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EOL Guidance on pain NS MOM
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
Pain may be defined as an unpleasant sensory or emotional experience associated with actual or potential tissue damage. Chronic pain is defined as pain still present after three months despite appropriate treatment. Breakthrough pain is defined as pain of moderate or severe intensity occurring against a background of controlled chronic pain.
1.1 Who is eligible for care by St Peter’s Hospice?
· Anyone over the age of 18 with an active and advanced life limiting disease such as cancer, heart and/or lung disease and neurological diseases;
· Patients referred to St Peter’s Hospice may be close to the end of active treatment when a doctor has advised either that no further treatment will be of benefit or that further treatment is purely for the relief of difficult symptoms;
· The patient may be near the end of their life and may have chosen to die in a hospice. The patient (or their chosen representative i.e. next of kin) must agree to the referral;
· St Peter’s Hospice provides care to the people of Bristol, South Gloucestershire, North Somerset and part of B&NES.
1.2 Who can make a referral to St Peter’s Hospice?
Anyone can make a referral but usually patients are referred by a health or social care professional such as their GP, District Nurse or Hospital Palliative Care Team. The patient’s GP must be in agreement with the referral.
Once a patient has been accepted by St Peter’s Hospice they will be contacted by a triage nurse to let them know what will happen next. For the majority of patients the first contact they will receive will be a telephone call from the triage nurse to introduce the service and assess any urgent issues. This will often be followed by a visit from a Community Nurse Specialist or perhaps an invitation to an outpatient appointment.
· assess their general emotional, psychological and spiritual state
· assess their current coping style – is it helpful, is this their usual approachor has it changed with the disease/pain?
· assess impact on family/carers
Identify and communicate (to patient & family, health professionals):
· causes of pain and management plan
· the correct use/expectations of medications and other treatments
· understanding of the patient’s personal situation
· practical and emotional support available
Help to develop coping strategies
Coping strategies developed for chronic pain may be useful within the palliative care setting.
They are based on living with pain, adapting living to the new requirements and the maintenance of normal activity as far as possible. Many chronic pain clinics have clinical psychologists who specialise in this field.
Relaxation and distraction techniques and creative/complementary therapies
There are a number of techniques and therapies, provided by a wide range ofprofessionals, which aim to encourage relaxation, finding distraction and otherinterests. Most patients will find at least some of these approaches will help.
Transcutaneous electrical nerve stimulator (TENS) or Acupuncture
The Palliative Care Adult Network Guidelines are accessible from here: http://book.pallcare.info/index.php provides information about morphine preparations and information regarding other oral and injectable strong opioids, relative potencies of oral and subcutaneous opioid analgesics and opioid equivalents.
Hard copies of the Drug chart and patient information leaflet are available in GP Practices and with Community Nursing teams. The version attached below is provided as a last resort as these are not designed to be printed locally.
Service commissioned by NHS England on behalf of NS CCG
Accurate assessment of pain is essential to plan appropriate interventions or treatments. Uncontrolled pain limits a person’s ability to self care, affects their response to illness and reduces their quality of life. Pain can be classified into the following modalities: Physical, Psychosocial and Spiritual.
Physical: Related to the underlying disease e.g. cancer, abdominal distension from ascites. Related to treatment e.g. surgery, chemotherapy, radiotherapy, drug related neuropathies. Associated factors e.g. constipation, pressure sores, bladder spasm, stiff joints, postherpetic neuralgia. Other chronic conditions e.g osteoarthritis, angina.
Psychosocial: Psychosocial factors may have a profound influence on an individual’s perception and experience of pain, and can affect how the sufferer responds emotionally and behaviourally. There is a large body of scientific evidence to support the role of anxiety and depression, fear, pain-related beliefs and coping styles in the mediation of pain perception in chronic non-malignant pain.
Spiritual: People suffering from chronic unremitting pain can experience spiritual distress/pain. It is important to identify spiritual needs in order to offer appropriate support. The spiritual dimension of an individual includes meaning, relatedness, hope and forgiveness – this may or may not include a religious belief system.
