Guidelines for Prescribing Opioids in Palliative Care

Transcription

1 Guidelines fr Prescribing Opiids in Palliative Care Owner: HDFT Palliative Care Team Authr: Dr V Barrs D Sa, Cnsultant in Palliative Medicine Issue date: February 2018 Review date: February 2020 Ratified and apprved by: Area Prescribing Cmmittee On: 23 rd February 2018 Distributin: All H&RD staff caring fr adult palliative care patients Versin 2 Feb 2018 Page 1 f 24 Review Date

2 CONTENTS 1. SCOPE ABBREVIATIONS PRINCIPLES OF PAIN MANAGEMENT AND ANALGESIA WEAK OPIOIDS FOR MILD TO MODERATE PAIN STRONG OPIOIDS FOR MODERATE TO SEVERE PAIN GENERAL PRINCIPLES OF OPIOID PRESCRIBING OPIOID SIDE EFFECTS OPIOID TOXICITY IF THE OPIOID IS NOT WORKING OPIOID CONVERSION CHART CONSULTATION, APPROVAL AND RATIFICATION PROCESS DOCUMENT CONTROL DISSEMINATION AND IMPLEMENTATION MONITORING COMPLIANCE AND EFFECTIVENESS REFERENCE AND ASSOCIATED DOCUMENTS APPENDICES Cnsultatin Summary Mnitring, Audit and Feedback Summary 24 Versin 2 Feb 2018 Page 2 f 24 Review Date

3 1. SCOPE This guidance applies t all clinical staff in Harrgate and Rural District (H&RD) wh care fr adult palliative care patients. Fr further advice, please cntact: Palliative Care Team (PCT): Mnday-Friday 08:30-16:30: Out f hurs: Saint Michael s Hspice Medical advice is available after review f the patient by a dctr f specialist trainee grade r abve Pharmacy: Ward pharmacist Main pharmacy: Mnday-Friday 08:30-19:00, Saturday and Sunday 10:00-14: Outside the hurs abve: cntact n call pharmacist via switchbard 2. ABBREVIATIONS BD twice a day cap capsule CNS central nervus system CSCI cntinuus subcutaneus infusin GFR glmerular filtratin rate HDFT Harrgate and District NHS Fundatin Trust HaRD Harrgate and Rural District inj injectin IR immediate release IV intravenus MR mdified release OD nce a day PCT Palliative Care Team PO rally PRN as required QDS fur times a day SC subcutaneus SD syringe driver tab tablet TD transdermal TDS three times a day Versin 2 Feb 2018 Page 3 f 24 Review Date

4 3. PRINCIPLES OF PAIN MANAGEMENT AND ANALGESIA Pain management Pain is cmmn in palliative care patients with bth advanced cancer and nn-malignant cnditins. Pain is a ttal, persnal experience with physical, psychlgical, scial and spiritual dimensins. Management requires a multidisciplinary apprach. Regular review f the pain, effect and side effects f analgesics, and hw the pain is affecting the patient and their family is vital fr gd pain cntrl. Nt all pain experienced by a patient with cancer is caused by the cancer itself. Often several pains cexist. Gd histry taking, examinatin and apprpriate investigatins are essential as analgesic ptins will be determined by the specific cause, type and severity f pain. Analgesia Analgesics can be divided int three classes: Nn-piid simple analgesics eg paracetaml Opiids Adjuvants r c-analgesics eg NSAIDs, amitriptyline, pregabalin Medicines frm different classes are used alne r in cmbinatin accrding t the type f pain and respnse t treatment. Mst piid medicatins act via µ receptrs in the CNS. Sme als have effects n ther receptrs, giving them a different side effect prfile. Sme are mixed agnist-antagnists eg buprenrphine. Nalxne is an antagnist at all piid receptrs. Mrphine is the mst cmmnly used piid in advanced cancer and ther end-stage cnditins, althugh nn-piids (eg paracetaml), a weak piid (eg cdeine) and/r an adjuvant may suffice. Alternative piids may be required in patients with renal and liver impairment r in thse wh develp side effects (see p15-16 r seek specialist advice). Sme pains are nly partially piid-respnsive. These include bne pain, nerve damage/cmpressin, visceral distensin, tenesmid pain, activity prvked pain, chemtherapy-induced neurpathy and pains unrelated t the underlying illness, such as tensin headache and pst-herpetic pain. These may require ther measures including adjuvants, nerve blckade r nclgical treatments, if cancer related. Please refer t A Guide t Symptm Management in Palliative Care, Yrkshire and Humber Palliative and End f Life Grups, fr guidance, r discuss with the PCT. Versin 2 Feb 2018 Page 4 f 24 Review Date

