Intended for healthcare professionals

Practice Guidelines

Prescribing strong opioids for pain in adult palliative care: summary of NICE guidance

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2806 (Published 23 May 2012) Cite this as: BMJ 2012;344:e2806
  1. Michael I Bennett, professor of palliative medicine1,
  2. John Graham, director and consultant in clinical oncology2,
  3. Mia Schmidt-Hansen, researcher2,
  4. Matthew Prettyjohns, health economist2,
  5. Stephanie Arnold, information specialist2
  6. On behalf of the Guideline Development Group
  1. 1Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9LJ, UK
  2. 2National Collaborating Centre for Cancer, Cardiff CF10 3AF, UK
  1. Correspondence to: M I Bennett m.i.bennett{at}leeds.ac.uk

Pain is common in advanced cancer but also in the late stages of other incurable non-malignant diseases, such as heart failure and neurological conditions.1 2 Almost half of patients with advanced cancer are undertreated for their pain, largely because clinicians are reluctant to use strong opioids for effective analgesia.3 4 Strong opioids such as morphine are indicated for moderate to severe pain and should be prescribed only after a full assessment of the analgesic needs of the patient.

This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the care of people with advanced and progressive disease who require strong opioids for pain control.5 These patients are defined as those in moderate to severe pain who may never have used strong opioids, or those whose pain has been inadequately controlled by weak opioids such as codeine or tramadol. The guideline does not cover all aspects of pain management (including second line approaches) or pain control during the last days of life (for example, for patients who are being managed by the Liverpool care pathway, a care pathway that integrates the best aspects of care for dying patients that can be used in any clinical setting).

Recommendations

NICE recommendations are based on systematic reviews of the best available evidence. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Communication and provision of information

When offering strong opioids as pain treatment to a patient with advanced and progressive disease:

  • Ask about concerns such as addiction, tolerance, side effects, or fears that treatment implies the final stages of life. Reassure patients that addiction is very rare and that tolerance does not significantly affect pain management or result in the need for escalating doses. It is often helpful to explain to patients that strong opioids are indicated solely because of the level of pain that the patient experiences and not because they are near to the end of life

  • Provide verbal and written information on the indications for strong opioids, effectiveness, speed of onset of pain relief, side effects and safe storage of the drugs

  • Give information on out of hours contact, follow-up, and further prescribing

  • Offer access to frequent review of pain control and side effects.

[All of the above are based on very low quality evidence from qualitative studies and on the experience and opinion of the Guideline Development Group (GDG)]

When barriers to treatment are identified and managed, patients are more likely to take analgesia as prescribed. This is best done with face to face advice plus information that the patient and carer can take away (such as a leaflet or DVD). This approach can result in measureable improvements in pain control and reduce adverse effects.6

Starting strong opioids—titrating the dose

If the patient is able to take oral medication, titrate the starting dose, taking account of pain control and side effects:

  • Offer regular, oral sustained-release or oral immediate-release morphine (depending on patient preference), with rescue doses of oral immediate-release morphine for breakthrough pain

  • Use a typical daily starting dose of 20-30 mg oral sustained-release morphine given as 10-15 mg twice daily with 5 mg oral immediate-release morphine for breakthrough pain (if the patient has no hepatic or renal impairment)

  • Adjust the dose to balance pain control and side effects, with frequent review

  • Seek specialist advice if this balance is not reached after a few dose adjustments or if the patient has moderate to severe hepatic or renal impairment.

[All of the above are based on low quality evidence from randomised controlled trials and on the experience and opinion of the GDG]

Starting strong opioids—maintenance phase

If the patient can take oral medication and if the optimal balance of pain control and side effects has been achieved:

  • Offer oral sustained-release morphine as first line maintenance treatment

  • Do not routinely offer transdermal patch formulations as first line maintenance treatment to patients in whom oral opioids are suitable

  • Offer oral immediate-release morphine for the first line rescue medication of breakthrough pain in patients receiving maintenance oral morphine treatment

  • Do not offer fast-acting fentanyl as first line rescue medication

  • Seek specialist advice if pain remains inadequately controlled.

