prescribing strong opioids for patients with moderate to severe renal or hepatic impairment.

Source guidance

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First-line maintenance treatment: are oral opioids suitable?

First-line maintenance treatment: are oral opioids suitable?

Maintenance oral morphine treatment

Maintenance oral morphine treatment

Maintenance oral morphine 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 (also see Communication and review) and consider seeking specialist advice.

Source guidance

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First-line treatment for breakthrough pain

First-line treatment for breakthrough pain

First-line treatment for breakthrough pain

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.

Source guidance

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Transdermal patches or subcutaneous delivery

Transdermal patches or subcutaneous delivery

Transdermal patches or subcutaneous delivery

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 caution when calculating opioid equivalence for transdermal patches:
  • A transdermal fentanyl 12 microgram patch equates to approximately 45 mg oral morphine daily.
  • A transdermal buprenorphine 20 microgram patch equates to approximately 30 mg oral morphine daily.

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.

Source guidance

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Paths in this pathway

Pathway created: June 2012 Last updated: November 2013

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

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