Pain Management in Palliative Care Dr Tasha Nishiyama.

Pain Management in Palliative Care

Dr Tasha Nishiyama

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

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

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

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

Side Effects - Opioids

Constipation Nausea and vomiting – although often

transient and controllable Drowsiness – often dose related and

temporary Respiratory depression – although shouldn’t

occur if doses are titrated appropriately Consider prescribing laxative and antiemetics

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 isn’t 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?

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

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?

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

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 hasn’t 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

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

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

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?

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/anticipatory medications.

Syringe Driver Prescription

Sample Prescription Syringe driver prescription should contain

either 60mg diamorphine/24 hours or 90mg morphine/24 hours

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

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

Syringe Drivers Used for symptom control when other ways of

administering the medication is unsuitable or inadequate Uncontrolled pain on it’s 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.palliativedrugs.com or by contacting the palliative care team

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?

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

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.

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

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.

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

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 Don’t forget the anxiolytics (as anxiety can be a big

contributing factor) e.g. diazepam or lorazepam

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/index

Bradford and Airedale Palliative Care http://www.bradford.nhs.uk/PalliativeCare/Pages/welcome.aspx

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

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