Control of Pain in Patients with Cancer

Transcription

1 for Control of Pain in Patients with Cancer National Council for Hospice and Specialist Palliative Care Services Northern Ireland Guideline Group Department of Health, Social Services & Public Safety An Roinn Sláinte, Seirbhísí Sóisialta agus Sábháilteachta Poiblí

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3 General Palliative Care Guidance Department of Health, Social Services & Public Safety Northern Ireland Group of the National Council for Hospice and Specialist Palliative Care Scope, Purpose and Applicability This document is intended to be a practical clinical guideline for the control of pain in patients with cancer. Its target group is hospital staff, primary care team members and nursing home staff. It attempts to apply the clinical principles outlined in the document 'Control of Pain in Patients with Cancer' published by "Scottish Intercollegiate Guidelines Network" (SIGN). This document has been adapted with the permission of SIGN. Rigour of Development A full evidence based reference list is available with the SIGN document. This can be accessed at Contents not based on the SIGN document are referenced separately. Stakeholder Involvement This document has been developed as one part of the recommendations identified in the Regional Review of Palliative Care Services, 'Partnerships in Caring'. The development of these Pain Guidelines was led by the Northern Ireland Group of the National Council for Hospice and Specialist Palliative Care, whose membership is detailed in Appendix 4. They will be reviewed and updated in two years. A wide consultation process with potential users was undertaken. Implementation Local ownership of the implementation process is crucial to success in changing practice. For this reason the guidelines group is responsible for the development of the guidelines but not for implementation. Implementation of the Regional Guidelines for Pain Management is the responsibility of each HPSS Trust, HPSS and Voluntary Providers, in partnership with education providers and individual professionals. Note The authors have, as far as it is possible, taken care to ensure that the information given in this text is accurate and up-to-date. However, readers are strongly advised to confirm that the information, especially with regard to drug usage, complies with the latest legislation and standards of practice. The authors do not accept responsibility or legal liability for any errors in the text, or for the misuse or misapplication of material in this work. Issue Date: May 2003 Review Date: May

4 Contents: Principles of pain management...3 Assessment of pain...4 Pharmacological Pain Management...5 Analgesic Ladder...5 Morphine / Diamorphine...6/7 Breakthrough Medication...7 Alternative Opioids...7 Predictable Opioid adverse effects...10 Opioid Toxicity...10 NSAIDS...11 Adjuvant Analgesics...11 Movement Related Pain...12 Treatment Related Pain...13 Interventional Techniques...13 Systemic Anti Cancer Therapy...13 Non Pharmacological Management...14 Appendix 1 - Using Naxolone...15 Appendix 2 - Opioid Equivalences...16 Appendix 3 - Fentanyl prescribing...18 Appendix 4 - Guidelines Development Group...19 Sources of Information and advice for Health Professionals

5 PRINCIPLES OF PAIN MANAGEMENT IN PATIENTS WITH CANCER 1. Pain is a subjective experience with social, psychological and spiritual dimensions. Pain in cancer is not always due to the cancer itself and may have multiple causes, some longstanding. 2. Patients should be given information and instruction about pain and should be encouraged to take an active role in their pain management. 3. Successful pain management involves comprehensive assessment, individualised treatment planning and regular review. Oral analgesia should be used where possible, titrated to pain relief and given prophylactically for persistent pain. 4. A patient's treatment should start at the level of the World Health Organisation analgesic ladder appropriate for the severity of the pain. Aetiology should be considered to optimise pain management. Not all pain in cancer patients is due to the cancer itself (approximately 70%) but is also associated with cancer therapy, debility due to the cancer and pre-existing conditions. 5. If the pain severity increases and is not controlled on a given step, medication from the next step of the analgesic ladder should be prescribed, rather than another analgesic from the same step (see analgesic ladder). 6. All patients with moderate to severe cancer pain, regardless of aetiology, should receive a trial of opioid analgesia. 7. Analgesia for continuous pain should be prescribed on a regular basis, and also prescribed as needed for "breakthrough pain". 8. It may be appropriate to involve the wider multiprofessional team for pain control; options may include oncological treatment and non-pharmacological measures. 3