5 The principles gverning analgesic use are summarised in the WHO Methd fr Relief f Cancer Pain: By muth, where pssible By the clck: prescribe bth regularly and PRN By the ladder WHO analgesic ladder After assessing the severity f pain, the analgesic ladder can be used t identify apprpriate analgesics fr the level and nature f pain In sme situatins it is apprpriate t g straight frm step 1 t step 3 The patient shuld be reassessed regularly and analgesia prescribed, wrking up the ladder, until pain is managed Titrate dse against effect, with n rigid upper limit fr mst piids except buprenrphine, cdeine and tramadl Alternative analgesia, adjuvants and nn-pharmaclgical interventins shuld be cnsidered at each level f the ladder Versin 2 Feb 2018 Page 5 f 24 Review Date

6 4. WEAK OPIOIDS FOR MILD TO MODERATE PAIN 1. Cdeine This is a pr-drug f mrphine: its analgesic effect is via cnversin t mrphine. This varies between patients and in abut 10% f the ppulatin cdeine is ineffective. C-cdaml cntains paracetaml and cdeine and is much mre effective than cdeine alne (number needed t treat 2 vs 17). It is available in three strengths cntaining either 8mg, 15mg (nt stcked by HDFT) r 30mg f cdeine. In elderly r frail patients a lwer strength may be required. The maximum dse is 240mg in 24hrs- a ceiling effect exists abve this ie higher dses d nt give any further analgesic effect. It shuld be used with cautin in patients with renal impairment (see p15) as its metablites are renally excreted and therefre accumulate in renal failure. Cdeine is particularly cnstipating, s it is imprtant t prescribe a laxative with it. Preparatins available in HDFT: Cdeine tabs: 15mg, 30mg; 15mg/5ml linctus C-cdaml 8/500 tab, 8/500 effervescent tab, 30/500 tab 2. Tramadl This is nt usually used in palliative care because f its cgnitive side effects in frailer patients. Hwever if it is being taken with n adverse effects, it may be cntinued. The maximum dse is 400mg per day It shuld be used with cautin in patients with renal impairment (see p15) as its metablites are renally excreted and therefre accumulate in renal failure. Preparatins available in HDFT: Tramadl 50mg cap, 100mg MR tab, 50mg sluble tab Versin 2 Feb 2018 Page 6 f 24 Review Date

7 5. STRONG OPIOIDS FOR MODERATE TO SEVERE PAIN A. Oral This is the preferred rute fr the majrity f patients. 1. Mrphine This is the first line strng piid used in H&RD. It shuld be used with cautin in patients with renal impairment (see p15) as its metablites are renally excreted and therefre accumulate in renal failure. It is metablised in the liver s in severe hepatic impairment the dse may need t be reduced, r given less frequently than usual (see p16). Seek specialist advice in this situatin. It is available in: Immediate release (IR) tablets and liquids which are usually effective after minutes and t last up t 4 hurs. Mdified/slw release (MR) tablets, granules and capsules which are usually effective after 4 hurs and t last fr 12 hurs. Preparatins available in HDFT: Mrphine sulphate IR slutin 10mg/5ml, 20mg/ml (generic) IR tab 10mg (Sevredl) Mrphine sulphate MR tabs: 5mg, 10mg, 15mg, 30mg, 60mg, 100mg, 200mg 20mg (MST/Mrphgesic) MR sachets: 20mg, 30mg, 60mg, 100mg (MST) 2. Oxycdne Oxycdne is a strng piid with a similar dsing schedule t mrphine; it is available in MR tablets which last 12 hurs and IR liquid r capsules which last up t 4 hurs. It may cause less nausea, itch, cgnitive impairment and hallucinatins than mrphine in sme patients, s it is a useful secnd line strng piid fr thse wh have nt tlerated mrphine. Oral xycdne is twice as strng as ral mrphine. Cnsult the dse cnversin chart (see p20) when cnverting t xycdne r ask advice frm the Palliative Care Team r pharmacy. Versin 2 Feb 2018 Page 7 f 24 Review Date

