Chronic Non Malignant Pain - Strong Opioid Prescribing Guideline and Educational Pack

Transcription

1 Appendix 4G Chrnic Nn Malignant Pain - Strng Opiid Prescribing Guideline and Educatinal Pack Backgrund Opiids have been increasingly prescribed t treat chrnic nn malignant pain. There is evidence frm clinical trials that they can be effective, in the shrt and medium term, in prviding symptmatic imprvement in smatic, visceral and neurpathic pain. Cmplete relief f pain is rarely achieved. The gal shuld be t reduce pain sufficiently t facilitate engagement with rehabilitatin and the restratin f useful functin. The management f persistent pain fcuses nt nly n reductin in pain intensity but als n imprvement in sleep, md, and physical, vcatinal, scial and emtinal wellbeing. The safety and efficacy f piids in the lng term is uncertain, as is the prpensity fr these drugs t cause prblems f tlerance, dependence and addictin. The benefits f piid treatment fr the patient must be balanced against burdens f lng term use as therapy fr persistent pain may need t be cntinued fr mnths r years. There is n gd predictive factr f the analgesic effect f piids in chrnic nn malignant pain. If deemed apprpriate, the individual shuld have a mnitred piid trial ver a perid f 6 weeks t determine the effectiveness f the treatment and the presence f side effects. If the clinical decisin is made t cntinue the prescriptin f the piid, there shuld be nging timely reassessment. Recmmendatins are made n determining the suitability f an piid trial, the chice f piid, the cnduct f an piid trial and lng term mnitring f the patient. When starting piid therapy, there must be clear agreement regarding respnsibility fr prescribing. It is gd practice fr patients t be given prescriptins frm ne prescriber nly. If cncerns abut addictin arise, the number f dses prescribed shuld be reduced. The aim f this pack is t: Update clinicians n current prescribing guidelines fr strng piids Prvide a range f reference materials which clinicians can use fr cntinuing prfessinal/ persnal develpment Date written: April 2015 Review Date: April 2017 Fife Integrated Pain Management Service 1

2 Chrnic Nn Malignant Pain Strng Opiid Prescribing Guideline- Shrt Summary(Adapted frm the West f Sctland Chrnic Nn-Malignant Pain Guidance. December 2012) BEFORE INITIATING OPIOIDS CONSIDER What is the cause f persistent pain? Bipsychscial aspects cnsidered? Have ther apprpriate methds f pain management been tried? Neurpathic pain? (Refer t lcal neurpathic pain guidelines) Is a trial f piids apprpriate fr this patient? (see belw) Lng Term Effects f Opiids Endcrine -Influences HPA axis leading t hypgnadism & lw bne mass Immunlgical -Nt fully understd but may have an immunlgical mdulating affect leading t immunsuppressin Opiid induced hyperalgesia -Patient may present with increased diffuse pain Suggested Areas Where Opiids Are Nt Recmmended N previus imprvement with piids Sleep Apnea N Clinical Evidence f Lng Term Effectiveness In: Headache Nn Specific Lw Back Pain Fibrmyalgia Unexplained Persistent Pain Clser Mnitring Required fr Patients With Mental Health Disrders Depressin and Anxiety Related t Pain Current r past histry f substance misuse Family histry f substance misuse Cmplete Opiid Risk Tl t Assess Risk and Cnsider Referring t Lcal Pain Clinic Cmmence Opiid Trial (Duratin 6 weeks) AIM 30% Imprvement in Pain And/r Significant Imprvement in Functinal Ability Prir t Initiatin Explain advantages and disadvantages Initiatin f Opiids Explain the cncept f an Opiid Trial and reasns fr discntinuatin Agree achievable patient specific gals Recrd baseline levels f pain and functinal ability Discntinue all Step 2 Analgesia i.e. Single r cmbinatin analgesics cntaining: Cdeine Dihydrcdeine Tramadl Lw Dse Buprenrphine Patches *Cntinue step 1 analgesia such as paracetaml/nsaids Cmmence Oral Mrphine Sulphate MR 10mg BD fr Opiid Naïve patients & increase by 10-20mg BD every 2 weeks. Alternatively use Opiid Cnversin Chart t transfer frm Step 2 analgesia minus 50% f ttal daily dse fr safety. Assess patient every 1-2 weeks If Mrphine MR is nt tlerated Recmmence trial using Oxycdne 5mg MR BD If prblems with swallwing cnsider alternative ral slw release preparatins e.g. suspensin If issues with GI absrptin use Fentanyl 12mcg/hr Increase dse every 2 weeks until pain relief has been achieved r maximum dse f 30mg BD is achieved Increase dse every 2 weeks until pain relief has been achieved r maximum dse f 60mg BD is reached. Treat side effects as per NHS Fife Frmulary as required Regular Assessment Regularly assess pain and functinal ability If trial is successful initially mnitr every 3 mnths, then six mnthly Measure sex hrmnes if patient reprting symptms f hypgnadism and if abnrmal seek advice frm lcal endcrine clinic. Cnsider weaning piids every 6 mnths t see if dse is still ptimal. Observe fr signs f drug abuse. Avid using shrt acting piids If there is NO clinical benefit gained with a full trial f ne piid there are n randmised cntrlled trials, which suggests that ne piid is mre effective than anther. If piid trial unsuccessful, reduce dse by 10-20mg Mrphine r equivalent every 2 weeks until discntinued Cnsider Referral t a Pain Specialist fr: Difficulty tapering r prblem drug use Patients with piid sensitive pain wh require dse higher than 60mg Mrphine Sulphate MR Capsules (Zmrph ) BD r equivalent. Opiid insensitive prblematic pain Diagnstic difficulties Date written: April 2015 Review Date: April 2017 Fife Integrated Pain Management Service 2

