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How to use strong opioids in cancer patients

Learn how to effectively use strong opioids in cancer patients for pain management. This guide covers the definition of pain, evaluation methods, different types of strong opioids, their potency ratios, and treatment for opioid toxicity. Dr. Nicholas Herodotou, a consultant in Palliative Medicine, provides insights and recommendations for using opioids in cancer patients.

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How to use strong opioids in cancer patients

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  1. How to use strong opioids in cancer patients • Dr Nicholas Herodotou • Consultant in Palliative Medicine • L&D University Hospital

  2. Looking at… • Definition • Strong opioids • How to titrate • Photos

  3. What is pain?

  4. What patient says it is • ‘Unpleasant sensory & emotional experience associated with actual or potential tissue damage’ (Twycross)

  5. Pain is multi-dimensional • Physical • Psychological • Social • Spiritual TOTAL PAIN

  6. Evaluating pain

  7. Multi-modal approach to pain

  8. WHO PAIN LADDER

  9. ..A bit about morphine

  10. Extracted from opium (exudate derived from seed pods of opium poppy, Papaver Somniferum) • Opium used in Mesopotamia 3400BC as analgesic & anxiolytic • Main constituents of opium are morphine & codeine • Morphine first isolated in 1804 by German pharmacist Friedrich Seturner called it ‘Morphium’ after Morpheus, the Greek god of dreams

  11. PAPAVER SOMNIFERUM

  12. Opioid receptors & effect of agonist

  13. Use spread when hypodermic needle developed in 1853 • Initially used as ‘cure’ for alcohol & opium addiction • Heroin diacetylmorphine (Diamorphine) is a semi-synthetic opioid first synthesised from morphine by acetylation in 1874 • Before 1910 heroin used as cough medicine for children (Bayer)-heroin bottle photo! • Still illegal to prescribe diamorphine in USA

  14. Issues around strong opiates • Doctrine of double affect • ‘Shipman syndrome’ • No maximum dosage • Not all opiates are the same • Addiction

  15. Strong opioids • Morphine (MST, Oramorph, Sevredol) • Diamorphine (Heroin) • Oxycodone (Oxycontin & Oxynorm) • Fentanyl • Methadone

  16. Strong opioids to use • Morphine-1st line • Oxycodone-2nd line • Fentanyl-2nd or 3rd line • Diamorphine-SC or syringe driver

  17. Weak opioids • Dihydrocodeine(DF118) • Tramadol • Codeine • Co-codamol (Tylex) 30/500 • Co-dydramol 10/500

  18. Potency ratio of opiates to oral morphine

  19. Opioid toxicity • Agitation & confusion • Gastric Stasis • Sedation • Myoclonus • Pruritus & allodynia

  20. Treating opioid toxicity • Check renal function • Reduce dose of opioid by 1/3, or change opioid, e.g., morphine to oxycodone • Lorazepam 0.5-1mg for anxiety/myoclonus • Alternate route such as Fentanyl patch

  21. Morphine • Oramorph or Sevredol (rapid release) T1/2 4 hrs • MST (slow release) T1/2 12 hrs • Use as 1st line • Renally excreted, metabolites are morphine-3-glucuronide (M3G) & M6G which accumulate in renal failure • Peak plasma levels 20-30 min

  22. Diamorphine (heroin) • Given SC or IM (rarely) • Highly hydrophilic, rapidly absorbed • Peak plasma levels s/c in 5 min • Same T1/2 and renally excreted as Morphine • 3x more potent than oral morphine, e.g. 15mg oramorph= 5mg s/c diamorphine

  23. Oxycodone (generic) • Semi-synthetic opioid derived from thebaine in 1916 • Oxycontin was licensed in USA in 1996 as non-dependant narcotic • Oxynorm (fast acting)T1/2 4 hrs • Oxycontin (slow release), T1/2 12 hrs • NEVER write generic oxycodone on FP10

  24. Buprenorphine • Potent partial μ opioid receptor agonist, Κ & δ receptor antagonist • Useful for low-middle pain intensity • Doesn’t suppress gonadal axis so libido maintained • Poorly absorbed orally so sublingual tabs & transdermal patch better bioavailability • Clinical benefit for neuropathic pain syndromes

  25. Fentanyl • Matrix patch, T1/2 72 hrs-Durogesic stick better • 12, 25, 50, 100 mcg/hr patches • ‘25’=90mg morphine/24 hrs • Safe in renal failure • Less constipating as lipophilic