6 ASSESSMENT OF PAIN Diagnosis of the potential cause of the pain and subsequent effective management is achieved by carrying out a full assessment, which includes: 1. History- from the patient and determine: Number and site of pain(s) Intensity/severity of pain(s) Radiation of pain. Timing of pain. Duration of pain Quality of pain Aggravating / relieving factors / sensory disturbances / associated power loss Type of pain e.g. neuropathic, visceral, somatic or mixed Analgesic drug history including dose and route of administration Impact of psychological factors e.g. anxiety or depression Effect on activities of daily living. 1. Carry out a physical examination. 2. Identify the likely cause of pain. 4. Arrange for appropriate diagnostic investigations. 5. Arrange for multidisciplinary professional assessment to include physiotherapy and occupational therapy. 6. Review frequently for effectiveness and / or adverse effects of medication. 4

7 TREATMENT OF PAIN PHARMACOLOGICAL MANAGEMENT World Health Organisation Analgesic Ladder (1986) STEP 3: MODERATE TO SEVERE PAIN OPIOID FOR MODERATE TO SEVERE PAIN + A NON-OPIOID ± ADJUVANT Moderate to Severe Pain Prescribing Notes Drug options First line - Morphine p.o. - Diamorphine alternative opioids - Fentanyl - Hydromorphone - Oxycodone The oral route is the recommended route of administration and should be used where possible. Morphine is the oral opioid of choice. If the oral route is not appropriate diamorphine is the recommended parenteral opioid of choice. In the absence of optimal pain management or if adverse drug effects occur seek Specialist Palliative Care advice A trial of alternative opioids should be considered for moderate to severe pain where dose titration is limited by side effects of morphine / diamorphine. Ensure antiemetics and laxatives are available for the patient. STEP 2: MILD TO MODERATE PAIN 5 OPIOID FOR MILD TO MODERATE PAIN PLUS A NON-OPIOID ± ADJUVANT STEP 1: MILD PAIN Drug options - Codeine 60mg 6hrly - Dihydrocodeine 60mg 6hrly NON-OPIOID ± ADJUVANT Drug options - Paracetamol 1g qid - Non-steroidal antiinflammatory drugs (NSAIDs) Pain persisting or increasing (Mild to Moderate Pain) Patients with mild to moderate pain should receive a weak opioid plus a non-opioid. Consider combination preparations eg co-codamol 30/500. If the effect of a weak opioid for mild to moderate pain given regularly at its optimum dose is not providing adequate pain relief move to step three of the analgesic ladder. Mild Pain Patients with mild pain should receive either a NSAID or paracetamol at licensed doses. The choice should be based on a risk/benefit assessment for each individual patient. Paracetamol is commenced at 1g 6 hourly. Do not prescribe two paracetamol containing products. Patients receiving a NSAID who are at risk of gastrointestinal side effects should be prescribed a proton pump inhibitor or misoprostol. General Palliative Care Guidance

8 Morphine Initiating and Titrating Oral Morphine Morphine is available in a variety of formulations from different manufacturers. Refer to current BNF44 Sect "Opioid analgesics". "Prescribing in palliative care" (BNF44 p13) provides information on formulations, strengths and administration. Note: Initiation of opioids should not be delayed due to unfounded fears concerning psychological dependence. Patients should be encouraged to discuss their fears about morphine and should be reassured that they will not become psychologically dependent on their opioid analgesia. Specialist Palliative Medical advice is recommended when initiating analgesic therapy in patients who have renal impairment, are on dialysis or are stopping dialysis. When initiating normal release morphine (ie Sevredol/Oramorph), start with 5-10 mg orally at four hourly intervals (six times in 24 hours) with access to prn dosing, (Cautions: Patients with renal impairment or the elderly and frail). Each day assess the pain control, severity of side effects and total amount of morphine required, including breakthrough doses, in the previous 24 hours. Divide the total amount required in the previous 24 hours by six. Prescribe this dose every four hours and alter the breakthrough analgesia dose accordingly (this is the same as the four hourly dose) i.e. one sixth of the total daily regular morphine dose. (See section entitled "Movement Related Pain". If a patient is unable or unwilling to use breakthrough doses but is still in pain, the dose of normal release morphine prescribed four hourly should be increased. The increase depends on the individual but is usually in 30-50% increments. If still in pain after 2-3 doses have been taken, increase by one third to one half. Once suitable pain control is achieved by the use of normal release morphine, conversion to the same total daily dose of modified release morphine (MST or MXL) should be considered e.g. normal release morphine 5mg 4 hourly = 30mg in 24 hours = MST 15mg bd = MXL 30mg od. If pain control is not achieved in 48 hours or there are excessive side effects, contact your local Palliative Care Team for advice. 6

