In this Trust there is a care of the dying pathway, this pathway includes flowcharts for the management of pain, nausea, terminal restlessness and respiratory tract secretions (death rattle). However palliative care is broader than care of the dying, it includes the care of people with advanced illness; cancer and non-cancer.
Pain Assessment
A body chart or visual analogue scale (VAS) may be useful.
Principles
Assessment of pain type and accurate diagnosis.
Tailor treatment to patient.
Regular and PRN analgesia.
Reassess within 24-48 hours.
Realistic goals -
painfree sleep
painfree at rest
painfree on movement
For each pain assess likely cause using PPQRST
P Provoking factors - what brings on the pain or makes it worse?
P Palliating or relieving factors.
Q Quality – e.g. ache/tender/shooting/burning.
R Radiation - try and identify dermatome.
S Severity - does it make them cry/eyes water. Consider asking patient to grade 1-5 or grade as mild, moderate, severe.
T Temporal factors - constant, intermittent.
80% cancer patients with pain have two or more pains.
WHO analgesic ladder
Step 1 Paracetamol
Step 2 Weak opioids e.g. codeine or dihydrocodeine or paracetamol and codeine preparations e.g. co-dydramol
Step 3 Strong Opioids e.g. Morphine, diamorphine, fentanyl, oxycodone, hydromorphone
NB: Adjuvant drugs may be used at any step.
Starting morphine
Give 5-10mg morphine solution orally 4 hourly (10mg if changing from weak opioid) and ensure equivalent PRN doses of morphine are prescribed.
If this does not last 4 hours or not effective increase dose by 30-50% steps e.g. 5mg > 7.5mg > 10mg > 15mg > 20mg > 30mg > 45mg > 60mg > 90mg
When pain control stable convert to MXL (Once Daily Morphine) or Zomorph (Twice Daily Morphine)
Calculate total dose of morphine per 24 hours that the patient has needed and give as MXL once daily, at 17.00 hours where possible. or divide the total daily dose by 2 and give Zomorph twice 12 hourly.
e.g. 20mg morphine solution 4 hourly = 120mg/24 hours give as MXL 120mg daily or Zomorph capsules 60mg BD.
Also prescribe oral morphine solution or immediate release tablets 2 - 4 hourly prn for breakthrough pain at 1/6 total daily oral morphine dose (20mg in above example).
When starting morphine
Warn the patient that there may be some temporary drowsiness.
Warn the patient that there may be temporary nausea and prescribe metoclopramide 10mg 8 hourly or haloperidol 1.5 - 3.0mg at night when needed.
Prescribe laxatives codanthramer or docusate and senna.
Reassure patient that morphine will not be addictive.
When pain is difficult to control
Is the pain still sensitive to morphine? Check that the breakthrough dose of morphine is right. Give the correct dose and reassess after 20 - 30 mins
Is the pain morphine non-responsive e.g. colic, neuropathic pain, skeletal muscle spasm?
Do you need help? - Contact Palliative Care Team
Adjuvant treatment for pain relief
Consider the following in addition to WHO pain ladder.
NSAIDs
e.g: Ibuprofen 400mg tds
Diclofenac 50mg tds (also available as slow release tabs and suppositories)
Caution: Airways disease, renal impairment, coagulation disorders.
Bone pain - NSAIDs, radiotherapy. If severe exclude fracture (?surgical intervention), nerve or cord compression.
Nerve pain - This can be caused by pressure on a nerve and/or infilitration of a nerve.
Nerve compression may be worse on movement. Sensory changes may not be present. Prescribe dexamethasone 16mg daily for 5 days then reduce by 2mg daily to maintenance dose.
Exclude cord compression. Consider radiotherapy, anticonvulsants.
Nerve damage (neuropathic pain) – chronic, unpleasant pain with sensory changes at rest – burning, shooting, stabbing. TENS may be useful (Contact Physiotherapy for more information).
Step 1 - Give amitriptyline 10 –25mg nocte increase by 10 –25mg every third day to 75mg. If there is no response after a reasonable trial discontinue and try anticonvulsant. If partial response, continue amitriptyline and add in anticonvulsant.
Step 2 – Gabapentin is licensed for all types of neuropathic pain.
|
Dose Titration - |
Fast |
Slow |
|
Day 1 - 300mg on |
Day 1 - 100mg tds |
|
|
Day 2 - 300mg bd |
Day 7 - 300mg tds |
|
|
Day 3 - 300mg tds |
Day 14 - 600mg tds |
|
|
Day 4 - 400mg tds |
||
|
Increase by 300mg/day upto 600mg tds |
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|
Doses above 600mg tds are outside UK licence. Slow titration is recommended if elderly or renal impairment. |
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Note: There are significant cost implications of using gabapentin.
Headaches if caused by brain metastases - dexamethasone - 16mg daily for 5 days then reduce by 2mg daily to maintenance dose.
Visceral pain - bowel colic, bladder spasm use hyoscine butylbromide 20mg s/c stat or 40 - 120mg s/c over 24 hours. Liver capsule pain use NSAIDs, dexamethasone initially 8 - 16mg daily. Ureteric colic - diclofenac 100mg IM or PR.
Skeletal muscle spasm - use heat, massage, baclofen, diazepam.
