Pain relief in Palliative Care

What is the model used for palliative care pain?

WHO pain ladder

What is in step 1 of the WHO pain ladder?

Non-opioid with(out) adjuvant

What is step 2 of WHO pain ladder?

Opioid for mild/moderate pain , with(Out) non-opioid/adjuvant

What is step 3 of the WHO pain ladder?

Opioid for moderate/severe pain, with(Out) non-opioid/adjuvant

What is the WHO method for managing pain?

By the mouth, by the clock, by the ladder, for the individual and attention to detail

What are some examples of weak opioids?

Codeine, tramadol

What is the main strong opioid used for severe pain?

Morphine

What are some alternative strong opioids?

TD buprenorphine, TD fentanyl, hydromorphone hydrochloride, methadone or oxycodone

When is a medication review required for as required medications in pain for palliative care?

More than 2 doses within 24 hours

What is the pain management strategy now for children with cancer pain?

Two step process

What can also be used for bone metastases due to their significant pain as well as analgesia?

Radiotherapy, bisphosphonates and radioactive isotopes of strontium chloride

What can be used for neuropathic pain in palliative care?

TCAs e.g., amitriptyline or gabapentin or pregabalin

What are some other drugs used for pain in palliative care?

• Cannabis-related drugs e.g., Sativex spray

• Oxcarbazepine

• Ketamine

What is the recommended started dose of morphine in opioid naive patients without renal/hepatic issues?

20-30mg morphine as oral immediate release or oral sustained release and 2.5-5mg oral immediate release morphine for breakthrough during titration, if 3 doses in 6 hours review

What should happen once patients pain is controlled on morphine?

Start on 4-hourly immediate release morphine to same total 24hour dose - 12hour modified release or 24 hourly

When should the first dose of a modified-release preparation of morphine be given after the immediate-release is stopped?

Within 4 hours of the last dose

What side effects are key to look out for for patients switching from morphine immediate release to mR?

Nausea and vomiting, constipation

What is the recommended dose for breakthrough pain’s MINIMUM requirement?

1/10

What is the recommended dose for breakthrough pain’s MAXIMUM requirement?

1/6

What form of fentanyl should be avoided for breakthrough pain?

Fast-acting fentanyl

What can be used instead of morphine if patients cannot tolerate it or they have a poor egFR?

Oxycodone

What are the potential routes available if oral morphine isn’t suitable and pain requirements are stable?

Transdermal fentanyl or buprenorphine

When are transdermal patches not suitable?

Acute pain or patients where analgesia requirements change rapidly as the long time to steady state prevents rapid titration

What should be considered when switching daily doses of opioids to a different opioid?

Total dose in a 24 hour period

What dose reduction is advised for switching between opioids?

25-50%

What factors affect the potential dose reduction when switching between opioids?

Pain severity, age, fragility, tolerability and current opioid dose

What is the advise when switching between different formulations of morphine?

From oral to SC/IM/IV - dose is generally ½ or 1/3 of oral dose and should be 2x-3x larger when going from SC/IV/IM to oral