3 NHS Fife Chrnic Nn Malignant Pain Strng Opiid Prescribing Patients may be managed by the General Practitiner and/r the Pain Specialist. This guideline is t aid primary care and secndary care teams in managing patients, wh have chrnic pain, with piids. This guidance shuld be used in cnjunctin with lcal and/r natinal guidance n the assessment f pain and with reference t British Pain Sciety Guidelines. Key Pints The aim f using piids in the shrt t medium term is t supprt the rehabilitatin and restratin f physical and mental functin f patients. There is evidence frm clinical trials that piids can be effective, in the shrt and medium term, in prviding symptmatic imprvement in a variety f nn-cancer pain cnditins. The safety and efficacy f piids in the lng term is uncertain. Once dse f piid is stabilised patients shuld be reviewed at least every 6 mnths t assess nging need, reducing dse as apprpriate Patients whse pain remains uncntrlled shuld be referred t specialist services Opiids can als have untward effects in terms f tlerance, dependence and addictin. Befre initiating piids cnsider the fllwing: What is the cause (diagnsis) f persistent pain in yur patient? Has a bipsychscial assessment been made? Have ther apprpriate methds f pain management been tried? (e.g. ther medicatins, graded exercises, psychlgical methds) Des yur patient have neurpathic pain? (Refer t DN4 Tl available in NHS Fife Frmulary, Appendix 4C: Guidance n the Management f Chrnic Nn-malignant Pain) Wuld a trial f piids be suitable fr this patient? (see belw) Des the patient drive? On the 2 nd March 2015 in England and Wales it became an ffence t drive with certain cntrlled drugs in excess f specified levels in the bdy, whilst this is nt the case in Sctland patients shuld still be aware and recgnise this is in additin t the existing rules n drug impaired driving and fitness t drive. Situatins where piids are nt recmmended r where clser mnitring wuld be required: There are n chrnic pain cnditins in which piids are cmpletely cntraindicated. Cnsideratin shuld be given t using the Opiid Risk Tl (see Appendix 1) t assess fr ptential high risk/dependent patients. If patients are assessed as mderate t high risk clser mnitring will be required Nt Recmmended N imprvement with piids in the past Sleep Apnea N Clinical Evidence fr Lng Term Effectiveness in the fllwing cnditins: Headache Nn Specific Lw Back Pain Fibrmyalgia Unexplained Persistent Pain Ptential High Risk/Dependent Patients Requiring Clser Mnitring Mental Health Disrders Depressin and Anxiety Related t Pain Current r past histry f substance misuse Family histry f substance misuse Date written: April 2015 Review Date: April 2017 Fife Integrated Pain Management Service 3

