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Prescribing in palliative care
Palliative care is the active total care of patients whose
disease is not responsive to curative treatment. Control
of pain, of other symptoms, and of psychological, social
and spiritual problems, is paramount to provide the best
quality of
life for
patients and their
families.
Careful
assessment
of
symptoms
and needs
of
the patient
should be undertaken by a multidisciplinary team.
Specialist palliative care is available in most areas as day
hospice care,
home-care teams (often known as Mac-
millan teams),
in-patient
hospice care,
and hospital
teams.
Many acute hospitals and teaching centres now
have consultative,
hospital-based teams.
Hospice care of
terminally ill
patients has shown the
importance of symptom control
and psychosocial
sup-
port
of
the patient
and family.
Families
should be
included in the care of the patient if they wish.
Many patients
wish to remain at
home with their
families.
Although some families may at first be afraid
of
caring for
the patient
at
home,
support
can be
provided by community nursing services,
social
ser-
vices,
voluntary agencies and hospices together
with
the general practitioner. The family may be reassured by
the knowledge that
the patient
will
be admitted to a
hospital or hospice if the family cannot cope.
Drug treatment
The number of
drugs should be as
few as possible, for even the taking of medicine may be
an effort.
Oral medication is usually satisfactory unless
there is severe nausea and vomiting,
dysphagia,
weak-
ness,
or
coma,
when parenteral
medication may be
necessary.
Pain
Analgesics are more effective in preventing pain than in
the relief of established pain; it is important that they are
given regularly.
Paracetamol (p.
259) or a NSAID (section 10.1.1) given
regularly will
often make the use of
opioid analgesics
unnecessary.
A NSAID may also control
the pain of
bone secondaries
;
if necessary,
flurbiprofen or indome-
tacin can be given rectally.
Radiotherapy,
bisphosphon-
ates (section 6.6.2),
and radioactive isotopes of
stron-
tium (
Metastron
c
available from GE Healthcare) may
also be useful for pain due to bone metastases.
An opioid analgesic (section 4.7.2)
such as codeine
(p.
264),
alone or
in combination with a non-opioid
analgesic at
adequate dosage,
may be helpful
in the
control of moderate pain if non-opioid analgesics alone
are not sufficient.
Alternatively,
tramadol
(p.
271) can
be considered for moderate pain.
If these preparations
do not control
the pain,
morphine (p.
268) is the most
useful
opioid
analgesic.
Alternatives
to
morphine,
including
hydromorphone
(p.
267),
methadone
(p.
267), oxycodone (p.
269), and transdermal fentanyl
(see below and p.
265) are best initiated by those with
experience in palliative care.
Initiation of
an opioid
analgesic should not
be delayed by concern over
a
theoretical
likelihood
of
psychological
dependence
(addiction).
Equivalent single doses of opioid analgesics
These equivalences are intended only as an approximate
guide; patients should be carefully monitored after any
change in medication and dose titration may be required
Analgesic
Dose
Morphine salts (oral)
10 mg
Diamorphine hydrochloride (intramuscular)
3 mg
Hydromorphone hydrochloride
1.3 mg
Oxycodone (oral)
5 mg
Oral route
Morphine (p.
268) is given
by mouth
as an
oral solution or as standard (‘immediate release’) tablets
regularly every 4 hours,
the initial
dose depending
largely on the patient’s previous treatment.
A dose of
5–10 mg is enough to replace a weaker analgesic (such
as paracetamol),
but 10–20 mg or more is required to
replace a strong one (comparable to morphine itself). If
the first dose of morphine is no more effective than the
previous analgesic, the next dose should be increased by
30–50%,
the aim being to choose the lowest dose that
prevents pain. The dose should be adjusted with careful
assessment of
the pain,
and the use of
adjuvant anal-
gesics (such as NSAIDs)
should also be considered.
Although morphine in a dose of
5–20 mg is usually
adequate there should be no hesitation in increasing it
stepwise according to response to 100 mg or occasion-
ally up to 500 mg or
higher
if
necessary.
It
may be
possible to omit the overnight dose if double the usual
dose is given at bedtime.
When the pain is controlled and the patient’s 24-hour
morphine requirement is established, the daily dose can
be given as a
modified-release preparation
in a single
dose or in two divided doses.
Preparations
suitable
for
twice-daily
administration
include
Morphgesic
c
SR
tablets (p.
268),
MST Con-
tinus
c
tablets or
suspension (p.
269),
and
Zomorph
c
capsules (p.
269).
MXL
c
capsules (p.
269) allow admin-
istration of
the total
daily morphine requirement
as a
single dose.
The starting dose of
modified-release morphine pre-
parations
designed for
twice daily administration is
usually 10–20 mg every 12 hours if no other analgesic
(or only paracetamol) has been taken previously, but to
replace a weaker opioid analgesic (such as co-codamol)
the starting dose is usually 20–30 mg every 12 hours.
Increments should be made to the dose,
not
to the
frequency of
administration,
which should remain at
every 12 hours.
The effective dose of modified-release preparations can
alternatively be determined by giving the oral
solution
of morphine every 4 hours in increasing doses until the
pain has
been controlled,
and then transferring the
patient
to the same total
24-hour
dose of
morphine
given as the modified-release preparation (divided into
two portions
for
12-hourly administration).
The first
dose of the modified-release preparation is given with,
or within 4 hours of,
the last dose of the oral
solution.
The patient should be monitored closely for treatment
efficacy and side-effects.
If
pain occurs
between regular
doses
of
morphine
(‘breakthrough
pain’),
an
additional
dose
(‘rescue
dose’) should be given.
An additional
dose should also
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Prescribing in palliative care
BNF 61
Prescribing in palliative care