8 Its metablites are renally excreted but cause fewer side effects than mrphine, s it may be safer t use than mrphine in renal impairment (see p15). Preparatins available in HDFT: Oxycdne IR caps: 5mg, 10mg, 20mg (Shrtec) Oxycdne IR slutin: 5mg/5ml (generic), 10mg/ml (Shrtec) Oxycdne MR tabs: 5mg, 10mg, 40mg, 60mg, 80mg, 120mg (Oxylan/OxyCntin/Lngtec) B. Transdermal (patches) Patches shuld nt be ffered as first line treatment t patients fr whm ral piids are suitable. They may be useful in patients with pr cncrdance with taking ral piids, r with swallwing r absrptin prblems. They are suitable fr patients wh have pain already stabilised n ther piids. They shuld nt be started in unstable pain r in the last days f life due t their lng titratin perid (24-48 hrs) and duratin f actin. Absrptin can be affected by skin temperature r vasdilatin eg having a lng ht bath can cause piid txicity. Sweating can cause prblems with patch adhesin. If this is a persistent prblem an alternative rute f delivery may be apprpriate. Fr patients in last hurs and days f life already using a transdermal patch, cntinue administratin f TD patches as prescribed. Give additinal piid via syringe driver if necessary. Either mrphine IR r xycdne IR can be used fr breakthrugh pain. 1. Fentanyl Fentanyl is metablised in the liver. Metablites are renally excreted but d nt usually cause txic effects when they accumulate in renal failure. It is less cnstipating than mrphine, hwever almst all mrphine-induced cnstipatin can be managed with regular use f apprpriate laxatives (see p17) Beware f small dses: a 25mcg/hr patch = 90mg f mrphine per day. Fentanyl patches shuld be used nly in peple wh have previusly tlerated piids as there is a risk f significant respiratry depressin in thse wh are piid naïve. Patches shuld be changed every 72 hurs. Versin 2 Feb 2018 Page 8 f 24 Review Date

9 Dses shuld nt be changed mre frequently than every 3 days. Preparatins available in HDFT: Fentanyl patches 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100mcg/hr (Matrifen) 2. Buprenrphine Buprenrphine causes less hypthalamic-pituitary axis suppressin and immunsuppressin than ther piids, s may be mre suitable fr lnger term use. Buprenrphine may have an anti-hyperalgesic effect. It may be useful fr patients wh require lw dse piids but cannt tlerate r take cdeine. The maximum recmmended dse is 140mcg/hr. BuTrans dses shuld nt be changed mre frequently than every 7 days. Transtec dses shuld nt be changed mre frequently than every 3 days. Because buprenrphine has bth high receptr affinity and prlnged receptr binding, nalxne in standard dses des nt reverse the effects f buprenrphine and higher dses must be used (see page 19). Preparatins available in HDFT: 5mcg/hr, 10mcg/hr, 20mcg/hr (Butec,Relitrans) change patch every seven days 35mcg/hr, 52.5mcg/hr, 70mcg/hr (Transtec) change twice a week eg Mnday and Thursday 35mcg/hr, 52.5mcg/hr, 70mcg/hr (Hapctasin) change every 3 days C. Subcutaneus (SC) SC preparatins can be given either as stat dses r as a cntinuus subcutaneus infusin (CSCI) via syringe driver (SD). This rute is indicated if the patient is unable t take ral medicatin eg in last days f life, r if there are cncerns abut absrptin eg because f vmiting r bwel bstructin. It may als be indicated fr severe unstable pain: seek specialist advice. Fr patients with a syringe driver in place, the same medicatin shuld be used fr SC PRN dses. Versin 2 Feb 2018 Page 9 f 24 Review Date