4 Initiatin f Opiids Prir t the cmmencement f piid therapy, it is essential that apprpriate infrmed cnsent is btained frm the patient and if necessary family/carers. The discussin shuld include: A clear explanatin f the advantages and disadvantages f piid therapy, which shuld include shrt term and lng term side effects, ptential fr tlerance and addictin, detrimental impact n quality f life and advice n driving and perating machinery as per the guidance n use f strng piids in Chrnic nn malignant pain issued by the British Pain Sciety & the RCGP which can be fund nline The British Pain Sciety's Opiids fr persistent pain:gd Practice Agreeing achievable patient specific gals. This may include an agreed expected reductin in pain scre (30%), imprvement in sleep pattern and functinal ability. An explanatin f the cncept f an Opiid Trial and what circumstances wuld surrund the discntinuatin f piid medicatin. A discussin abut the legislatin cncerning taking strng piids and driving, shuld the patient have a driving license and drive a vehicle. Infrmatin can be fund nline Cnsider the Lng Term Effects f Opiids: Endcrine -Influences HPA axis leading t hypgnadism & lw bne mass Immunlgical -Nt fully understd but may have an immunlgical mdulating affect leading t immunsuppressin Opiid induced hyperalgesia -Patient may present with increased diffuse pain Opiid Trial Anticipated length f trial wuld be 6 weeks. Expectatin: 30% imprvement in pain and/r significant imprvement in functinal ability. Discntinue all Step 2 analgesia and replace with Step 3 during the trial hwever cntinue with Step 1 analgesia such as paracetaml/nsaids and adjuvants. (See Appendix 4) Step 2 Analgesia:- Frmulary Single r cmbinatin analgesics: cdeine, C-cdaml, C-Dydraml ( R ) r Tramadl Nn Frmulary Single r cmbinatin analgesics: Dihydrcdeine, Tramacet ( nn-smc apprved) Buprenrphine patches (4 day patch Nn SMC apprved, 7 day patch Nn Frmulary). Bth Tramacet and buprenrphine patch wuld require an Individual Patient Treatment Request frm t be cmpleted if it was required t be prescribed)) Date written: April 2015 Review Date: April 2017 Fife Integrated Pain Management Service 4

5 Step 3 Analgesia Starting Dse Titratin f dse if necessary Maximum Dse 1 st Line Mrphine Sulphate Sustained Release (Zmrph ) 10mg BD Increase by 10-20mg BD Every 2 weeks 60mg BD 2 nd Line Oxycdne Sustained Release (Lngtec ) 5mg BD Increase by 5 10mg BD every 2 weeks 30mg BD If there are issues with swallwing cnsider alternative ral slw release preparatins e.g. suspensin. 2 nd Line r if issues with GI absrptin Fentanyl (Matrifen ) 12mcg/hr (Equivalent t 45mg mrphine in 24 hurs) Increase by 12mcg/hr every 2 weeks 25mcg/hr (Equivalent t ~80mg mrphine in 24 hurs) Use a single agent by the ral rute, using sustained release preparatins. If n cntraindicatin, first line chice is sustained release Mrphine Sulphate SR 10mg BD prescribed as Zmrph in piid naïve patients. Fr patients already n reasnable dse step 2 analgesics, cnvert using piid cnversin chart see Appendix 2, then reduce ttal daily dse by 50% as a safety precautin. If Mrphine Sulphate SR is nt tlerated despite treatment f side effects (see belw), recmmence trial using sustained release Oxycdne SR. Oral rute is preferred, hwever if the patient has prblems with swallwing r GI absrptin, Transdermal Fentanyl preparatins shuld be used, recgnizing that titratin will take lnger than ral preparatins. Increase dse every 2 weeks until required pain relief has been achieved r side effects are intlerable r until 60mg BD Mrphine Sulphate SR r equivalent is reached. Fr patients reaching dses in excess f 60mg BD Mrphine Sulphate SR cnsider referral t the Pain Specialist Clinic. Reassess the patient 1-2 weekly. Regular Assessment Onging Efficacy carry ut recrdings f pain scre and functinal assessment. Varius tls can be used t help assess pain including verbal rating scales (VRS e.g. mild/mderate/severe) and numerical rating scales (NRS Pain scred n 0-10 scale where 0 is n pain and 10 is wrst pain imaginable) If the piid trial is nt successful, discntinue piid by tapering dse slwly, reducing the daily dse by 10 20mg r equivalent nce every 2 weeks. If pain flares up during reductin, this may be due t withdrawal r lss f placeb effect. The patient shuld be reassured and piid reductin paused until symptms settle. (See patient infrmatin leaflet abut reducing piids) There are n high quality randmized cntrlled trials, t suggest that ne piid is mre effective than anther. If there is NO clinical benefit with a full trial f ne piid, there is n indicatin t repeat the trial with anther piid seek pinin f Pain Specialist. If piid trial is successful, cntinue with mnitring f dse, pain scre, functin and side effects every 3 mnths initially until dse is stable, then every 6 mnths. Cnsider weaning ff piids every 6 mnths t see if dse is still ptimal. A patient infrmatin leaflet is available at: Opiid Reducing Leaflet Avid using shrt acting piids fr breakthrugh pain. Keep daily dse f lng acting piid as lw as pssible, with a maximum f 30 days supply. Measure hrmnes if patient reprting symptms f hypgnadism and if abnrmal seek advice frm lcal endcrine clinic. Assess fr signs f prblem drug use. Refer t British Pain Sciety advice; Pain & Substance misuse: Imprving the patient experience Date written: April 2015 Review Date: April 2017 Fife Integrated Pain Management Service 5