It is imperative that patients’ anxieties and frequent misconceptions related to the above factors are explored. Pain will not be adequately controlled unless patients feel a degree of control over their situation. To ignore psychological and spiritual aspects of care may often be the reason for seemingly intractable pain. Having prescribed analgesics, the patient’s pain should be under constant supervision and the response to treatment reviewed regularly.
The patient, if competent and able to communicate, is the most reliable assessor of pain and should, where possible, be the prime assessor of their pain.
A detailed pain assessment should include:
1. Clinical History
Site and number of pains
Intensity/severity of pains
Radiation of pain
Timing of pain
Quality of pain
Aggravating and relieving factors
Power/functional loss and the effect on activities of daily living
Aetiology of pain e.g. cancer, treatment related, osteoarthritis, other pathology
Type of pain: nociceptive, neuropathic, referred, mixed etc.
Analgesic and other drug history
Presence of clinically significant psychological disorder e.g. depression or anxiety
Contribution from psychosocial and spiritual factors
Patient understanding and beliefs concerning pain
2. Physical Examination
3. Identification of the likely cause of pain and classify the type of pain
4. Arrangement for appropriate diagnostic investigations
5. Arrangement for multi-disciplinary professional assessment when practicable.
6. Regular review to determine the effectiveness of treatment. The frequency of review depends upon the severity of the pain and associated distress.
Components of successful pain management include:
1.An understanding that pain is a subjective experience, with social, psychological and spiritual dimensions. Pain may have multiple causes, some longstanding.
2.Comprehensive, individualised and holistic assessment and treatment planning, including regular review and reassessment with involvement of the wider multi-professional team as appropriate.
3.Patient and carer involvement, which should include information about pain and its management. Patients should be encouraged to take an active role in their pain management.
4.Aetiology should be considered to optimise pain management.
5.Treatment should start at the level of the World Health Organisation (WHO) analgesic ladder appropriate for the severity of the pain (see Analgesic prescribing). Increase in analgesia should be in accordance with the principles of the ladder. If 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.
6.Oral analgesia should be the preferred form of delivery where possible, titrated until pain is relieved and given regularly if pain is persistent.
7.Morphine is currently considered to be the strong opioid of choice.
8.Analgesia for continuous pain should be prescribed on a regular basis, and also prescribed as needed for “breakthrough pain” in appropriate dosages.
9.Adjuvant analgesics should be considered where appropriate as per WHO ladder.
General Principles of Analgesic Prescribing
The principles outlined in this section are based on the World Health Organisation (WHO) three step analgesic ladder which is currently the most widely accepted guideline:
By the mouth – ideally the oral route should be used first line.
By the clock – regular analgesia ensures blood levels are maintained and reduces the need for PRN medication.
By the ladder – analgesia should be increased in response to the degree of pain according to the WHO analgesic ladder.
Individual dose titration – to achieve optimal pain relief with fewest side effects.
Use of adjuvants – if appropriate.
Attention to detail – analgesia should be reviewed regularly and adjusted as necessary.
There needs to be a clear reason for not using Morphine when initiating strong opioids for the first time, and this reason needs to be documented in the patient’s record. Morphine is the opioid of first choice.
Non-opioid ± adjuvant
non-steroidal anti-inflammatory drugs (NSAIDs)
Patients with mild pain should receive either paracetamol ± NSAID at licensed doses. The choice should be based on a risk/benefit assessment for the individual patient.
Caution re. NSAID contraindications and adverse effects.
Opioid for moderate to severe pain + / - non-opioid + / - adjuvant
Morphine remains the first-line strong opioid of choice. Alternatives should be considered if dose titration is limited by side-effects or there is renal impairment (see further details below):
STOP step 2 opioid
Prescribe 10mg immediate release oral morphine every 4 hours, (ie 6 doses over 24 hours). A smaller dose of 5mg every 4 hours may be more appropriate in the frail or elderly or renal impairment (eGFR 30-60ml/min).
Prescribe oral morphine for 'when required use' for breakthrough pain. Breakthrough doses are traditionally one sixth of the total 24 hour dose of oral morphine but given up to a maximum of one hourly.
Titrate the opiate dose to achieve pain relief. Each day add up the total dose of morphine used in the last 24 hours (the total of regular and when required doses) and divide by 6 to give the new 4 hourly dose. Remember to increase the 'When required' opiate dose at each dose up-titration.