9 Diamorphine - parenteral administration Patients requiring parenteral opioids (i.e. a patient who is vomiting or unable to swallow) should receive the appropriate dose of diamorphine via the subcutaneous route. To calculate the 24 hour dose of subcutaneous Diamorphine, divide the total 24 hour oral dose of morphine by three. Administer this dose of diamorphine subcutaneously in syringe driver over 24 hours. Patient should also be prescribed a breakthrough dose of subcutaneous diamorphine (i.e. 1 6 of 24 hour Diamorphine dose) Conversion ratio: oral morphine : parenteral diamorphine is 3mg : 1mg Breakthrough analgesia (prn dosing) Every patient on an opioid should have access to breakthrough analgesia (i.e. 1 6 of total daily opioid dose) Following the delivery of oral breakthrough analgesia, wait 30 minutes to assess the response. If pain persists, repeat analgesia and reassess in a further 30 minutes. If pain still persists, full reassessment of the patient is required. Alternative Opioids A small proportion of patients develop intolerable adverse effects with oral morphine before achieving adequate pain relief. Switching to an alternative opioid may achieve successful analgesia with reduced adverse effects. This assessment and decision is optimally made by a specialist in Palliative Medicine. Equi-analgesic doses of alternative opioids can vary between individuals and within individuals over time and vary with drug and dose. Therefore theoretical equi-analgesic doses can only be taken as an approximate guide when switching patients from one opioid to another. Careful clinical observation is required during such switches. Oxycodone Normal release preparation - Oxynorm capsules and liquid. Modified release preparation - Oxycontin tablets. Conversion ratio: Morphine to oxycodone is approximately 2:1. If patient is already on morphine then the total 24-hour morphine dose should be divided by two for the equivalent 24-hour oxycodone dose e.g. 80mg morphine / 24 hours = morphine MR 40mg bd = oxycodone 40mg / 24 hours = Oxycodone MR 20mg bd. 7

10 Fentanyl patch (Durogesic) A range of transdermal patches providing analgesia over 72 hours is available. Indications for Use Transdermal Fentanyl is not usually appropriate for patients with uncontrolled pain. 1. Use for stable pain only. 2. Consider use in patients who have difficulty with the oral route. 3. Consider use as an alternative opioid whether there are adverse effects such as drowsiness, confusion, nausea and vomiting or constipation with other opioids. 4. Consider use in patients who prefer patches to tablets/capsules. There is a lag time to onset of analgesia (achievement of steady state occurs in hours) and off set of analgesia once the patch is removed. Due to the development of a skin reservoir, there are some special considerations. Continue analgesia for 12 hours when initiating patch e.g. 4 hourly morphine or a final 12 hour modified release preparation. (See Appendix 3) Do not adjust dose until 48 hours have elapsed, use prn opioid dosing if pain recurs during this time. Take extra care when removing patch and introducing alternative opioids e.g consider using prn oral or subcutaneous dosing for the first hours and then retitrate as previously outlined. Because of the above considerations, if patient is moribund and has increasing pain needs: Do not remove patch. Add additional opioid for uncontrolled pain as a subcutaneous infusion using syringe driver. Calculate the required dose based on equivalent breakthrough dose. For additional advice on Fentanyl prescribing see Appendix 3 and manufacturers literature Oral Transmucosal Fentanyl Citrate (OTFC) (ACTIQ) OTFC formulation is an effective, fast acting, and fast clearing treatment for opioid responsive breakthrough pain and is increasingly used as analgesia of choice for incident pain. British Journal of Cancer (2001) 84(5), Transmucosal absorption into the blood stream is rapid with peak plasma concentration achieved at 20 minutes. 8