6 Referral t a pain specialist is recmmended fr: Patients with previus mental health prblems, substance misuse, dependency r addictin Difficulty tapering r prblem drug use Patients with piid sensitive pain wh require dse higher than 60mg Mrphine Sulphate Tablets BD r equivalent. Opiid insensitive prblematic pain Diagnstic difficulties Treatment f Side Effects further infrmatin Cnstipatin The majrity f patients taking piids fr mderate t severe pain will develp piid induced cnstipatin; tlerance des nt develp t this side effect. Guidelines suggest that the best prphylactic treatment fr piid induced cnstipatin is a cmbinatin f a stimulant laxative and a stl sftener. Refer t NHS Fife Frmulary, Sectin 1.6 and Appendix 1C management f Cnstipatin in Adults Nausea/Vmiting Nausea and vmiting are cmmn when starting n piids but generally tlerance develps after 5-10 days. If a prphylactic antiemetic is required fr a patient cmmencing an piid fr mderate t severe pain please refer t the NHS Fife Frmulary, Sectin 4.6 Itch Opiid induced itch ccurs in arund 1% f thse wh receive a systemic piid. It is thught t be caused by a central mechanism rather than by histamine release, therefre in sme cases antihistamines are nt effective. Emllients shuld be used liberally if the patient has dry skin. Trial f a sedating antihistamine such as chlrphenamine is suggested, if this is nt effective after a few days it shuld be stpped. (3) Renal Impaired patients Fr thse patients with renal impairment, the likelihd f piid txicity with any piid increases and the fllwing guiding principles shuld be fllwed when prescribing piids; Use the smallest effective dse/frequency. Titrate carefully and mnitr fr adverse effects. It shuld be nted there is n advantage in using Oxycdne ver Mrphine in CKD Stage 1-3 renal impaired patients. In patients with CKD stage 4/5 kidney disease, cnsult with the patients lcal renal specialist befre cmmencing piid treatment. General advice wuld be t avid lng acting preparatins and where they are used, delay their intrductin until the patient s dse requirements are fully established. If there are clinical cncerns cnsult lcal renal specialists. References 1. West f Sctland Chrnic Nn Malignant Pain Guideline. December Scttish Intercllegiate Guidelines Netwrk. SIGN Guideline 136.Management f Chrnic Pain. December Scttish Palliative Care Guidelines 2014 Scttish Palliative Care Guidelines - Hme 4. FIPMS medicatin infrmatin page n the Knwledge Netwrk via intranet. ( Requires Athens Passwrd Access) Date written: April 2015 Review Date: April 2017 Fife Integrated Pain Management Service 6