As pain becomes more controlled convert the patient to a modified release (MR) oral morphine preparation. Add up the total dose of morphine used in the last 24 hours (the total of regular and when required doses) and divide by 2 to give the new 12 hourly dose of modified release morphine e.g Zomorph Capsules.
Renal Impairement: morphine metabolites accumulate in renal impairment. Avoid morphine if eGFR < 30ml/min. See Adult Palliative Care Network Guidelines for further advice about extending dosing intervals reducing doses and changing opiates.
Discuss the following information with the patient: 1. Explore the patient’s ideas, concerns and expectations about starting morphine.
2. Emphasise the need for regular administration and explain about breakthrough medication. 3. Warn about possible side effects. 4. Reassure that when used for pain relief, morphine is not addictive, will not shorten life and will continue to be effective even when used long term.
Explain that this will occur with opioids; give softening and stimulant laxatives eg docusate and senna.
If constipation persists despite optimal laxative dosing, consider an opioid with less constipating effects such as fentanyl (TLS Blue).
Patients being prescribed opioids should have access to anti-emetic and laxative pre-emptively.See BNSSG: Gastrointestinal symptoms for more information or EOLgastrointestinal symptoms NSCCG
Nausea & vomiting
Explain that this may occur with opioids
If patients are unable to tolerate oral medication, the subcutaneous route is the preferred route for administration of anti-emetic medication
Metoclopramide (TLS Green) for nausea/vomiting associated with starting opioid medication, delayed gastric emptying.
Cyclizine (TLS Green) for nausea/vomiting associated with intracranial disease.
Alternatives: (TLS Blue)
Haloperidol (TLS Blue) for nausea/vomiting associated with metabolic derangement or drugs.
More information available on page 5 of St Peter's hospice guidelines or EOL gastrointestinal symptoms NSCCG
Encourage the patient to report any other side effects they feel might be due to opioids.
excessive drowsiness confusion, vivid dreams and/or hallucinations (often need to ask patient specifically) myoclonic jerks
Toxicity may occur with any opioid but particularly with morphine when the patient has renal impairment.
For hallucinations or vivid dreams add haloperidol and if toxicity either reduce the opioid dose (if pain free) or switch to an alternative opioid.
Avoid naloxone unless respiratory rate is <8/minute and patient drowsy. See St Peter's hospice guidelines page 5.
Respiratory rate will need monitoring for 12 hours after last dose of mr opioid.
For more information changing strong opioids and converting from oral medication to a patch or syringe driver please see the Clinical Guidelines on the management of pain on the St Peters Hospice Website, click here
For information on Opioid Potency Ratios please see the last page of the Clinical Guidelines on the management of pain on the St Peters Hospice Website, click here
When oral administration is not possible because of dysphagia, vomiting or weakness, consider changing to a transdermal patch or to csci using a syringe driver.
Other reasons for changing strong opioids can be:
· reduction in side effects eg constipation (fentanyl, buprenorphine less constipating)
· problems with oralcompliance etc
If there is difficulty achieving good pain control without unacceptable side effects, changing the strong opioid may be appropriate. However, most problems can be solved by improving the titration, or using adjuvant drugs.
The dose conversion (total daily or prn dose) from oral morphine to sc morphine is normally 2:1, and from oral morphine to sc diamorphine 3:1, but allow flexibility depending on the need for increased or decreased analgesia.
Seek specialist advice when:
· converting from higher doses of one opioid to another, because conversionratios may be different at higher doses
Metabolites of morphine and some other opioids accumulate in renal impairment (of which eGFR is a better indicator than serum creatinine in patients with loss of muscle bulk), leading to opioid toxicity manifested as:
· increasing drowsiness or confusion
· vivid dreams/hallucinations
· muscle twitching/myoclonus/jerking*
· hyperalgesia on light touch or on being turned*
* always seek specialist advice in cases of severe renal or hepatic impairment.
This is an important cause of ‘terminal agitation’. It may respond to a reduction in the dose and/or frequency of administration, but it is often better to switch to an opioid which does not accumulate in renal impairment such as fentanyl, buprenorphine or alfentanil.