11 When the lozenge is used over 15 minutes, it has a rapid onset of pain relief of 5-10 minutes with a duration of effect approximately 2 hours (consult manufacturer's patient advice leaflet). Initiation and Titration The OTFC lozenge (ACTIQ) strength range is mcg fentanyl. It is recommended to commence at the lowest dose 200mcg lozenge initially. If no pain relief is achieved within 30minutes,the 200mcg fentanyl lozenge can be repeated. With opioid responsive pain it is recommended to titrate upwards to the lowest effective lozenge strength. There is no conversion ratio for OTFC, titration is required to determine the optimum breakthrough dose. Depending on the number of lozenges required per breakthrough episode in 24 hours, the total opioid 24-hour dose should be reviewed. Hydromorphone (Palladone) Normal release preparation: (Palladone Capsules) Hydromorphone 1.3mg = morphine 10mg Hydromorphone 2.6mg = morphine 20mg Modified release preparation: (Palladone SR Capsules) Hydromorphone 2, 4, 8, 16, 24mg = morphine 15, 30, 60, 120 and 180 mg respectively. Conversion ratio: Morphine to Hydromorphone is approximately 7.5:1 Therefore morphine 120mg/24 hrs = morphine MR 60mg bd = hydromorphone 16mg/24 hrs = hydromorphone MR 8mg bd and hydromorphone 2.6mg for 4 hourly PRN dose As hydromorphone is available as both normal release and controlled release capsules, allow titration as described for oral morphine. Methadone Because of its long half-life, risk of accumulation and opioid toxicity, it is not recommended for use outside Specialist Palliative Care practice. Should a patient on methadone be discharged into the community or be on a general hospital ward, and develop opioid toxicity, discontinue the methadone and consult a Specialist in Palliative Medicine. For Opioid Dose Equivalences see Appendix 3. Seek specialist palliative medical advice for indications and optimal choice of opioid switching when pain is poorly controlled 9

12 Predictable Opioid Adverse Effects Constipation: Patients receiving an opioid must have access to regular prophylactic laxatives. A combination of stimulant and softening laxative will be required e.g. Codanthramer. Nausea and vomiting: Patients commencing an opioid for moderate to severe pain should have access to a prophylactic antiemetic e.g. (metoclopramide 10mg tid or haloperidol 1.5-3mg nocte). Patients may develop tolerance to this side effect in 7-10 days. Sedation: Patients receiving opioids for moderate to severe pain for the first time should be warned that sedation may occur. This is usually limited to the first few days. Patients should be advised of the risks of driving or using machinery. The use of other sedative drugs or drugs with sedative side effects should be rationalised. Dry mouth: All patients should be educated on the need for, and methods to achieve, good oral hygiene. Sugar free chewing gum can stimulate saliva. Less common side effects Skin itch, gastroparesis, urinary hesitancy and retention. Note A trial of alternative opioids should be considered in patients with opioid responsive pain who are unable to tolerate morphine adverse effects. (see alternative opioid section). Opioid toxicity and its management Symptoms and signs: These may include persistent drowsiness, pinpoint pupils, confusion / agitation, hallucinations, myoclonic jerks, cognitive impairment and respiratory depression. Check renal and hepatic function and rule out other causes of systemic deterioration e.g. infection, hypercalcaemia. Treat precipitating causes. Adjuvants or opioid switching may be required if pain remains problematic after dose reduction. Management: reduce the dose of opioid, ensure adequate hydration and treat the agitation / confusion e.g. haloperidol mg orally or subcutaneously. For persisting agitation this dose can be repeated after one hour, but with caution in the elderly. If there is a slow respiratory rate, distinguish true opioid toxicity from the slow and irregular breathing which may accompany the terminal phase. For respiratory depression associated with opioid toxicity, discontinue opioid immediately and review. 10