10 1. Mrphine NICE guidance recmmends either mrphine r diamrphine as first line parenteral strng piid. Previusly, diamrphine was used first line in HaRD. In January 2019, this was changed t mrphine. This change was made because f repeated supply issues with diamrphine, the wish t prescribe in the same way as neighburing areas which use mrphine, and cst savings. Mrphine is less sluble than diamrphine and therefre takes up mre vlume in a syringe driver. This can ccasinally be a prblem, depending n dses and ther medicatins included in the driver. If vlume is an issue, please cntact the Palliative Care Team fr advice. Diamrphine may be suggested as an alternative. Mrphine shuld be used with cautin in patients with renal impairment (see p15). In piid naïve patients, start with mrphine 2.5-5mg SC PRN r 5mg-10mg SC/24hrs via CSCI. Preparatins available in HDFT: Mrphine inj: 10mg/ml, 15mg/ml 2. Diamrphine This is used first line in sme areas. Use under advice f Palliative Care Team nly. May be suggested if vlume f mrphine in a syringe driver is prblematic. It shuld be used with cautin in patients with renal impairment (see p15). Preparatins available in HDFT: Diamrphine inj: 5mg, 10mg, 30mg, 100mg 3. Oxycdne Patients n ral xycdne can be cnverted t a subcutaneus infusin f parenteral xycdne. As with ral xycdne, it is suitable fr sme patients with renal impairment (see p15). Preparatins available in HDFT: Oxycdne inj: 10mg/ml, 20mg/2ml, 50mg/ml Versin 2 Feb 2018 Page 10 f 24 Review Date

11 4. Alfentanil Specialist use nly: please cntact the Palliative Care Team. Alfentanil is a synthetic derivative f fentanyl which is nly available parenterally. It is safe t use in renal failure. Beware f small dses: 1mg = 30mg ral mrphine. It has a half-life f nly apprximately 90mins s stat injectins dn t last lng and xycdne is usually used instead. Preparatins available in HDFT: Alfentanil inj: 1mg/2ml, 5mg/ml D. Other rutes Frmulatins f sublingual, buccal and nasal IR fentanyl are available and are fr use nly n recmmendatin f the Palliative Care Team. Preparatins and brands available in HDFT are crrect in February Current infrmatin can be fund in netfrmulary n the intranet r by cntacting Pharmacy. Preparatins available in the cmmunity are listed in the BNF. Versin 2 Feb 2018 Page 11 f 24 Review Date

12 6. GENERAL PRINCIPLES OF OPIOID PRESCRIBING 1. Initiatin Fr the majrity f patients, ral mrphine is the first line strng piid. This can be prescribed either as immediate release (IR) r mdified release (MR), whichever is mst suitable fr the patient. IR ral mrphine has a rapid nset f actin (abut 20 minutes) but it requires administratin every 4 hurs t maintain a cntinuus analgesic effect. Cnsequently, it is difficult t cver pain thrughut 24 hurs, unless the persn is being clsely mnitred. MR preparatins have a slwer nset f actin (1 2 hurs) and later peak levels (4 hurs) than IR preparatins, and last up t 12 hurs. Fr patients with n renal r hepatic cmrbidities, start with 10 30mg f ral mrphine per day (eg 5 15mg ral mrphine MR BD, r 2.5-5mg ral mrphine IR QDS), plus an apprpriate dse f ral mrphine IR fr breakthrugh pain (see pint 3. PRN medicatin belw). Lwer the starting dse if the patient is elderly r frail. If prescribing liquids, prescribe in mg rather than ml as differing strengths are available. Prescribe regular laxatives and PRN anti-emetics (see p17). 2. PRN medicatin All patients taking regular piid analgesics (ral, subcutaneus r transdermal) shuld als have immediate release piids prescribed fr breakthrugh pain t take PRN. This is usually apprximately 1/6 f the ttal daily dse, but a range may be apprpriate (eg 1/10 t 1/6). The maximum frequency and dse f PRN piids in 24 hurs shuld be clearly stated. Advise the patient t take breakthrugh analgesia befre the pain gets severe, as liquid mrphine and xycdne take minutes t have their full effect. When changing the backgrund dse, the PRN dse shuld be changed accrdingly. If the persn's backgrund pain is satisfactrily cntrlled but they experience incident pain (pain n mvement r particular events, such as wund dressing, being washed, weight-bearing): Versin 2 Feb 2018 Page 12 f 24 Review Date

