Opioids in palliative care: safe and effective prescribing of strong opioids

1. Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults Support for education and learning Training slide set for primary and secondary care June 2012 NICE clinical guideline 140

2. What this presentation covers • Part 1 • Background/ scope • Aims and learning objectives • Part 2 • Clinical case scenarios Part 3 • Discussion and evaluation

3. Part One

4. Background • Pain which results from advanced disease remains under-treated • Strong opioids, especially morphine, are the principal treatments for pain related to advanced and progressive disease • Prescribing advice has been varied and sometimes conflicting

5. Scope • This guideline covers:- • first-line treatment with strong opioids for patients • the following drugs: buprenorphine, diamorphine, fentanyl, morphine and oxycodone • the clinical pathway needed to improve pain management and patient safety when prescribing strong opioids as a first-line treatment

6. Aims • The aims of the workshop are to: • promote awareness and understanding of NICE’s recommendations • increase knowledge of how to apply them as part of routine practice, whilst taking account of individualised care • practise identifying the risk factors and indicators for use of opioids

7. Learning objectives 1 • By the end of the session, participants should have improved knowledge on: • the verbal and written information on strong opioid treatment that should be given to patients and carers • patient side effects such as constipation, nausea and drowsiness • appropriate first line treatment for patients

8. Learning objectives 2 • actions to take for patients who have moderate renal or hepatic impairment or are unable to take oral opioids • ‘starting doses’ of strong opioids for patients • how to effectively titrate opioid doses • how to prescribe effective breakthrough medication

9. Pre-workshop quiz • ? Please complete the pre-workshop quiz

10. Part 2

11. Clinical case scenarios for primary care • List selected scenarios……..

12. Scenario 1: Begum • Presentation • Begum Akhtar is a 38 year old woman who was diagnosed with liver metastases from colorectal cancer 6 weeks ago. She has pain in her right upper quadrant which she describes as intense 6/10 on a 10 point visual analogue scale • She started taking strong opioids 4 weeks ago. She felt drowsy when she started her morphine but her pain was reduced usefully. One week after starting her morphine the intensity of her pain increased and her dose was adjusted

13. Scenario 1: Begum • Medical history • Begum Akhtar has been well since the onset of her symptoms. Her only surgery is the hemi-colectomy 1 year previously • Begum Akhtar is married and has two children of school age

14. Scenario 1: Begum • On examination • Begum Akhtar is taking morphine sustained-release 30 mg twice daily. She has a supply of morphine liquid but is not using this as a dose of 10 mg makes her feel drowsy. She has constant pain in her right upper quadrant and is having difficulty sleeping. She has not reported feeling constipated • She has tried taking other adjuvant medications such as non-steroidal anti-inflammatory drugs (NSAIDs), regular paracetamol and a small dose of dexamethasone, with no effect

15. Scenario 1: Begum • Next steps for management • 1.1 Question • What medication advice do you give to Begum Akhtar?

16. Scenario 1: Begum • 1.1 Answer • Advise Begum Akhtar to try increasing her sustained-release morphine to 40 mg twice daily for 1 week and then increase to 50 mg twice daily. She should try taking a dose of morphine liquid 10 mg at night to help her sleep • At each dose change, discuss expected side effects • Explain that several dose adjustments might be needed to achieve useful pain relief

17. Scenario 1: Begum • Next steps for management • Begum Akhtar comes back to the surgery 2 weeks later. Sustained-release morphine 40 mg twice daily has improved her pain to 5/10 in the day. She is struggling to manage her daytime pain. She is sleeping better with her night-time dose of immediate-release morphine • 1.2 Question • What do you advise about Begum Akhtar’s medication?

18. Scenario 1: Begum • 1.2 Answer • Advise Begum Akhtar that her drowsiness may reduce in a few days. If she still feels drowsy she should reduce her dose back to 40 mg twice daily • Arrange to talk to her again within 5 days for a medication review

19. Scenario 1: Begum • Next steps for management • Begum Akhtar still feels sleepy after 1 week on morphine 50 mg twice daily. She has dropped the dose to 40 mg twice daily and her pain has worsened • 1.3 Question • What is the next best step?