Inflammatory e.g. cellulitis treat infection. NSAIDs, dexamethasone.
Subcutaneous drug administration
The IM route is normally avoided. (Low muscle mass, cachexia, painful injections).
The SC route is appropriate for:
- Swallowing difficulties
- Bowel obstruction.
- Established nausea and vomiting due to gastric stasis.
Subcutaneous administration is not just for the terminal phase and is not an alternative to ineffective oral treatment. ( Reassess uncontrolled pain and opiod responsiveness).
Subcutaneous diamorphine
Given via syringe driver or bolus injection.
Not for terminal restlessness - midazolam may be useful. Seek advice from Palliative Care Team.
Conversion oral morphine to diamorphine SC injection
Calculate total daily morphine dose in mg and divide by 3 e.g. MXL
180mg every 24 hours/3=60mg diamorphine over 24 hours s/c by syringe
driver. If pain is not well controlled consider 30 - 50% increase in dose.
Alternate strong opioids
Note - There are significant cost
implications of prescribing alternative strong opioids.
Fentanyl patches - replaced every 72 hours
Only use for opioid sensitive pain .
Fentanyl is slowly absorbed through skin. Takes at least 12 hours to
reach therapeutic dose. It is therefore important to provide
alternative analgesia for 12 hours after applying the first patch.
e.g. if converting from 12 hourly m/r morphine, apply the patch and
give the final
m/r dose at the same time.
Slow release from skin depot after patch removed (blood levels 50% by
17 hours).
Morphine/24 hours equivalence to fentanyl patch size
|
Fentanyl patch Dose (mcg/hr) |
Total daily oral Morphine dose (mg) |
4 hourly oral Morphine dose (mg) |
4 hourly s/c Diamorphine dose (mg) |
4 hourly Hydromorphone dose (mg) |
4 hourly oral Oxycodone dose (mg) |
|
25 |
<135 |
<20 |
5 |
2.6 |
10 |
|
50 |
135-224 |
25-35 |
10 |
3.9 |
15 |
|
75 |
225-314 |
40-50 |
15 |
6.5 |
25 |
|
100 |
315-404 |
55-65 |
20 |
7.8 |
30 |
|
125 |
405-494 |
70-80 |
25 |
10.4 |
40 |
|
150 |
495-584 |
85-95 |
30 |
11.7 |
45 |
|
175 |
585-674 |
100-110 |
35 |
14.3 |
55 |
|
200 |
675-764 |
115-125 |
40 |
15.6 |
60 |
|
225 |
765-854 |
130-140 |
45 |
18.2 |
70 |
|
250 |
855-944 |
145-155 |
50 |
19.5 |
75 |
|
275 |
945-1034 |
160-170 |
55 |
22.1 |
85 |
|
300 |
1035-1124 |
175-185 |
60 |
23.4 |
90 |
Hydromorphone
It is available as an immediate release and controlled release (over 12 hours) formulations.
Immediate Release : 1.3mg & 2.6mg capsules
Controlled Release : 2mg, 4mg, 8mg, 16mg & 24mg capsules.
Both forms of the drug may be swallowed whole or opened and sprinkled onto cold soft food (not suitable to be emptied down PEG or NG tubes).
Place in Therapy
Patient is intolerant of morphine or experiencing unacceptable level of side effects with oral morphine, particularly sedation/hallucinations.
Can be used as breakthrough medication for patients using fentanyl patches but intolerant of morphine.
Patients having difficulty swallowing oral dosage forms
Analgesic potency ratio of oral morphine to oral hydromorphone is 5-10:1 (an average 7.5:1)
Oxycodone
Also available as immediate or controlled release (over 12 hours) formulations.
Immediate Release : 10mg/ml & 5mg/5ml liquid
Controlled Release : 10mg, 20mg, 40mg & 80mg tablets
Place in Therapy
Patient is intolerant of morphine or experiencing unacceptable level of side effects with oral morphine.
Can be used as breakthrough medication for patients using fentanyl patches but intolerant of morphine, especially if patient is using high dose fentanyl as concentrated solution of instant release oxycodone is available.
Analgesic potency ratio of oral morphine to oral oxycodone is approximately 2:1.
It causes less vomiting and pruritus but more constipation than morphine.
(Referenced from Palliative Care - Pain & Symptom Control Guidelines - St. Ann's Hospice - 2nd Edition, Published Sept 2002)
Phone the specialist palliative care team for advice on the management of pain and other problems in advanced disease.
Macmillan nurses
Mike Connolly, Frances Mellor, Vicky Mercer, Helen Dutton and Tina Foley.
Wythenshawe Hospital ext. 2547 or aircall
Medical Staff
Dr. Heather Anderson - Aircall bleep
Dr. Kate Grady - Pain Clinic ext. 2502
Pharmacist
Jennie Pickard - Wythenshawe Pharmacy or bleep via switch
Secretary
Sandra Pearson ext. 2547.
Reference book
UKMI, Drug Information Letter 117 - Palliative Care Prescribing
A to Z of Hospice & Palliative Medicine - Peter Kaye (EPL Publications, Reprinted 1998)
Available on all wards.
Compiled by the Directorate of Palliative Care.