13 Give a breakthrugh dse f an immediate-release piid apprximately 30 minutes befre the precipitating factr ccurs D nt keep increasing the 24-hur dse f piid. D nt include the breakthrugh dses administered fr incident pain when reassessing maintenance piid analgesia requirements. See the cnversin chart n page 20 fr breakthrugh dses f mrphine fr fentanyl and buprenrphine patches. 3. Cmmunicatin and infrmatin When ffering analgesia with strng piids t a patient, ask them abut cncerns such as: addictin tlerance side effects fears that treatment implies dying Prvide verbal and written infrmatin n strng piid treatment t patients and carers (using HDFT patient infrmatin leaflet: Infrmatin fr patients abut piid therapy, als available n the intranet under including: when and why strng piids are used t treat pain that piids are nt addictive when used t treat pain piids are being prescribed because f the level f pain they are experiencing, nt because they are near t the end f life hw effective they are likely t be hw, when and hw ften t take strng piids (fr backgrund and breakthrugh pain) hw lng pain relief shuld last side effects and signs f txicity (see p18) safe strage fllw-up and further prescribing infrmatin n wh t cntact ut f hurs Offer patients access t frequent review f pain cntrl and side effects 4. Driving Since March 2015 it has been an ffence t drive whilst taking certain specified cntrlled drugs, including sme piids, if these drugs cause driving t be impaired. All patients wh are prescribed piids shuld be advised that the plice are able t test and prsecute drivers wh they suspect may have impaired driving due t taking such drugs. Versin 2 Feb 2018 Page 13 f 24 Review Date

14 Patients shuld be advised that it is their respnsibility t cnsider whether they believe their driving is, r might be impaired n any given ccasin, eg, if they feel sleepy, r if in any dubt, they shuld NOT drive. Patients shuld be advised that when driving they shuld carry suitable evidence t shw that the cntrlled drug is prescribed medicatin. Patients must be warned that driving with impaired cncentratin due t medicatin they are taking, even if that medicatin is prescribed, is a criminal ffence. Discuss the ptential impact n driving and give the patient the HDFT patient infrmatin leaflet: Infrmatin fr patients abut the law n driving having taken certain drugs (als available n the intranet under Further infrmatin is available at: althcare-prfs-drug-driving.pdf 5. Titratin Reassess pain and the respnse t analgesia regularly. If the pain is inadequately cntrlled and piid respnsive, the backgrund dse f piid shuld be increased, taking the PRN requirements int accunt, after assessment f the effect and side effects f these. Use the piid dse cnversin chart n page 20 when prescribing, reviewing r changing piid prescriptins t ensure that the ttal dse f piid taken in a 24-hur perid is cnsidered. It is nt usually advisable t increase the 24 hur dse by greater than 30%. This is ccasinally indicated fr escalating severe pain but nly under specialist advice. 6. Opiid switching There is n evidence fr differing analgesic efficacy between mrphine, xycdne, fentanyl and buprenrphine. Sme patients may experience fewer adverse effects with xycdne, fentanyl r buprenrphine than with ral mrphine. It is apprpriate t switch frm ne piid t anther if: the pain is piid sensitive but side effects prevent the dse frm being increased further despite treatment an alternative methd f administratin is needed eg TD, SC Versin 2 Feb 2018 Page 14 f 24 Review Date