20. Scenario 1: Begum • 1.3 Answer • Begum Akhtar’s pain is responsive to opioids but she is getting sedative side effects. A different opioid should be tried – for example, buprenorphine, diamorphine or oxycodone. Dose conversion tables are a rough guide only • Always explain to the patient that they may get side effects from the new drug

21. Scenario 1: Begum • 1.4 Question • What should you advise Begum Akhtar about driving?

22. Scenario 1: Begum • 1.4 Answer • Begum Akhtar should not drive if she feels drowsy or has poor concentration. Opioid symptoms may vary at different times of day. Lack of sleep and pain can also interfere with driving. Opioids may be more sedating if patients are given other medications in addition • Advise Begum Akhtar that she must consider whether she feels fit on every occasion that she wants to drive

23. Scenario 1: Begum • Next steps for management • Begum Akhtar is taking a new opioid preparation. She feels drowsy when she takes a dose that controls her pain • 1.5 Question • What do you suggest?

24. Scenario 1: Begum • 1.5 Answer • You should seek specialist advice

25. Scenario 2: Helena • Presentation • Helena presents at her GP surgery with worsening abdominal pain. The pain is mainly localised to the right upper quadrant of her abdomen and can vary in nature, but for the past 2 weeks has been present most of the time • It has prevented her from sleeping for the past 3 nights, and she feels exhausted

26. Scenario 2: Helena • Past medical history • Helena is 68 and retired. A year ago she was found to have a large abdominal mass, which was found to be an ovarian carcinoma • It was found to have spread throughout her peritoneal cavity at presentation and therefore a palliative treatment regimen was started. Despite chemoradiotherapy, she developed widespread intraperitoneal lymph node involvement • Continues on next slide

27. Scenario 2: Helena • Past medical history: continued • A recent CT-scan showed four separate small masses in her liver, likely to be metastases • Recent blood tests including liver and renal function have been normal • She has been taking two co-codamol 30/500 tablets four times a day, but they only had a limited effect. She has tried NSAIDs but cannot tolerate them as they give her severe epigastric discomfort

28. Scenario 2: Helena • On examination • She is not jaundiced but does look very tired. Her abdomen is distended and on palpating her liver the GP notes that it is enlarged • The area around her right upper quadrant is very tender, but there is no guarding or rebound tenderness

29. Scenario 2: Helena • Next steps for management • 2.1 Question • She has been taking two co-codamol 30/500 tablets four times daily • What would you discuss with her about next steps specifically regarding pain management options?

30. Scenario 2: Helena • 2.1 Answer • It would appear that she needs stronger pain relief, and she should be offered regular oral morphine, either as an immediate-release or as a sustained-release preparation • She should also be offered rescue doses of oral immediate-release morphine for breakthrough pain. You should also investigate the possibility of constipation

31. Scenario 2: Helena • 2.2 Question • What dose of morphine would you start her on?

32. Scenario 2: Helena • 2.2 Answer • She has been on two tablets of co-codamol 30/500 four times daily. This equates to an equivalent daily dose of oral morphine of approximately 24 mg over a 24‑hour period • She could be started on oral immediate-release morphine 5 mg every 4 hours (amounting to a total daily dose of 30 mg of oral morphine) • Continues on next slide

33. Scenario 2: Helena • 2.2 Answer: continued • Alternatively she could be started on oral sustained-release morphine 15 mg every 12 hours • It is important that she also understands that if this dose regimen is insufficient and she has breakthrough pain, she can take additional oral immediate-release morphine 5 mg as required

34. Scenario 2: Helena • 2.3 Question • When you mention the word morphine, she flinches and says “Oh no!” What would you discuss with her?

35. Scenario 2: Helena • 2.3 Answer • Establish what her concerns are and what her ideas about morphine and strong opioids are. It is likely that she has worries and preconceptions about morphine; for instance, she may think morphine signifies the imminent end of her life or that it will kill her. She may also be fearful of addiction • You should offer her a follow-up consultation to discuss these matters further and to review how her pain control is going

36. Scenario 2: Helena • 2.4 Question • She has a lot of questions about morphine, including how often to take the medication and when to take breakthrough doses • She also wants to know what side effects to look out for. What would you do to provide her with more information?

