Pain

Guidelines for Opioids in palliative care (a NICE draft)


What is NICE about opioids?

NICE is the National Institute for Health and Clinical Excellence in the UK.  It is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health.  It makes recommendations to the NHS on:

  • new and existing medicines, treatments and procedures.

  • Treating and caring for people with specific diseases and conditions.

A recent guideline that I have particularly appreciated was the one on Tumors of Unknown Primary. These recommended the establishment of multidisciplinary clinics that included palliative care physicians involvement with medical oncologists.

NICE has just released a draft set of guidelines for Opioids in Palliative Care.  They welcome feedback on these. While one has to be registered with NICE to give this feedback, I am sure we can arrange any comments left here to make there way to them. We may even get the director of the NICE Center for Clinical Practice, Fergus MacBeth, to visit this blog.  I have included the summary of their recommendations below but encourage you to visit to the full version at their website.

1.1 List of all recommendations

Communication1.1.1 When offering a patient pain treatment with strong opioids, ask them about concerns such as:

  • addiction
  • tolerance
  • side effects
  • fears that treatment implies the final stages of life.

1.1.2 Provide verbal and written information on opioid therapy to patients and carers, including the following:

  • when and why opioids are used to treat pain
  • the potential for non-effectiveness
  • taking opioids for background and breakthrough pain, addressing:
  •        how, when and how often to take opioids
  •        how long pain relief should last
  • side effects and signs of toxicity
  • safe use
  • follow-up and further prescribing.

1.1.3  Offer patients access to frequent review of pain control and side effects and information on who to contact out of hours, particularly during initiation of treatment.

First-line treatment – titration

1.1.4 When starting treatment with strong opioids, offer patients with advanced and progressive disease regular oral sustained-release or immediate-release preparations (depending on patient preference and clinical presentation), with rescue doses of oral immediate-release preparations for breakthrough pain.

First-line maintenance therapy

1.1.5 Offer oral sustained-release morphine as first-line maintenance therapy to patients with advanced and progressive disease who require strong opioids.

1.1.6 Do not routinely offer transdermal patch formulations as first-line maintenance therapy to patients in whom oral opioids are suitable.

1.1.7 If pain remains uncontrolled despite optimising first-line therapy, review analgesic strategy and consider seeking specialist advice.

First-line treatment with opioid patches if oral opioids are not suitable

1.1.8 Consider initiating transdermal opioids with the lowest acquisition cost for patients in whom oral opioids are unsuitable and analgesic requirements are not changing rapidly, supported by specialist advice where needed.

Breakthrough pain

1.1.9 Offer immediate-release oral morphine for the first-line rescue medication of breakthrough pain.

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

Management of constipation

1.1.11 Inform patients that constipation affects nearly all patients receiving strong opioid therapy.

1.1.12 Prescribe laxative therapy (to be taken regularly at an effective dose) for all patients initiating strong opioids.

1.1.13 Inform patients that treatment for constipation takes time to work and adherence is important.

1.1.14 Optimise laxative therapy for the management of constipation before considering switching opioids.

Management of nausea

1.1.15 Advise patients that nausea may occur when starting opioid therapy or at dose increase, but that it is likely to be transient.

1.1.16 If nausea persists, prescribe and optimise anti-emetic therapy before considering switching opioids.

Management of drowsiness

1.1.17 Advise patients that mild drowsiness or impaired concentration may occur when starting opioid therapy or at dose increase, but that it is often transient.

1.1.18 In patients with either persistent or moderate-to-severe central nervous system side effects:

  • consider dose reduction if pain is controlled
  • consider switching opioids if pain is not controlled.

1.1.19 If side effects remain uncontrolled despite optimising therapy, consider seeking specialist advice.

@jfclearywisc
UW Pain and Policy Studies Group.

 

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