  26. Fentanyl • Useful 2nd line opiate • Always write up correct PRN morphine • ‘New’ rapid release fentanyl preps: • Effentora, buccal • Abstral, SL • Instanyl, nasal

  27. General rules using opioids • Always prescribe a laxative: not lactulose! • Generally don’t get nausea with non-IV • No absolute contraindication

  28. Always write up correct PRN morphine dose • Half oral dose when giving SC, e.g. Morphine 10mg PO=5mg morphine SC • Avoid use solely PRN opiates for pain management without titration (see graph)

  29. Graph of plasma opiate levels vs time Twycross

  30. Starting strong opioids • If opiate naive start at low dose 5mg 4hrly (on drug chart) or start MST 10mg BD at home • PRN oral morphine (every 4 hrs) • Laxatives! • Total up all morphine requirement in 24 hrs and divide by 2 for MST dose

  31. Titration example • Regular 5mg 4hrly= 5x6=30mg/24hr • PRN Oramorph needed was 6x5mg=30mg/24 hr • Total morphine needed to control pain is 30 + 30=60mg, so 60/2= 30mg MST BD • Always adjust PRN morphine dose to fit regular morphine, e.g. if on MST 30mg BD, needs Oramorph PRN 10mg written up (1/6 of total 24hr dose)

  32. Converting to fentanyl patch • Last MST dose at night • Put patch on in morning and give PRN morphine until pain controlled (upto 8-12 hrs) • If on morphine syringe driver (CSCI), put patch on and keep driver going for 6-hrs at 1/3 reduced dose and then stop • If from patch to CSCI, start driver immediately & take patch off

  33. Case scenarios

  34. Case scenario 1 • 80 year old with newly diagnosed metastatic breast cancer. Previously been on Tramadol 100 mg QDS for neuropathic pain in breast & arm, but no longer effective. • What morphine dose would you start her on? • How would you work out the PRN morphine dose? • What else would you include?

  35. Solution 1 • Tramadol 1/5 strength of morphine, 100x4=400/5 • So 80mg morphine/24hrs needed. But if in pain can increase by 1/3 to 100mg/24 hrs or 50mg MST BD • 1/6 of total 24 hr morphine dose. So 100/6= 15-20mg Oramorph PRN • A laxative such as co-danthramer or Movicol

  36. Case scenario 2 • 50 year old with metastatic ca lung discharged from hospital to home. Sudden acute deterioration. He was taking MST 300mg Bd for pain relief along with Diclofenac 50mg TDS. He is agitated, sweaty, confused and having myoclonic jerks. • What immediate blood tests are you interested in? • What medication would you alter? • What would you change it to and what dose? • Other drug you could add in?

  37. Solution 2 • Check U&E to rule out ARF 2nd NSAID (also check corr ca2+) • Stop the NSAID & switch to 2nd line opiate like Oxynorm • Reduce opioid dose by 1/3. 600mg morphine/24hrs= 300mg Oxynorm/24hrs. Reduce by 1/3 down to 200mg Oxynorm/24hrs (remember PRN Oxynorm as well) • BZP such as Lorazepam or Clonazepam for myoclonus

  38. Case scenario 3 • 25 year old with osteosarcoma recently had his MST increased from 100mg BD to 200 mg BD. Now drowsy although pain better controlled. • What would you do? • How would you start a Fentanyl patch?

  39. Solution 3 • Reduce the dose and add in NSAID for bone pain (check U&E) or switch to 2nd line opioid such as Oxynorm or fentanyl patch • Look at conversion chart, but as general rule, fentanyl patch size/5=4 hrly diamorphine dose. So x3=4hr oral morphine dose. 25 mcg fentanyl patch=90-100 mg Oramorph/24 hrs • Patient will therefore need a 100 mcg/hr fentanyl patch • Remember to give correct PRN Oramorph or Oxynorm

  40. Case scenario 4 • 64 year old with Mesothelioma having uncontrolled neuropathic pain in his right lung. On escalating dose of MST 300mg BD, but having drowsiness, myoclonic jerks & sweats. Now vomiting & unable to take oral medication. He is terminally ill & prognosis of hours-days • What would you do? • What drugs would you use and why?

  41. Solution 4 • Put on LCP • Start syringe driver(SD) with diamorphine or Oxynorm & midazolam • 600/3= 200 mg diamorphine/24hrs into driver or can use Oxynorm 600/2= 300mg PO/24 hrs. Reduce by 1/3 in SD so 200mg Oxynorm. • Give stat doses 2.5-5mg midazolam, put 10 mg in SD but keep giving SC stat doses every 20-30min and titrate up until sedated

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