Prescribing for Palliative Patients; a primary care approach

1. Dr Laura Smith GP ST1 Prescribing for Palliative Patients; a primary care approach

2. Contents • The role of the GP in palliative care • Out of hours – out of ideas? • Pain • Assessment • Analgesia • Which one? • When? • Which Route? • Quiz

3. The role of the GP in palliative care • Palliative care: 'the active, holistic care of patients with advanced, progressive illness' • Why is the GP ideal to facilitate this? • long-established relationships with their patients • used to dealing with co-morbidity and uncertainty • trained to treat patients holistically • Care needs to be PROACTIVE

4. When should we think about palliative care? • If a patient is diagnosed with cancer? • If a patient needs a syringe driver? • If a patient has hours to live? ...When a patient is in the last year of their life (GSF) Identify GP Assess Plan

5. Imagine you are a GP... • How many of your patients are in the last year of their life? • 10% • 1% • 0.1% • On average, each GP has 20 deaths per year: • How many of these will be from cancer? • How many will be from organ failure? • How many from dementia/frailty or MOF? • How many will be sudden/unexpected?

6. Out of hours – out of ideas? Groups of 2-3 Imagine you are working as the OOH GP: you are called out to a patient who is near the end of life suffering with cancer. His wife is concerned because... ...he won't stop hiccuping doctor, it has been going on for hours! What would you prescribe?

7. Pain in Palliative Care • How many patients with cancer suffer pain? • 10% • 30% • 50% • 70% • 100% • How many patients dying with non malignant disease suffer pain? • 25% • 45% • 65% • 85%

8. Pain tolerance Sleep Listening Physio Social inclusion Relief of symptoms Relaxation Boredom Diversion Mental isolation Understanding Insomnia Depression Elevated mood Explanation Discomfort Finding meaning Insomnia Fatigue Anger Sadness Fear Anxiety Pain is a complex subjective phenomenon and is affected by the emotional context in which it is endured

9. History taking • SOCRATES • Physical effects or manifestations • Functional impact of pain • Psychosocial factors • Spiritual aspects • Self assessment important as pain subjective • Help patient to actively manage their pain • What is causing the pain?

10. The WHO pain ladder

11. Adjuvants

12. Non Opiates Paracetamol Weak Few side effects NSAIDS Good for bone pain SE: GI Bleed

13. Opiates Weak opioids Codiene Tramadol Use with non-opioids Strong opioids Morphine “For patients with no renal or hepatic comorbidities, offer a typical total daily starting dose schedule of 20-30 mg of oral morphine plus 5 mg oral immediate-release morphine for rescue doses during the titration phase” NICE

14. Converting between oral preparations Example: Mr Jones takes 60mg of codeine qds for his bony mets but is still in agony – what dose of morphine would you start him on? Answer: 60 x 4 = 240mg in 24 hours of codeine 240 / 10 = 24mg morphine needed in 24 hours Therefore try 5mg every four hours = 30 mg in 24 hours

15. Breakthrough pain 1/6th of total 24 hour dose can be given as a “rescue dose” for pain between doses of regular morphine This can be repeated every 4 hours AIM: Prevent pain, not relieve pain

16. Parental route of administration When should this be used: Patient unable to swallow, vomiting, weakness, dysphagia IM/SC morphine = ½ oral morphine dose IM/SC diamorphine = 1/3 oral morphine dose

17. Transdermal route of administration NOT for acute pain, or for patients whose analgesic requirements change rapidly Use if: problems with oral route, constipation, subacute obstruction or morphine intolerance

18. Poor kidney function: preventing and managing opioid toxicity Consider dose reduction +/- increased dose interval Use immediate-release oral formulation Switch to alfentanil, buprenorphine or fentanyl, which are the opioids of choice where eGFR <30ml/minute Frequent monitoring and review Seek specialist advice

19. Top Tips • Continuous pain = regular analgesia NOT prn • Take breakthrough analgesia before undertaking a potentially pain-provoking activity • KISS: Minimum number of drugs in the most acceptable form and dose intervals possible • Written guidance for patients and families • Regular review of effectiveness and side effects • Adequate prn medications

20. Quiz Mr Smith comes to see you in your morning surgery. 18 months ago he was diagnosed with bowel cancer. He underwent surgery and chemotherapy but 1 month ago was diagnosed with recurrence with spread to the liver. He comes to see you as he is getting worsening continuous abdominal pain. You take a careful history and you wish to change his pain relief.