15 A switch is nt indicated fr prly cntrlled pain nly. Take int cnsideratin the ttal amunt f piid that is being taken in 24 hrs. Patients may be n mre than ne piid eg c-cdaml and mrphine sulphate IR slutin. Peple metablise piids differently, s cnservative cnversins are recmmended, especially at high dses, and it may be apprpriate t cnsider a dse reductin. Ensure that PRN medicatin is prescribed, review frequently and titrate up as necessary. It is advisable t duble check and dcument calculatins in the patient recrd, including calculatin f the PRN dse. Opiid withdrawal symptms can ccur when switching. If this ccurs, give a small dse f the initial piid. Guidance n timing f switches between different rutes f administratin: ral t CSCI Frm IR piid: start syringe driver immediately. Frm 12-hurly MR piid: start syringe driver 4 hurs befre next ral dse due. CSCI t ral Stp the SD and give first ral dse at the same time. ral t transdermal Frm IR piid: apply patch when cnvenient and use ral IR piid as required. Frm twice daily MR piid: apply patch at same time as last dse f MR ral piid. Seek specialist advice fr ther switches. Warn the patient that they may need extra PRN dses f medicatin fr the first few days after a switch f rute f administratin. 7. Prescribing in renal impairment If renal functin is impaired, the glmerular filtratin rate (GFR) is reduced, meaning renally excreted drugs will take lnger t clear. Therefre it may be necessary t alter the dse r frequency f drugs t prevent accumulatin. Mrphine and its active metablites accumulate in renal impairment and can cause piid txicity. The extent t which this affects the patient depends n bth the GFR and its rate f change. Bth fentanyl and buprenrphine are safer than mrphine in patients with renal failure. When cnsidering whether r nt t switch t an alternative piid, the clinical situatin needs t be taken in t accunt eg hw well the patient is tlerating mrphine despite reduced renal functin, and hw rapidly the renal functin is likely t deterirate. Fr this Versin 2 Feb 2018 Page 15 f 24 Review Date

16 reasn there are n recmmendatins fr piid prescribing based n GFR alne, but the fllwing are suggestins: Cnsider switching frm cdeine, mrphine and diamrphine if the GFR is belw 50ml/min. This may nt be necessary if there are n piid side effects and renal functin is stable, hwever the use f mrphine is nt usually recmmended belw a GFR f 30ml/min. Oxycdne is a suitable alternative, but belw a GFR f 10 it can als cause txicity and use f fentanyl, buprenrphine r alfentanil is recmmended instead. See p8-10 fr further infrmatin. Cntact the PCT fr advice if needed. 8. Prescribing in hepatic impairment Hepatic impairment can cause increased bi-availability f medicatins, accumulatin f drugs r metablites and prlnged half-life. In additin, disruptin t the bld brain barrier can lead t higher CNS cncentratins f drugs. The fllwing are recmmended: Lw dses with careful mnitring Lnger interval between dses than usual Using IR rather than MR preparatins Cntact the PCT fr advice if needed. Versin 2 Feb 2018 Page 16 f 24 Review Date

17 7. OPIOID SIDE EFFECTS 1. Cnstipatin Infrm patients that cnstipatin affects nearly all patients receiving strng piid treatment. Prescribe laxative treatment, eg macrgls r senna, t be taken regularly at an effective dse, fr all patients. Infrm patients that treatment fr cnstipatin takes time t wrk and adherence is imprtant. Optimise laxative treatment fr managing cnstipatin befre cnsidering switching strng piids because f this. 2. Nausea and vmiting Advise patients that nausea may ccur when starting strng piid treatment r at dse increase, but that it is likely t be settle within a few days. If nausea persists, prescribe and ptimise anti-emetic treatment (eg halperidl 1.5-3mg ncte r metclpramide 10mg TDS) befre cnsidering an piid switch. 3. Drwsiness Advise patients that mild drwsiness r impaired cncentratin may ccur when starting strng piid treatment r at dse increase, but that it is ften transient. Warn patients that impaired cncentratin may affect their ability t drive (see p13-14) and undertake ther manual tasks. In patients with either persistent r mderate-t-severe CNS side effects, cnsider a dse reductin r an piid switch. 4. Dry muth Try: Cld, unsweetened drinks Frequent sips r sprays f cld water Ice cubes, crushed ice, r ice lllies Lubricant n the lips Sugar-free prducts eg chewing gum, mints, biled sweets, r pastilles If side effects remain uncntrlled despite ptimising treatment, cnsider seeking specialist advice. Versin 2 Feb 2018 Page 17 f 24 Review Date