37. Scenario 2: Helena • 2.4 Answer • She may need help in drawing up a timetable showing the times when she should take her medication • It is also important to mention potential side effects like constipation, nausea, vomiting, drowsiness and hallucinations • You may wish to provide her with some additional written information • Continues on next slide

38. Scenario 2: Helena • 2.4 Answer: continued • If there is access to a specialist community palliative care team, this may further help in following up medication queries and monitoring response to treatment • It is also important to discuss whom she can contact out of hours, if her pain should get worse or she develops side effects. When you mention possible interference with driving Helena admits that she finds it too painful and relies on her partner now to ‘chauffeur’ her around

39. Scenario 2: Helena • 2.5 Question • Helena returns 2 days later and says that the pain control is working reasonably well, but that she is finding taking regular oral immediate-release morphine every 4 hours cumbersome • She says she has read the leaflets and would like to consider a sustained-release preparation. What would you do?

40. Scenario 2: Helena • 2.5 Answer • Establish how much immediate-release morphine she has been taking regularly and how much she has been taking in addition for breakthrough pain • Offer an oral sustained-release preparation of morphine every 12 hours that is equivalent in dose to her current oral immediate release preparation and advise her she can take additional oral immediate-release morphine for breakthrough pain as required • Continues on next slide

41. Scenario 2: Helena • 2.5 Answer: continued • For instance, if she has been taking 5mg immediate-release oral morphine every 4 hours (that is, six times a day equalling 30 mg over 24 hours), offer oral sustained-release morphine 15 mg twice daily (every 12 hours) • In addition, she should be told that she can still take oral immediate-release morphine for breakthrough pain

42. Scenario 2: Helena • 2.6 Question • She returns several weeks later. Her sustained-release morphine has been titrated up to 30 mg twice daily and she is taking four additional doses of immediate-release morphine 10 mg as rescue doses for her breakthrough pain • Despite this, she remains in pain. She has also found that she is seeing shapes and figures appear and disappear. What action should you take?

43. Scenario 2: Helena • 2.6 Answer • There are several issues here, so seek advice from your local specialist palliative care team; her pain is not being controlled and she is getting side effects • If her pain were well controlled, an opioid dose reduction may have been indicated, but this is not the case. Establish whether she thinks the oral morphine is actually reducing her pain when she takes it (that is, is this still an opioid-responsive pain?)

44. Scenario 3: Vera • Presentation • Vera is a 70 year old woman with bone and liver metastases from a breast cancer primary • Past medical history • None, normal renal function, mild hepatic impairment

45. Scenario 3: Vera • On examination • Right upper quadrant pain, which is constant. Vera is currently taking 30/500 mg co‑codamol four times a day • Next steps for management • 3.1 Question • What strong opioid should Vera be prescribed and at what dose?

46. Scenario 3: Vera • 3.1 Answer • There is no renal impairment and only mild hepatic impairment • Vera should be offered (unless contraindicated) regular oral sustained-release or immediate-release morphine (depending on her preference) with rescue doses of oral immediate‑ release morphine for breakthrough pain • Continues on next slide

47. Scenario 3: Vera • 3.1 Answer: continued • The typical daily starting dose should be 10 -15 mg sustained-release oral morphine 12 hourly plus rescue doses of 5 mg immediate-release oral morphine for breakthrough pain • or • 2.5 - 5 mg immediate-release oral morphine 4-hourly plus rescue doses of 5 mg immediate-release oral morphine for breakthrough pain

48. Scenario 3: Vera • Next steps for management • Following discussion, Vera was started on 10 mg sustained-release oral morphine 12-hourly and 5 mg immediate-release oral morphine for breakthrough pain • 3.2 Question • What information should you provide to Vera about the management of side effects at this point of initiating opioid therapy?

49. Scenario 3: Vera • 3.2 Answer • Discuss the risk of constipation with Vera, and prescribe laxatives when initiating strong opioids • Advise her that nausea may occur when starting opioid treatment, but it is likely to be transient • Also advise Vera that mild drowsiness or impaired concentration may occur when starting opioid treatment, but that it is often transient

50. Scenario 3: Vera • 3.3 Question • What drug group should be prescribed for Vera at the time of initiating opioid therapy?