21. Question 1 Mr Smith currently takes: Paracetamol 1g po qds Ibuprofen 400mg po tds Codeine 60mg qds Oral morphine 20mg immediate release tablets twice daily You wish to convert him to a higher dose of morphine and stop the codeine – what dose of immediate release morphine tablets will you prescribe? A) 10mg prn B) 10mg 4 hourly C) 5mg 4 hourly D) 20mg 4 hourly

22. Question 2 What breakthrough dose of oromorph does he need? A)10mg B) 5mg C) 6mg D) 10ml

23. Question 3 Mr Smith returns to the surgery later that week. You review his analgesia use: He has taken 10mg four hourly regularly but most days has needed a breakthrough dose before bed and when taking his dog for a walk (twice a day). How would you alter his morphine dose? A) 45mg four hourly with 10mg breakthrough B) 15mg four hourly with 10mg breakthrough C) 15mg four hourly with 15mg breakthrough D) 20mg four hourly with 20mg breakthrough

24. Question 4 As a good GP what else might you prescribe Mr Smith when you prescribe his morphine? A)Naloxone B)Phosphate enema C)Lactulose and senna D)Ondansetron

25. Question 5 Mr Smith comes the following week – his pain much better controlled and he is not needing any breakthrough treatment, but is concerned that he feels he is taking medication all the time. What could you do? A)Tell him to skip some doses and see how he feels B)Convert him to a twice daily morphine slow release dose of 45mg bd C)Convert him to a twice daily morphine slow release dose of 90mg bd D)Prescribe a fentanyl “25” patch

26. Question 6 2 months later you are asked to see Mr Smith on a home visit. He has been reviewed by your colleagues and is now taking 75mg bd or MR morphine sulphate tablets. He now describes a burning and tingling type pain in his feet which is making it difficult to walk. It started 14 months ago after the chemotherapy but is now worsening. What would you prescribe? A) MR MST 90mg bd B) Amitriptiline 10mg po nocte C) Gabapentin 600mg tds D) Crutches

27. Question 7 Unfortunately several weeks later Mr Smith is admitted to hospital overnight unwell with confusion. When discharged home the EDS notes for GP state: “Please alter medication as found to have renal impairment.” On his last repeat prescription he was on 90mg bd MR MST, ibuprofen 400mg tds, amitriptiline 10mg nocte with 30mg oromorph as breakthrough prn, lactulose 10ml bd, senna TT po nocte. Which of his medicines needs to be altered? A)Reduce ibuprofen only B)Stop MST only C)Stop ibuprofen, change MST to fentanyl patch D)Reduce ibupofen, change MST to fentanyl patch

28. Question 8 What dose of fentanyl patch will you prescribe and when should it be started? A) Fentanyl “50” apply at same time as last dose of MR MST given B) Fentanyl “25” apply 12 hours after last dose MR MST given C) Fentanyl “75” apply at same time as last dose of MR MST given D) Fentanyl “12” apply 12 hours after last dose MR MST given

29. Question 8 Luckily whilst you are working this out the receptionist receives a phone call from the oncall FY1 – who sent the EDS in error: the patient does not have renal failure – but has deteriorated so could you do a home visit to check on him? On visiting the patient you confirm that he has quickly deteriorated, but he wishes to die at home, with his family supporting him. He is too weak to swallow tablets, and seems in pain. You wish to convert his 90mg bd MR MST to subcut diamorphine - what is the daily dose? A) 45mg B) 30mg C) 90mg D) 60mg

30. Question 9 The Macmillan nurse telephones you to let you know that no diamorphine is in stock – they only have sub cut morphine can you re-prescribe it? What daily dose do you use now? A) 45mg B) 30mg C) 90mg D) 60mg

31. Question 10 You visit Mr Smith on a home visit 3 days later. He is in bed, and is asleep. His breathing has slowed but is very noisy due to secretions. His wife is upset thinking that he is in distress. You think he may be entering the last few hours of life. What might you prescribe? A) Increase his morphine to speed up his death and lessen the agony for his wife. B) Hyoscine hydrobromide 400 microgram subcut C) Midazolam 2.5-5mg subcut D) Cyclizine 50mg subcut

32. Summary • The role of the GP in palliative care • Pain • Assessment • Analgesia • Which one? • When? • Which Route?

33. References Pain Control in Palliative Care: Patient.co.uk Liverpool Care Pathway for the Dying Patient (LCP) Palliative Care Guidelines: NHS Scotland Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults: NICE guidelines

34. Final thoughts Mr Smith passes away peacefully that night. His family are happy with the care he has received and thank you for not putting him on that awful death pathway like they do in Liverpool! How do you respond?