18 8. OPIOID TOXICITY All patients being titrated n mrphine shuld be mnitred fr side effects and signs f CNS txicity (cnfusin, drwsiness, agitatin, hallucinatins, myclnic jerks, respiratry depressin). Management will depend n the situatin, but the fllwing shuld be cnsidered: Omitting next dse f piid Checking renal functin Reducing dse Switching piid Other methds f analgesia Nalxne This is rarely needed: see belw Nalxne In palliative care patients receiving piids fr pain relief, nalxne shuld nt be used fr drwsiness r delirium which is nn-life threatening, because f the dangers f reversing the analgesia and precipitating hyperalgesia and acute physical withdrawal, which, in sme cases, may be fatal. The aim is t increase the respiratry rate, nt the cnscius level. The dses f nalxne advised in the BNF fr treatment f acute piid txicity may NOT be apprpriate fr the management f piid-induced respiratry depressin and sedatin in thse receiving palliative care and in chrnic piid/piate use. (Patient Safety Alert Nvember 2014) If respiratry rate 8/min, patient easily rusable and nt cyansed: Reduce piid dse; may require missin f next dse (see abve) If respiratry rate <8/min and the patient is uncnscius: Stp piid eg remve patch, stp syringe driver Dilute nalxne 400mcg/ml (1ml ampule), t 10ml using 0.9% saline fr injectin Give 0.5ml (20mcg) IV every 2 mins until respiratry rate >8/min Further bluses may be required as the half-life f nalxne is shrter than many piids With very lng acting piids eg fentanyl r buprenrphine patch, it may be necessary t set up a 24 hur IV infusin f nalxne based n the blus requirements. Seek specialist advice. Versin 2 Feb 2018 Page 18 f 24 Review Date

19 Reversal f buprenrphine-induced respiratry depressin Because buprenrphine has bth high receptr affinity and prlnged receptr binding, nalxne in standard dses des nt reverse the effects f buprenrphine and higher dses must be used: 1. Remve buprenrphine patch 2. Give xygen by mask 3. Give IV nalxne 2mg stat ver 90sec 4. Cmmence nalxne 4mg/h by IVI 5. Cntinue CIVI until the patient's cnditin is satisfactry (prbably <90min) 6. Mnitr the patient frequently fr the next 24h, and restart IVI if respiratry depressin recurs 7. If the patient's cnditin remains satisfactry, restart buprenrphine at a reduced dse, eg half the previus dse The nn-specific respiratry stimulant dxapram can als be used, 1 1.5mg/kg IV ver Versin 2 Feb 2018 Page 19 f 24 Review Date

20 9. IF THE OPIOID IS NOT WORKING Cnsider: 1. Are piids the right analgesic? Nt all pain is piid respnsive. Reassess and cnsider the aetilgy f the pain. Adjuvant medicatin may be required: refer t A Guide t Symptm Management in Palliative Care, Yrkshire and Humber Palliative and End f Life Grups, fr guidance. Palliative raditherapy is helpful fr bne metastases, and is ften given as a single treatment. In certain patients a nerve blck r ther interventin may help. Discuss with the PCT r cancer pain management team in Leeds. Cnsider nn-drug measure eg TENS, acupuncture, massage, cmplementary therapies. 2. Is the dse high enugh? If there is a partial respnse r inadequate duratin f pain relief, ie if pain returns less than 4 hurs after IR ral mrphine r less than 12 hurs after MR mrphine, and there are n side-effects, increase the dse by 30% increments. Remember t change the PRN dse when changing the backgrund dse. 3. Is the drug being absrbed? If there is uncntrlled vmiting, dysphagia, bwel bstructin r a high stma utput, cnsider alternative rutes f delivery, eg SC, TD. 4. Are adjuvants required? Refer t A Guide t Symptm Management in Palliative Care, Yrkshire and Humber Palliative and End f Life Grups, fr guidance, and discuss with the Palliative Care Team if necessary. Versin 2 Feb 2018 Page 20 f 24 Review Date