13 If respiratory rate 8/min and the patient is easily rousable and not cyanosed, adopt a policy of 'wait and see'; consider reducing or omitting the next regular dose of morphine and re-assess pain. If respiratory rate is 8 / min or less, urgent hospital admission is indicated for monitoring. Consider reversal of respiratory depression (see appendix 1). The aim is to reverse respiratory depression without compromising pain control. This may not fully reverse sedation. The patient's background analgesia will subsequently need to be reviewed. Seek specialist palliative medical advice for continuing problems. Non-opioid Analgesics Non-steroidal anti-inflamatory drugs (NSAIDs) NSAIDs are of particular benefit for pain associated with inflammation, eg soft tissue infiltration and bone metastases. Because of adverse effects on platelet function, renal function and related gastro intestinal toxicity, NSAIDs are used with caution. COX-2 inhibitors may offer a reduced risk of gastrointestinal damage. It is usual practice to prescribe a gastro-protective agent (proton pump inhibitor or misoprostol) in patients at risk of gastrointestinal side effects. Adjuvant Analgesics These are considered when the pain appears to be only partially opioid responsive and / or the pain is clinically neuropathic in nature i.e. associated with sensory changes or atypical sensations (e.g. allodynia painful response to non painful stimuli) Patients with neuropathic pain should have a trial of a tricyclic antidepressant and / or an anticonvulsant. Patients with complicated pain should be referred early for specialist assessment and management. Anti-convulsants Example Gabapentin - Commence patient on 100mg tid gradually increasing the dose as tolerated until pain is controlled to a maximum of 1800mg in 24 hours. (Higher doses may be used by specialists in Cancer Pain.) Other anticonvulsants are also used e.g. Carbamazepine, Phenytoin, Sodium Valproate, Clonazepam. 11

14 Anti-depressants Example Tricyclic Antidepressants - Amitriptyline. Commence the patient on amitriptyline 10mg nocte, titrating gradually against pain response and unacceptable side effects. Usual dose range 10mg - 100mg per day. Note: The clinical response to either tricyclic anti-depressants or / and anti-convulsants may have a lag period of two to three days. Corticosteroids A therapeutic trial of oral high dose dexamethasone should be considered for raised intracranial pressure, severe bone pain, nerve infiltration or compression, pressure due to soft tissue swelling or infiltration, spinal cord compression or hepatic capsular pain. Usual commencing dose is dexamethasone 8-16mg daily. Review the response and gradually reduce to the lowest effective dose. Consider the need to prescribe a gastroprotective agent. Muscle relaxants For muscle spasm consider diazepam 5mg orally or midazolam 5mg sc in a syringe driver. Anti spasmodics Crampy abdominal pain is opioid "poorly responsive". Hyoscine butylbromide mg in divided doses may be given orally over 24hours. Since there is poor oral absorption, consider subcutaneous administration if colic is severe. Bisphosphonates Bisphosphonate treatment should be considered for all patients with multiple myeloma, and in the management of bone pain in patients with breast and prostate cancer. It should be considered for other patients with difficult to control bone pain. Ketamine This is used for neuropathic and other severe pain. Specialist initiation only. Movement Related Pain (Incident Pain) Some patients may be pain free at rest and have difficult pain on movement. To avoid opioid toxicity at rest when titrating opioids for these patients it may be imprudent to incorporate the analgesia for the incident pain into regular bd dosing. Optimum analgesia may be best achieved by other considerations: 12

15 Immobilisation and stabilisation of bone where possible, radiotherapy, nerve blocks, the use of pre-movement breakthrough analgesia, especially using rapid onset/offset preparations such as oral transmucosal fentanyl citrate. Treatment Related Pain Consider using appropriate analgesia to "cover" procedures such as chest drain insertion or bone marrow aspiration. Oral transmucosal fentanyl citrate may be useful if not opioid naïve. Some treatment related problems such as post-thoracotomy neuropathic chest pain and neuropathy secondary to chemotherapy may require specialist advice. Interventional Techniques In a small percentage of patients interventional techniques eg nerve blocks, plexus blocks or spinal analgesia may be indicated for difficult pain. (Seek specialist advice before considering intervention). Systemic Anti-Cancer Therapy Specific anti-cancer therapy including chemotherapy, hormonal therapy and radiotherapy should be considered as part of pain management in cancer patients. 13