7 Date written: April 2015 Review Date: April 2017 Fife Integrated Pain Management Service 7

8 APPENDIX 1 Printed with permissin frm LifeSurce Nt-fr-Prfit n behalf f Dr Lynn Webster (@LynnRWebsterMD). Reference Webster LR, Webster R, Predicting aberrant behaviurs in Opiid treated patients: preliminary validatin f the Opiid Risk Tl. Pain Medicine. 2005; 6(6):432 Date written: April 2015 Review Date: April 2017 Fife Integrated Pain Management Service 8

9 APPENDIX 2 Opiid Equivalent Dses Transdermal Opiids: Apprximate equivalence with ral mrphine Oral mrphine equivalent (mg/24 hurs) 30 t t t t t t t Transderma l fentanyl (mcg/hur) N.B. Published cnversin ratis vary and these figures are a guide nly. Mrphine equivalences fr transdermal piid preparatins have been apprximated t allw cmparisn with available preparatins r ral mrphine. Patient respnse may be variable Please check the mst recent BNF fr current cnversin guide. Oral mrphine t ther ral analgesics Oral t Oral Cnversin Rati Cmments Mrphine t Oxycdne 2:1 Oral Mrphine 10mg = Oral Oxycdne 5mg Mrphine t Tramadl 1:5-1:10 Oral Mrphine 10 mg = Oral Tramadl mg Mrphine t Cdeine 1:10 Oral Mrphine 10 mg = Cdeine 100 mg N.B. Published cnversin ratis vary and these figures are a guide nly. Patient respnse may be variable. Date written: April 2015 Review Date: April 2017 Fife Integrated Pain Management Service 9

10 APPENDIX 3 (with Acknwledgement t Prfessr Stephan A. Schug MD FANZCA FFPMANZCA) Treatment Cntract fr the use f Strng piid medicine (mrphine-like painkiller) fr the management f chrnic pain Patient name: Address: Date f birth: PLEASE COMPLETE ALL DETAILS I,,..understand that. (a strng piid ) is t be prescribed t me in an attempt t imprve my level f functining and reduce my pain. My medical practitiner and I have discussed that strng piid (mrphine-like) medicines may nly be partially helpful in achieving this gal and n ccasin will nt help at all. I understand that an piid medicine is nly ne part f the management f my chrnic pain. My medical practitiner and I agree t the fllwing cnditins regarding my treatment and the prescribing f an piid medicine fr my pain: 1. My medical practitiner is respnsible fr prescribing a safe and effective dse f an piid medicine. I will nt use an piid medicine ther than at the dse prescribed and I will discuss any changes in my dse with my medical practitiner. Finding the right dse f piid will mean having regular appintments with yur dctr, t assess any benefit r prblem. 2. I am respnsible fr the security f my piid medicine. Lst, misplaced r stlen medicines r prescriptins fr piid medicines will nt be replaced. 3. I will nly btain my piid medicine frm the medical practitiner wh signs this cntract, r ther dctrs in the same practice authrised t prescribe t me. I understand that n early prescriptins will be prvided. 4. Whilst mst peple d nt have any serius prblems with this type f medicine when used as directed, there can be side effects. My medical practitiner has explained the main nes t me, and I will tell him r her if I experience what culd be side effects. 5. Dependence r addictin t prescriptin pain killers is estimated t ccur in 1 in 20 patients. Either yur prescriber r the Pain & Dependency service can help yu with any prblem drug use. 6. As pssible dependence is imprtant in the management f my pain, I have infrmed my medical practitiner f any present r past dependence n alchl r drugs that I may have had, and f any illegal activity related t any drugs (including prescriptins medicines) that I may have been invlved in. 7. If there are cncerns that the medicatin is nt used prperly as prescribed and there are issues f safety t children the prescriber may discuss this case with ther nn NHS agencies 8. I am aware that prviding my piid medicine t ther peple is illegal and culd be dangerus t them. 9. My medical practitiner respects my right t participate in decisins abut my pain management and will explain the risks, benefits and side effects f any treatment. 10. My medical practitiner and I will wrk tgether t imprve my level f functining and reduce my pain. 11. I understand that my medical practitiner may stp prescribing my piid medicine r change the treatment plan if my level f activity has nt imprved, if I d nt shw a significant reductin in my pain, r if I fail t cmply with any f the cnditins listed abve. Patient s signature: Patient s name: Date: Medical practitiner s signature: Medical practitiner s name: Please prvide a cpy f the signed cntract t the patient. Why d I need t sign a treatment cntract? Bth yu and yur dctr are subject t strict regulatins when an piid medicine is prescribed. A treatment cntract is used s that yur dctr is sure that yu understand what is expected frm yu whilst yu take this type f medicine, and that yu cnsent t the requirements described in this cntract. Date written: April 2015 Review Date: April 2017 Fife Integrated Pain Management Service 10