21 10. OPIOID CONVERSION CHART T cnvert between piids, always cnvert t equivalent dse f ral mrphine first. These cnversins are apprximate guides based n prduct specificatins and clinical experience. They may differ frm guidance stated in the BNF. Peple metablise piids differently, s cnservative cnversins are recmmended, especially at high dses, and it may be apprpriate t cnsider a dse reductin. Ensure that PRN medicatin is prescribed (usually 1/6 f the ttal daily dse), review frequently and titrate as necessary. Leave patches in place in dying patients and give additinal piid via a syringe driver if necessary. 4 ORAL OXYCODONE eg 30mg x 2 x 4 SC OXYCODONE eg 15mg 2 ORAL MORPHINE eg 60mg 2 ORAL CODEINE, DIHYDROCODEINE, TRAMADOL eg 600mg Nt a clinical dse 10 x 2 SC MORPHINE eg 30mg Use first line x SC ALFENTANIL eg 2mg Use nly n advice f Palliative Care Team x 3 SC DIAMORPHINE eg 20mg Use nly n advice f Palliative Care Team Fentanyl patch mcg/hr Equivalent 24hr dse f ral mrphine PRN dse f Oramrph required 12 <45mg 5-10 mg 25 90mg 15mg mg 15-25mg mg 25-35mg mg 40-50mg mg 55-65mg mg 70-80mg mg 85-95mg mg mg Buprenrphine 7 day Patch Buprenrphine Patch mcg/hr Equivalent 24hr dse f ral mrphine PRN dse f Oramrph required 5 12mg 2.5mg 10 24mg 5mg 20 48mg mg Buprenrphine 3 r 4 day patch (check frequency f patch change) Buprenrphine Patch mcg/hr Equivalent 24hr dse f ral mrphine PRN dse f Oramrph required 35 84mg 10-15mg mg 15-20mg mg 20-25mg

22 11. CONSULTATION, APPROVAL AND RATIFICATION PROCESS See 16.1 Appendix DOCUMENT CONTROL Palliative Care Team 13. DISSEMINATION AND IMPLEMENTATION Staff bulletin Palliative and EL sectin f intranet 14. MONITORING COMPLIANCE AND EFFECTIVENESS 15. REFERENCE AND ASSOCIATED DOCUMENTS 1. A Guide t Symptm Management in Palliative Care, Yrkshire and Humber Palliative and End f Life Grups 2. Opiids in palliative care: safe and effective prescribing f strng piids fr pain in palliative care f adults, NICE CG140 May Palliative Care Frmulary, Twycrss R, and Wilcck A, Radcliffe Medical Press Ltd and website 4. Clinical Knwledge Summaries: Palliative Cancer Care- Pain 5. Patient Safety Alert: Risk f distress and death frm inapprpriate dses f nalxne in patients n lng-term piid/piate treatment, 20 Nvember Cnservative Management f Uraemia: Yrk Guidelines Infrmatin fr patients abut piid therapy, HDFT patient infrmatin leaflet 8. Infrmatin fr patients abut the law n driving having taken certain drugs, HDFT patient infrmatin leaflet 16. APPENDICES Appendix 1: Cnsultatin Summary Appendix 2: Mnitring, audit and feedback summary Versin 1 Jan 2018 Page 22 f 24 Review Date

23 16.1. Cnsultatin Summary Thse listed ppsite have been cnsulted and any cmments/actins incrprated as apprpriate. List Grups and/r Individuals Cnsulted Helen Lyn, Pharmacy Palliative Care Team Area Prescribing Cmmittee The authr must ensure that relevant individuals/grups have been invlved in cnsultatin as required prir t this dcument being submitted fr apprval. Versin 1 Jan 2018 Page 23 f 24 Review Date

24 16.2. Mnitring, Audit and Feedback Summary KPIs Audit / Mnitring required Audit / Mnitring perfrmed by Audit / Mnitring frequency Audit / Mnitring reprted t Cncerns with results escalated t Versin 1 Jan 2018 Page 24 f 24 Review Date