16 NON-PHARMACOLOGICAL MANAGEMENT OF PAIN Referral to other Health Care Professionals for consideration of their input Physiotherapy - Transcutaneous Nerve Stimulation (TENS)/Transcutaneous Spinal Electroanalgesia (TSE) - Controlled exercise/movement - Positioning - Splinting/immobilisation - Acupuncture/acupressure - Mobilisation of joints - Relaxation - Aid and appliance provision e.g. mobility aids, portable nebulisers - Massage - Gentle heat Occupational Therapy - Positioning (including provision of appropriate seating and pressure relief) - Aids and appliance provision e.g. dressing and feeding aids - Relaxation - Individual splinting - Home adaptations to facilitate activities of daily living Psychological Support - Counselling - Clinical psychology Spiritual Support Creative/expressive therapies - music therapy - art therapy Alternative Support - Aromatherapy - Reflexology Evidence for complimentary therapies is sparce. 14

17 APPENDIX 1: NALOXONE Naloxone for iatrogenic opioid overdose (based on the recommendations of the American Pain Society) If respiratory rate 8/min and the patient easily rousable and not cyanosed, adopt a policy of 'wait and see'; consider reducing or omitting the next regular dose of morphine and re-assess pain. If respiratory rate < 8/min, the patient is barely rousable/unconscious and/or cyanosed: Dilute a standard ampoule containing naloxone 400µg to 10ml with saline for injection. Administer 0.5ml (20µg) IV every 2 min until the patient's respiratory status is satisfactory Further boluses may be necessary because naloxone is shorter-acting than morphine (and other opioids). In patients who require opioids for pain relief the aim is to reverse respiratory depression without reversing pain control. This may not fully reverse sedation. Max MB and Payne R (1992) Principles of analgesic use in the treatment of acute pain and cancer pain. American Pain Society. P

18 APPENDIX 2: OPIOID EQUIVALENCES SECTION A The following table may be used to convert a patient from one opioid analgesic to another. The values given in the table are for guidance only. A patient should always be monitored for response to pain relief and side-effects following a dose conversation. The route of administration of opioid in the table is oral unless otherwise stated. This table is for converting a patient to or from oral morphine. OPIOID (route) Conversion Factor Dose equivalent to 10mg oral morphine Buprenorphine (sublingual) mg Codeine mg Dextropropoxyphene mg Diamorphine (sub-cut) 3 3mg Morphine (parentral) 2 5mg Dihydrocodeine mg Hydromorphone mg Oxycodone 2 5mg Tramadol mg For conversion TO oral morphine: MULTIPLY the dose of the CURRENT analgesic by the conversion factor for that analgesic. Codeine 240mg (in 24 hours) - convert to oral morphine (in 24 hours): 240mg X 0.08 = 20mg oral morphine. For conversion FROM oral morphine: DIVIDE the dose of oral morphine by the conversion factor for the INTENDED analgesic. Oral morphine 30mg (in 24 hours) - convert to Diamorphine (sub-cut) in 24 hours: 30mg 3 = 10mg Diamorphine (sub-cut) in 24 hours NOTE: For conversions involving fentanyl (transdermal) consult product literature or appendix 2. All opioid switches are considered in terms of oral morphine equivalents. Because of the possibility of incomplete opioid cross tolerance specialist practice advises a dose reduction of the order of at least 25%. Ref: Adapted from Twycross R, Wilcock A et al, Palliative Care Formulary (PCF2) 2nd ed, 2002, Page 171, Radcliffe Medical Press Adapted from Regnard C, Tempest S, A guide to symptom relief in advanced disease, 4th ed, 1998, page 19, Chesire: Hochland & Hochland Adapted from 16

19 APPENDIX 2 (continued): SECTION B: Fentanyl to Morphine conversion dose. 4 HOURLY MORPHINE (mg) <20 25 to to to to to to to to to to to 185 FENTANYL PATCH STRENGTH (Mcg/hr) HOURLY ORAL MORPHINE DOSE (mg) < to to to to to to to to to to to 1124 SECTION C: Morphine to Diamorphine conversion dose Morphine 30mg = Diamorpine 10mg SECTION D: Morphine to Hydromorphone conversion dose. 7.5:1 Morphine 10mg = Hydromorphone 1.3mg Morphine 20mg = Hydromorphone 2.6mg Morphine 15, 30, 60, 120 and 180 mg respectively = Hydromorphone 2, 4, 8, 16, 24mg. SECTION E: Morphine to Oxycodone Morphine 20mg = Oxycodone 10mg References J. Pereira, P. Lawlor and E. Bruera. Equianalgesic Dose Ratios for Opioids - A Critical Review and Proposals for Long-Term Dosing. Journal of Pain and Symptom Management: Including Supportive and Palliative Care, 22 (2) (2001) pp