11 APPENDIX 4 Pain Management WHO Ladder Step 3: (add strng piid) Step 0 Assessment f pain Step 1: Paracetaml Step 2: (add weak piid) 1 st Line: C-cdaml 30/500 (Paracetaml + cdeine) 2 nd line: C-Dydraml 20/500 (Paracetaml + DHC) (R ) 2 rd line Paracetaml + Tramadl 1 st line: Paracetaml + Mrphine Sulphate SR (preferred brand Zmrph ) 2 nd line: Paracetaml + Oxycdne MR (Lngtec ) Fentanyl patch (Matrifen ) Cnsider Analgesics, NSAIDs & neurpathic adjuvants in cmbinatin at all stages. Cnsider nn pharmaclgical measures at all stages BEFORE stepping up the pain ladder. There is limited evidence fr lng term use f piids in chrnic nn malignant pain. See Neurpathic guidance in Appendix 4C Guidance n the management f chrnic nnmalignant pain & NSAID guidance in Ch 10 Review f effect is essential after initiatin r dsage change f any pain medicatin Step 1: Regular Paracetaml 500mg 2 fur times daily Tablets r caplets preferred frmulatin nt capsules Patients with lw bdy weight(>33kg t<50kg) max daily dse is 60mg/kg nt exceeding 3g Patients > 50kg with risk factrs fr hepattxicity the max dse per administratin is 1g (i.e 2 x 500mg ). Maximum daily dse is 3g Date written: April 2015 Review Date: April 2017 Fife Integrated Pain Management Service

12 Appendix 5 Scttish Intercllegiate Guidelines Netwrk. SIGN Guideline 136.Management f Chrnic Pain. December Annex 4 Annex 4 Pathway fr using strng piids in patients with chrnic pain This pathway is drawn frm evidence identified in the guideline, infrmatin extraplated in the research fr the guideline and the clinical experience and cnsensus f the guideline develpment grup. Mre detailed pathways n pain assessment and management are available frm the British Pain Sciety. 195 Strng piids shuld nly be cnsidered after a full assessment and as part f a wider management plan, rather than as sle agents. Prescribers shuld have knwledge f piid pharmaclgy and be cmpetent and experienced in the use f strng piids. Step 1 Assessing suitability fr strng piid Assess pain Likely t respnd t piid, eg nciceptive; sme benefit frm weak piids cnsider piid trial Less likely t respnd t piid, eg neurpathic; n analgesia at all frm weak piids cnsider specialist advice befre piid trial OR avid piids. Assess patient fr relevant psychscial factrs: children in huse ther family members with a histry f substance misuse prblems increased risk f misuse r develping iatrgenic dependency: histry f herin abuse histry f alchl abuse histry f stimulant use mental health prblems ther cmrbidities: cgnitive impairment - cgnitive side effects are mre likely; cncrdance and safety may be an issue renal impairment - accumulatin f active metablites with sme piids gastrintestinal pathlgy - adverse effect n bwel functin. Other analgesics use simple analgesics, tpical therapies and anti-neurpathic agents (if apprpriate) fr piid sparing effect. Discuss the plan with the patient befre starting piids Prvide infrmatin leaflets (eg SIGN patient leaflet, British Pain Sciety patient leaflet) Establish gals f treatment: Primary: pain relief (define the degree that wuld be acceptable t the patient) Secndary: imprved functin, sleep, md Be aware that piids shuld NOT be used as anxilytics. Date written: April 2015 Review Date: April 2017 Fife Integrated Pain Management Service

