Palliative Care Guidelines - NHS Lanarkshire

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Palliative Care Guidelines: Choosing and Changing OpioidsChoosing and Changing Opioids in Palliative CareIntroduction• Opioids are used for pain and breathlessness.• Most palliative care patients respond well to titrated oral morphine.• A small number of patients may need to be changed to another opioid:o Oral route is not available.o Pain is responding but patient has persistent, intolerable side effects. (Consider reducingthe dose and titrating more slowly or adding an adjuvant analgesic before changing opioid)o Moderate to severe liver or renal impairment.o Poor compliance with oral medication.o Complex pain (consider adjuvant analgesics/ other pain treatments).Choosing an opioid for moderate to severe painFirst line opioids: (see: Pain management)Morphine• Range of oral preparations; SC injection and in a syringe driver/ pump.• Renally excreted, active metabolites – titrate morphine slowly and monitor carefully inchronic kidney disease.• Consider other opioids in stage 4-5 chronic kidney disease, dialysis patients.• Low doses and slow titration in liver impairment.Diamorphine• Highly soluble opioid used for SC injection and in a syringe driver/ pump.• Use for high dose SC breakthrough injections (above 180mg SC morphine/ 24hrs).Powder preparation is diluted in a small volume of water for injections.• As with morphine, cautious use in renal and liver impairment.Second line opioids:Oxycodone• For moderate to severe pain if morphine/ diamorphine are not tolerated.• Immediate and modified release oral preparations; SC injection; syringe driver/ pump.• Low concentration of preparation limits dose for SC injection to 10mg (1ml).• Avoid in moderate to severe liver impairment, clearance is much reduced.• Mild to moderate renal impairment: reduced clearance so titrate slowly and monitorcarefully. Avoid in stage 4-5 chronic kidney disease.Fentanyl• Topical patch lasting 72 hours; use if oral and SC routes unsuitable.• For stable pain if morphine is not tolerated; dose cannot be changed quickly.• No initial dose reduction in renal impairment but may accumulate over time.• Liver impairment; dose reduction may be needed in severe liver disease.Third line opioid: (seek specialist advice)Alfentanil• Short acting, injectable opioid for SC injection and in syringe driver/ pump.• In episodic/ incident pain can be given sublingually or subcutaneously.• Standard dose in renal disease including stage 4-5 chronic kidney disease.• Clearance may be reduced in liver impairment; reduce dose and titrate.Fourth line opioid: (specialist use only)Methadone• Oral methadone is used by specialists for complex pain; dosing is difficult due to the longhalf life; no renal excretion so standard dose in chronic kidney disease, half life prolongedin severe liver disease.© NHS Lothian Issue date: January 2009 Review date: March 20121
Palliative Care Guidelines: Choosing and Changing OpioidsOpioid toxicity• Wide variation in the dose of opioid that causes symptoms of toxicity.• Prompt recognition and treatment are needed. Symptoms include:o Persistent sedation (exclude other causes)o Vivid dreams/ hallucinations; shadows at the edge of visual fieldo Deliriumo Muscle twitching/ myoclonus/ jerkingo Abnormal skin sensitivity to touch• Reduce the opioid by a third. Ensure the patient is well hydrated. Seek advice.• Consider adjuvant analgesics and/or alternative opioids if still in pain.• Naloxone (in small titrated doses) is only needed for life-threatening respiratory depression.(see: Naloxone)Changing opioid• These doses / ratios are approximate (≈) and should be used as a guide.• Dose conversions should be conservative and doses usually rounded down.• Monitor closely; extra care if frail, elderly patient; renal or hepatic impairment.• Always prescribe an appropriate drug and dose for breakthrough pain:1/6 th of the 24 hour regular opioid dose.Equivalent doses of opioids recommended for use in palliative careImmediate release morphine Opioid dose Oral morphine: opioidpotency ratioOral morphine 5 mg≈ Oral codeine 60mg or 1:10oral dihydrocodeine 60mgOral morphine 10mg ≈ SC morphine 5mg 2:1Oral morphine 10mg ≈ SC diamorphine 3mg 3:1Oral morphine 10mg ≈ Oral oxycodone 5mg 2:1Oral morphine 10mg ≈ SC oxycodone 2-3mg 4:1Oral morphine 60-90mg in ≈ Fentanyl patchSee: Fentanyl24hrs25 micrograms/ hourOral morphine 30mg≈ SC alfentanil 1mg(1000 micrograms)30:1See: AlfentanilImmediate release oxycodoneOxycodone potency ratioOral oxycodone 5mg ≈ SC oxycodone 2-3mg 2:1See: OxycodoneEquivalent doses of opioids not generally recommended for palliative careOpioid dose Immediate release morphine Morphine: opioidpotency ratioOral tramadol 50mg ≈ Oral morphine 5-10mg 1:5 to 1:10Oral nefopam 30mg ≈ Oral morphine 10mg 1:3Buprenorphine patches10 micrograms/ hour≈ Oral morphine 10mg/ 24 hrs35 micrograms/ hour52.5 micrograms/ hour70 micrograms/ hour≈ Oral morphine 30-60mg/ 24 hrs≈ Oral morphine 60-90mg/ 24 hrs≈ Oral morphine 90-120mg/ 24 hrsOral hydromorphone 1.3mg ≈ Oral morphine 5-10mg 5:1 to 7.5:12Issue date: January 2009 Review date: March 2012 © NHS Lothian
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Palliative Care Guidelines - NHS Lanarkshire

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