20 APPENDIX 3 - FENTANYL PRESCRIBING ADVICE Initial Prescribing Patients should to be titrated on oral morphine before converting to transdermal fentanyl as the lowest strength patch (25mcg/hour) may be too strong. Never cut a patch. Patients previously on maximum dose step 2 analgesia may commence on a 25mcg/hour patch. Caution is recommended. Patients already on morphine should be converted to the correct dose of fentanyl using the conversion chart. See Appendix 2. Patients converting from alternative strong opioids should have their fentanyl patch dose calculated based on the oral morphine equivalent dose. Normal release morphine one sixth of equivalent 24 hour total morphine dose is recommended for breakthrough pain. Due to lag time in reaching therapeutic levels, current morphine or diamorphine dose should be continued for 12 hours after applying the first patch ie:- a) normal release morphine four hourly for 12 hours or b) final dose of modified release morphine taken as the patch is applied or c) keep syringe driver running for 12 hours after applying the patch. Subsequent Prescribing Patch change required every 72 hours. A steady state is not achieved for 48 hours after patch application, do not increase dose more frequently than this. In the interim use breakthrough dose of normal release morphine. Any dose increase should be based on breakthrough analgesic requirements (e.g. two or more in 24 hours) and should usually be in 25 mcg steps. If a patient becomes opioid toxic on a patch, remove the patch and prescribe prn dosing at 30% reduction of the equivalent morphine dose (See Appendix 2), for first 24 hours. The morphine dose may need to be increased over the subsequent days as the Fentanyl depot is fully absorbed. Caution Opioid withdrawal symptoms may be observed in about 10% of patients following a switch from morphine to transdermal fentanyl. These may include diarrhoea, nausea, abdominal cramps, agitation, sweating, shivering and vomiting. These are usually transient, but may occur for up to seven days and can be managed with normal release morphine as necessary. Patches should not be applied to recently irradiated skin. In patients already on strong opioids, the dose of laxatives should be reviewed and will often need to be reduced. Absorption may be increased by heat, therefore application of a local heat source eg hot water bottle should be avoided. Patients with fever should be observed for signs of opioid toxicity. Patch may not be appropriate in patients with excessive sweating because of poor skin adherence. 18

21 APPENDIX 4 - GUIDELINE DEVELOPMENT GROUP Dr Yvonne Duff Consultant in Palliative Medicine Antrim Area Hospital 45 Bush Road Antrim BT41 2RL yvonne.duff@uh.n-i.nhs.uk Dr I Clarkson GP Facilitator Ballyclare Group Practice George Avenue Ballyclare Co Antrim IPCLARKSON@aol.com Mrs M Brown Social Work Department Belfast City Hospital 79 Lisburn Road Belfast BT9 7AB Ms Patricia McGeeney Head Occupational Therapist Belvoir Park Hospital Hospital Road Belfast BT9 6JR Patricia.McGeeney@bch.n-i.nhs.uk Miss Alison Porter Senior Nurse (Cancer Services) Ulster Community & Hospitals Trust The Ulster Hospital Belfast BT16 0RH Alison.porter@ucht.n-i.nhs.uk Mr Ewan McGrattan Pharmacist Antrim Area Hospital 45 Bush Road Antrim BT41 2QB ewan.mcgrattan@uh.n-i.nhs.uk Dr Angela Garvey Altnavelvin Hospital Glenshane Road Londonderry BT47 6SB LHasson@alt.n-i.nhs.uk Mrs H Healy Foyle Hospice Home Care Team 61 Culmore Road Londonderry BT48 4JE care@foylehospice.fsnet.co.uk Dr O Morris Southern Area Hospice Services Craigavon Area Hospital Lurgan Road Portadown BT63 8DR omorris@cahgt.n-i.nhs.uk Dr Kiran Kaur Consultant in Palliative Medicine Royal Victoria Hospital Grosvenor Road Belfast BT12 6BA Kiran.kaur@royalhospitals.n-i.nhs.uk Ms J Rankin Physiotherapist Cancer Centre Belfast City Hospital Lisburn Road Belfast BT9 7AB Jane.rankin@bch.n-i.nhs.uk Dr Sheila Kelly Medical Director Marie Curie Centre Belfast Kensington Road Belfast BT5 6NF medicalbelfast@mariecurie.org.uk 19