13 Discuss the side effects/ptential prblems. The patient needs t be aware f the ptential side effects and they need t be acceptable t the patient, eg: GI dysfunctin nausea, vmiting, cnstipatin Central nervus system memry and cgnitive impairment, nightmares, hallucinatins, visual disturbance endcrine fertility, sexual functin immune functin misuse ptential tlerance piid-induced hyperalgesia. Define and discuss hw the trial will wrk set a timescale - expected duratin f trial, frequency f review set a dse - upper dse limit; aim fr lwest effective dse agree stpping rules with the patient befre starting: if treatment gals are nt met if there is n clear evidence f dse respnse if rapid tlerance develps necessitating high dse piids. Prceed t reductin and cessatin, r cnsider specialist referral/advice. Cnsider piid rtatin if the pain is piid respnsive but efficacy and dse titratin is limited by side effects. The medicines equivalent dse table is fr guidance nly and shuld be used with cautin. If the patient is n a high dse befre cnversin cnsider phased cnversin t avid withdrawal. Shrt acting piids may need t be used during cnversin until the crrect dse is established. Step 2 Starting a strng piid Factrs t cnsider Rute f administratin - ral r transdermal are the main rutes fr chrnic nn-malignant pain Chice f piid Dse: there is cnsiderable variability in the dse needed t effectively treat pain. Careful titratin t the lwest effective dse, balanced against side effects requires regular review. There are tw ptential ptins fr starting strng piids: 1. Start with lw dse f lng-acting preparatin. If the patient is already n ccdaml r dihydrcdeine, then they are nt piid naive, particularly if n maximum dse r mre than ne f these agents OR 2. While establishing dse, use an immediate release preparatin fr shrt term use, nly t determine apprximate dse range, then cnvert t equivalent lng-acting preparatin as sn as pssible. This may be mre apprpriate if the patient has multiple cmrbidities. Aim t establish n lng-acting piid with n immediate release piid if the chrnic pain is stable. Optins fr mild breakthrugh pain cnsider nn-piids (eg paracetaml, NSAIDs); weak piid. Date written: April 2015 Review Date: April 2017 Fife Integrated Pain Management Service

14 Step 3. Mnitring piid trial Mnitr adverse effects: Gastrintestinal Nausea/ vmiting: tlerance usually develps. Cnsider use f an antiemetic at initiatin f therapy. Due t the abuse ptential f cyclizine, avid if pssible. Cnstipatin: tlerance ften des nt develp t this. Use stl sfteners/stimulant laxatives r a cmbinatin. Cnsider piid preparatins less likely t cause GI effects. Central Nervus System If these d nt reslve, then either dse reductin r rtatin will be needed. Impaired memry, cncentratin Hallucinatins, milder visual disturbance Sedatin, cnfusin, cgnitive impairment Myclnic jerks. Other Sweating Reduced libid, fertility cnsider stpping, teststerne replacement, pssible piid rtatin; may need endcrine review Respiratry depressin stp piid until reslves; cnsider factrs cntributing t event Tlerance rtate piid r reduce and stp Opiid induced hyperalgesia - rtate piid r reduce and stp; seek specialist advice. Assess pain relief If there is gd pain relief n a stable dse f piid withut unacceptable side effects cntinue with at least annual review. If pain relief is inadequate due t: dse titratin nt being pssible due t adverse effects try piid rtatin n/minimal evidence f piid respnsiveness reduce and stp piid intlerable side effects try piid rtatin. Shrt-acting piids may need t be used during the cnversin bth t reduce physical withdrawal and while ptimum dse is being established. If the patient n a large dse f piid, cnsider phased cnversin (eg reduce the current piid dse by 50% and intrduce the new piid dse at less than the mrphine equivalent dse replacement dse (because f incmplete crss-reactivity). Cntinue with reductin f the ld piid and increase in new piid as indicated by respnse. At all times befre and during piid treatment signs f iatrgenic substance misuse shuld be sught and if prblems arise, then cnsider early specialist advice/referral. Step 4 Regular review, ideally with ne prescriber: At least annual, mre frequently if prblems arise Have a clear plan fr flare-up management (including availability t ut f hurs service). Date written: April 2015 Review Date: April 2017 Fife Integrated Pain Management Service