[All of the above are based on low quality evidence from randomised controlled trials and on the experience and opinion of the GDG]

Starting strong opioids if oral opioids are not suitable

Oral opioids may be unsuitable for people with swallowing problems, when oral absorption is impaired or when pain is unstable. In such cases:

  • Consider using transdermal patches with the lowest acquisition cost for patients in whom oral opioids are not suitable and analgesic requirements are stable, supported by specialist advice where needed

  • Use caution when calculating opioid equivalence for transdermal patches (a transdermal fentanyl 12 μg patch equates to 45 mg oral morphine daily; and a transdermal buprenorphine 20 μg patch equates to 30 mg oral morphine daily)

  • Consider using subcutaneous opioids with the lowest acquisition cost for patients in whom oral opioids are not suitable and analgesic requirements are unstable, supported by specialist advice where needed.

[All of the above are based on very low quality evidence from randomised controlled trials and on the experience and opinion of the GDG]

Management of side effects

Constipation

  • Tell patients that constipation affects nearly everyone receiving strong opioids.

  • Prescribe laxative treatment (to be taken regularly at an effective dose) to all patients who are starting to take strong opioids.

  • Treatment for constipation takes time to work and adherence is important so optimise laxative treatment before considering switching to a different strong opioid.

[All of the above are based on the experience and opinion of the GDG]

Nausea

  • Advise patients that nausea may occur when starting strong opioid treatment or when the dose is increased, but that it is likely to be transient.

  • If nausea persists, prescribe and optimise antiemetic treatment before considering switching to a different strong opioid.

[All of the above are based on the experience and opinion of the GDG]

Drowsiness

  • Advise patients that mild drowsiness or impaired concentration may occur when they start strong opioid treatment or when the dose changes, but that these are often transient. Warn patients that impaired concentration may affect their ability to do manual tasks such as driving.

  • In patients with either persistent or moderate to severe central nervous system side effects consider reducing the dose if pain is controlled or switching to a different opioid if pain is not controlled.

  • If side effects remain uncontrolled despite optimising treatment, consider seeking specialist advice.

[All of the above are based on the experience and opinion of the GDG]

Overcoming barriers

The Guideline Development Group wanted to ensure that clinicians starting opioid treatment routinely elicit and allay patient concerns to help overcome barriers to successful pain management. The group also recognised that clinicians may view morphine as less effective than other opioids, but it found no evidence from randomised clinical trials to support this.

Further information on the guidance

Methods

This guidance was developed by the National Collaborating Centre for Cancer using methods from NICE’s standard processes (www.nice.org.uk/guidelinesmanual). The guidance review process involved literature searches to identify relevant evidence, with critical appraisal of the quality of the identified evidence. A multidisciplinary team of service users, carers, and healthcare professionals (the Guideline Development Group) was established to review the evidence and develop the subsequent recommendations. The guidance then went through an external consultation with stakeholders. The GDG considered the stakeholders’ comments, reanalysed the data where necessary, and modified the guidance as appropriate.

NICE has produced three different versions of the guidance: a full version; a summary version known as the “NICE guidance”; and a version for people using NHS services, their families and carers, and the public. All these versions are available from the NICE website. Further updates of the guidance will be produced as part of NICE’s guideline development programme.

Future research and remaining uncertainties
  • What are the most clinically effective and cost effective methods of managing patients’ and carers’ concerns about strong opioids, including anticipating and managing adverse effects and engaging patients in prescribing decisions?

  • In patients starting strong opioids for treatment of pain: is prophylactic prescription of antiemetic treatment or availability of antiemetic treatment at the patient’s home more effective in reducing nausea than prescription on request?

  • In patients starting strong opioids: when drowsiness or confusion develops, is an early switch to a different opioid more effective in reducing these side effects than persistence with the current opioid at a reduced dose?

Notes

Cite this as: BMJ 2012;344:e2806

Footnotes

  • This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

  • The members of the Guideline Development Group were Damien Longson (chair), Michael Bennett, Margaret Gibbs, Natalie Laine, Catherine Piggin, Joy Ross, Lindsay Smith, Catherine Stannard, Anna-Marie Stevens, and Mark Taubert.

  • Contributors: All authors contributed to the conception and drafting of this article and revising it critically. They have all approved this version. MB and JG are guarantors.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: The National Collaborating Centre for Cancer was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary; MB has received honorariums for lectures from Cephalon and Grünenthal in the past three years but not during the period when the guideline was being developed; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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