Pain Management in Palliative Care

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Pain Management in Palliative Care

• Dr Tasha Nishiyama

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Aim and Objectives

• 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

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Key Points About Pain

• 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

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Analgesic Ladder

• 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

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Opioids

• 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

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Side Effects - Opioids

• Constipation
• Nausea and vomiting although often transient
  and controllable
• Drowsiness often dose related and temporary
• Respiratory depression although shouldnt occur
  if doses are titrated appropriately
• Consider prescribing laxative and antiemetics

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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 isnt 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?

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Case 1

• 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
  5-10mg 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

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Case 1

• 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?

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Breakthrough Pain

• 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

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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
  hasnt 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

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Write an FP10

• 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

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FP10 for Case 1

• 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

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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?

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Case 2

• 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/anticipat
  ory medications.

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Syringe Driver Prescription

• Sample Prescription
• Syringe driver prescription should contain either
  60mg diamorphine/24 hours or 90mg morphine/24
  hours

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Prescription of Anticipatory Medications

• 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

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First Line Anticipatory Medications

• 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

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Syringe Drivers

• Used for symptom control when other ways of
  administering the medication is unsuitable or
  inadequate
• Uncontrolled pain on its 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.palliatived
  rugs.com or by contacting the palliative care
  team

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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?

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Case 3

• 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

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Case 3

• Breakthrough analgesia for this case can be
  calculated as follows
• 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.

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Oxycodone

• 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

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Fentanyl

• 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.

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Buprenorphine

• 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

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Adjuvants

• 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
• Dont forget the anxiolytics (as anxiety can be a
  big contributing factor) e.g. diazepam or
  lorazepam

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Useful Sources Of Information

• 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/i
  ndex
• Bradford and Airedale Palliative Care
  http//www.bradford.nhs.uk/PalliativeCare/Pages/we
  lcome.aspx

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Further Advice

• 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

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Summary

• 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