Opioid toxicity may also occur in hepatic impairment, but clinical difficulties do not usually arise unless the impairment is severe: prothrombin time (or INR) is amore sensitive indicator of severe impairment than standard liver function tests.
All opioids can precipitate confusion and encephalopathy, but oral opioids will be particularly affected by the loss of first pass metabolism. Careful re-titration is necessary using both a reduction in the dose and a lengthening of dose interval, while considering an alternative opioid. In the dying patient, maintenance of good analgesia remains very important.
Doctors have a legal responsibility to advise patients if a disability is likely to make them a danger when driving. Taking morphine for medicinal reasons does not automatically disqualify from driving, but the following advice should be given:
· do not drive for at least two days, and preferably five, after starting or increasing morphine
· check fitness to drive by taking a trusted passenger and driving for 10 - 15 minutes on quiet roads
· inform the insurance company. If this is not done the patient may find they are not covered, irrespective of fault. It is illegal to drive uninsured.
It is now illegal in England and Wales to drive with legal drugs in your body if it impairs your driving.
Patients should carry suitable evidence that they are taking the drug appropriately/
No further information has been provided for this node
Consider early referral for palliative radiotherapy - usually a single fraction is effective. Radioactive isotope treatment may be used for multiple sclerotic metastases.
NSAIDs may be effective but beware side effects: discontinue if not helping. Gastro-protective agents should usually be prescribed.
IV infusions of bisphosphonates may reduce pain in patients with bone metastases, especially from breast and prostate cancer and myeloma: drugs and doses as per hypercalcaemia. See BNF for TLS indications
Consider referral to an orthopaedic surgeon for internal fixation for metastases in long bones at risk of fracture.
Vertebroplasty or cement fixation may be appropriate for isolated vertebral collapse in selected patients.
· physiotherapy, aromatherapy, relaxation, heat pad
· muscle relaxants:
baclofen (TLS Green first line for painful muscle spasm- caution in renal impairment)
diazepam (TLS Green),
dantrolene (TLS Green)- this may be used in conjunction with baclofen but the therapeutic effects may take weeks to develop,
The management of breakthrough pain should be individualised.
Consider the underlying cause of the pain e.g. radiotherapy.
Consider the avoidance/treatment of the precipitating factors of pain.
Consider modification of the background analgesic regimen. This may include titration of opioid analgesics, switching of opioid analgesics, or the addition of “adjuvant analgesics”.
Opioids are the “rescue medication” of choice in the management of breakthrough pain.
The dose of opioid “rescue medication” should be determined by individual titration.
Non-opioid analgesics may be useful in the management of breakthrough pain episodes. e.g. paracetamol, NSAIDs.
Interventional techniques may be useful in the management of breakthrough pain.
Non-pharmacological methods may be useful in the management of breakthrough pain episodes.
Practical Considerations in Managing Breakthrough Pain
Traditionally the most common form of medication used for BTcP has been immediate-release oral morphine (or other opioid). It may be necessary to take into account the background and extra opioid requirements for the previous 24h to assess the amount of background opioid needed for the following day. However it is reasonable for a patient to need an extra 1-3 extra doses a day without automatically increasing the regular background dose.
The pharmacokinetic/ dynamic profiles of these drugs are not ideally suited for most breakthrough pain episodes i.e. the relatively slow onset of action (onset of analgesia: 20–30 min; peak analgesia: 60–90 min) results in delayed/ineffective analgesia, coupled with ongoing adverse effects due to the prolonged duration of effect (3–6h) after the episode.
Nevertheless, oral opioids continue to have a place in the management of breakthrough pain lasting for more than 60 min.
If being used for pre-emptive management of incident pain or procedural pain, oral opioids need to be taken at least 30 min before the precipitant of the pain.
The parenteral routes of administration (intravenous, subcutaneous) can also be used.
Patients with significant ongoing pain should be prescribed regular opioids and these titrated as required and tolerated.
Every patient on regular opioids should have access to breakthrough analgesia which is traditionally approximately 1/6 (one sixth) of the total daily dose.
A lower dose (one tenth, is recommended in the BNF) may be adequate but this needs assessing on an individual basis.