22 Ms Anne O'Hagan Palliative Care Nurse Specialist Antrim Area Hospital 45 Bush Road Antrim BT42 2QB Dr B Corcoran Consultant in Palliative Medicine Belfast City Hospital Lisburn Road Belfast BT9 7AB bernie.corcoran@bch.n-i.nhs.uk Specialist Reviewers Dr D Hill MD FFARCSI Consultant Anaesthetist Ulster Community & Hospitals Trust The Ulster Hospital Dundonald Belfast BT16 0RH david.hill@ucht.n-i.nhs.uk Dr Richard Wilson Consultant Oncologist Northern Ireland Cancer Services Belvoir Park Hospital Hospital Road Belfast BT9 6JR r.wilson@qub.ac.uk Dr Julie Doyle Northern Ireland Hospice 74 Somerton Road Belfast BT15 3LH Julie.doyle@nihospicecare.com Dr Siophan Carey Strabane Health Centre Strabane Dr Mary Morris Principal Clinical Psychologist Oncology Unit, Altnagelvin Area Hospital Glenshane Road Londonderry Dr Pauline Wilkinson Northern Ireland Hospice 74 Somerton Road Belfast BT15 3LH Pauline.wilkinson@nihospicecare.com Dr Teresa Tate Chair of Clinical Issues and Research Committee National Council for Hospice and Specialist Palliative Care Services Britannia Street London WC1X 9JG 20

23 SOUCES OF INFORMATION AND ADVICE FOR HEALTH PROFESSIONALS Health professionals seeking information and advice about the control of cancer pain should contact their local specialist palliative care service. The Cancer Centre / Cancer Units have Hospital Specialist Palliative Care Teams and most other hospitals have the support of Macmillan Palliative Care Nurses. Cancer Centres and Cancer Unit Palliative Care Teams will provide out-patient services as will some of the other hospitals and these may be accessed from hospital or community. Each Health Board area in addition has community specialist palliative care nurses, who work in close conjunction with the primary care teams and will receive the support and advice of a consultant in palliative medicine. Macmillan GP facilitators are available in each Health Board. Their role is to facilitate GP's knowledge of Cancer and Palliative Care. They are accessed via the respective Boards or Macmillan Central Office. Macmillan Cancer Relief, 82 Eglantine Avenue, Belfast, BT9 6EU Tel: Fax: northernirelandfundraising@macmillan.org.uk Hospital Specialist Palliative Care Teams at Cancer Centre and Units can be contacted between 9am and 5pm, Monday to Friday. If the team member is not accessed an answering service is available and calls are promptly returned. Cancer Centre Belfast City Hospital Royal Victoria Hospital ext 4409 Belvoir Park Hospital Cancer Units Antrim Area Hospital Altnagelvin Hospital ext 4180 Craigavon Hospital ext 2820 Ulster Hospital Other Hospitals Daisy Hill Hospital Mater Hospital ext 2501 Erne Hospital Tyrone County Hospital Causeway Hospital Lagan Valley Hospital

24 Hospices and Specialist Palliative Care Units There are a number of Hospice and specialist palliative care units in Northern Ireland which provide in and out-patient management of pain and other complex symptoms. (They may also provide a range of other services including respite care, day hospice care, community palliative care and bereavement services). Southern Health Board Southern Area Hospice Eastern Health Board Marie Curie Centre Belfast Kensington Road, Belfast, BT5 6NF Western Health Board Foyle Hospice 61 Culmore Road, Londonderry, BT48 8JE Northern Ireland Hospice 74 Somerton Road, Belfst, BT15 3LH This currently provides inpatient services to the Northern Health Board Anaesthetic / Interventional Pain Management There is close contact between oncology / palliative care services and anaesthetic pain services. Patients who would benefit from these techniques are referred via the above services. 22

25 23 General Palliative Care Guidance

26 24 General Palliative Care Guidance

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28 Published by: Department of Health, Social Services and Public Safety, Castle Buildings, Belfast BT4 3SJ Telephone: (028) Textphone: (028) May 2003